An Interview with Dr. Dag Körlin:

Introduction

It is not unusual for people worldwide to be exposed to trauma. According to the World Mental Health surveys conducted by Kessler et al. (2017), 70% of the 68,894 respondents in 24 countries had experienced some form of lifetime trauma. Therapists trained in Guided Imagery and Music (GIM) are therefore advised to equip themselves with additional skills to assist clients with traumatic experiences.

With his background in medical and psychiatric training, Dr. Körlin combines breathing practice with music listening as a safe approach for his clients who have difficulty receiving GIM or Music Imagery (MI). This Music Breathing (MB) approach builds on clinical experiences and insights, and a holistic knowledge base (Körlin, 2019b). His contribution is recognized as showing how GIM can be applied in psychiatric settings (Abbott, 2019; Ahonen, 2019; Beck, 2019; Maack, 2012). Dr. Körlin (2019a) has also written a chapter on neuropsychological theory of traumatic imagery, and is an expert in this field.

According to Dr. Körlin (2019b), the aim of MB is to modulate arousal evoked by music listening in a non-ordinary state of consciousness. Clients with stress and trauma issues often have a limited Window of Tolerance (WoT) for musical elements that evoke memories of overwhelming events. If the WoT is exceeded, hyperarousal and swings between hyperarousal and hypoarousal may result. In such states, it is difficult to hold and process thoughts, emotions, and images. Breathing can be used to modulate the effect of music on arousal. MB involves first learning the meditative skills of Silent Breathing (SB) and then integrating these with music listening in a meditative state. MB requires the client to imagine a breathing volume from a small breathing center to a large breathing volume with adjustments and modulations in between. The small breathing center is the “geometric” focus of the meditative breathing volume, and is situated in the middle of the stomach, a few fingers below the navel (see Appendix, Figure 2). To select music, two variables are important: Level of Activation (A) and degree of Modulation (M). A/Ms have degrees ranging from 1–6 (see Appendix, Table 1). Low As support a low activation state with a small, centered breathing volume, which is the breathing center. An important part of SB and MB sessions is the painting of a breathing mandala, where the client depicts a body image of the imagined breathing volume and its breathing center.

In fact, in Dr. Körlin’s training manual (2020), an overview of stages of MB is as follows:

DB is a new, additional stage to what Dr. Körlin had previously described for MB. It is actually a natural small step that fosters the client’s initial readiness for learning SB. In SB, Dr. Körlin’s advice is to start by first learning triangular breathing to facilitate locating the breathing center, then proceeding to biphasic breathing. A diagram for triangular breathing and biphasic breathing is provided in the appendix, and the author has obtained permission from Dr. Körlin to reproduce both images. If the client has dissociated experiences of breathing, with difficulty in locating the breathing center, a special protocol, “Music Breathing for Dissociation,” is used.

In this semi-structured interview, Dr. Körlin describes briefly how he developed the practice of MB and how his approach evolved. He identifies some key features of his work, and how they are different from GIM, MI, and other types of breathing exercises such as Holotropic Breathwork (Taylor, 2003). Generally, GIM refers to the Bonny Method of GIM. The current Association for Music and Imagery (AMI) definition of the Bonny Method of GIM is:

GIM is a powerful intervention and may sometimes overwhelm the limbic alarm system of clients recovering from trauma (Grocke, 2019). In GIM, the images provoked by music listening present not only as symbols that carry multiple meanings, but also as unprocessed sensory, bodily, and affective experiences. As these overwhelming physical and psychological experiences may not manifest in symbolic imagery, they may sometimes appear in a distorted manner or get disconnected from the re-experience in music. GIM has the potential to help clients access and reintegrate these traumatic experiences. It is key when working with these clients to avoid hyperarousal and stimulating symbolization, as proposed by Dr. Körlin (2019a). MB is considered a way to counteract autonomic dysregulation.

In fact, many practitioners have presented different modified versions of GIM adapted to psychiatric populations. Beck (2019) has thoroughly reviewed how GIM has been used and modified with psychiatric clients over the past 40 years. Among all these modifications, two innovators in developing MI adaptations are Summer (2002) and Goldberg (1994). Summer’s MI is widely recognized as supportive or resource-oriented MI, a modified form of GIM (Summer, 2009, 2015). Summer (2015) developed a continuum of MI with different levels of practice depending on the client’s needs. Even though the focus of MI can be on simply creating a positive experience in the here-and-now moment for the supportive level, the ambiguous quality of classical music may still pose a risk to some clients with mental health issues. She emphasized the importance of using contained music with minimal texture that is focused on exposition, with minimal development and greater simplicity in its orchestral textures (Summer, 2002). Goldberg (1994) used non-classical music instead, with a distinctive feature of talk-over during the music as a safety measure when working with this population. She renamed her technique as Focused Music Imagery (FMI). The effectiveness of FMI was affirmed by Dimicelli-Mitran (2020) in her recent article that depicted its detailed steps and provided case examples.

When Dr. Körlin practiced GIM in psychiatry, he foresaw the need for a more accessible, approachable method among people who have experienced trauma due to their stress sensitivity and tendencies to dysregulation of arousal. The benefits and specific features of MB will be highlighted in the following interview. Dr. Körlin has given his consent for this interview to be disseminated in written format. This article will include the majority of the transcript of the interview, conducted in Sweden, and serves as a contribution to expanding the understanding of, as well as a complementary resource to, his MB practice.

Angela: Dr. Körlin, can you tell me a bit more about how you found out about GIM? And why do you use this instead of other types of psychotherapy approaches?

Dr. Körlin: I was originally trained as a psychodynamic therapist. In that [form of] therapy, you use [narrative] words mostly. Sometimes, people also free associate, but this is [usually] not fully let loose. We have so many other forms of cognition besides words [and linear logic]. For example, memory images of situations, perceptions, sensations, and emotions from our life. Images have another language. An image can be very concrete: e.g., a flash back [of trauma] that does not have any meaning beyond itself. It can also have symbolic meaning, layers of them. You can disentangle these layers by making a picture of your image, and then looking at it from various points of view. Each time you see something different. Each time you have a different view of your history. The image also includes your present state of mind; feelings, moods, body sensations, and degrees of alertness or relaxation. In all these states, the body reacts differently. You can, by making a picture of these states, look at them and analyze them. Later, you can see their meaning.

Angela: When you developed Music Breathing, why did you choose this method of breathing versus others? There are so many other available accepted types of breathing exercises existing in the world. Why introduce Silent Grounding Breathing?

Dr. Körlin: I have practiced meditation since I was about twenty years old. I was trained in a formal meditation, called Soto Zen. The teacher I had emphasized the awareness of the Hara, which is described as a point situated in the middle of the stomach, a few fingers below the navel. He said that if you focus your breathing in this point, you will have the desired effect of meditation, that is to experience nothing. In this center the breathing is very small. This is how I came into contact with meditation and have practiced it for many years; every day. Being in this state helps me go beyond my body limits, to experience myself as part of the whole while still staying grounded. The goal is to reach that state. When you are breathing, you calm down, sink down. You can experience this as centered in the stomach, a little below the navel. Later, I tried to combine reaching this state while listening to music. It is quite difficult to do that, because when you are in a meditative state, the idea is to stop the thought. So, the thoughts and emotions cease, die out and become still. It is a paradox to combine that with listening to music. Music becomes the content of the experience. You are not in meditation anymore. But, I tried to solve this by making the music an object of mindful observation.

Angela: What do you mean by that?

Dr. Körlin: I mean I allow the music to flow through without trying to get caught by it. I observe it passing through myself. That way I can listen to music in the most pure and effective way. I can, for example, take in the timbre of the instruments in a more intensive way, but still in a calm way, since I am in a calm center. So, this is a sort of paradox, trying to achieve emptiness when you have music in your mind. I think this is specific for this meditation. It is not the silent meditation that my teacher taught me. It is another form of meditative effort. It is still very good and effective.

Angela: So, if breathing itself has benefits, what is the benefit of adding music?

Dr. Körlin: Breathing can modulate the effect of the music to achieve a certain state of bodily [autonomic] activation. If you choose music that is very grounded, with low notes in it, you can imagine it as being in the center of the stomach. It is quite easy to do that. If the music is right for that state, you can just continue breathing slowly, with a small breathing volume. If the music expands, you need to expand the breathing space, so that the breathing contains the music. Loud music and fast music want to have a big breathing volume and a fast breathing rhythm containing the state of activation brought by the music.

Angela: Will that counteract what you want? Don’t you want to be calm? If you do lots of fast breathing when the music is fast, you are breathing too fast. Will that counteract the calmness?

Dr. Körlin: But the point is, it is not about breathing with high energy all the time. People do that. For example, like Holotropic Breathwork, you intentionally play music that is very rhythmic, very strong, propelling breathing in motoric way. You do that for a long time, you breathe hard for 45 minutes to 50 minutes.

Angela: Oh, that long…

Dr. Körlin: Yes, that long. Then, you get to a widened state of mind, as a rule. You increase the level of oxygen, and decrease carbon dioxide in the blood. You can feel the tingling of your fingers. Your sensations change. You can get a feeling like you are both inside and outside of your body at the same time. You can experience a fusion with the world, which is called a transpersonal state. But, in Music Breathing, the point is to adapt the breathing to the music in every moment. Sometimes, the music will be slow and low, and then your breathing will be small. If the music expands, you expand the breathing, you follow it. If it falls back again, you decrease the breathing again. You modulate the breathing in tune with the modulations of the music.

Angela: In that case, the music you choose for Music Breathing is very important. My question would be how long should the music be? In a GIM program, the music program can be as short as 20 minutes, or up to 45 minutes. I notice that you use the music in a way similar to music imagery in a way, like 3-10 minutes. Is that the length you usually use? Do you make it longer or shorter?

Dr. Körlin: I think it depends. If I do it by myself, I can do it for 10–15 minutes. But 15 minutes is the limit, because it is very taxing to do Music Breathing for that long. When you do it in a holotropic way, you do it in a group, and then get the support from the group. Everybody in a group is also breathing hard. You get energy from the group to continue. If you do it for yourself, for your own development, or if you do it for a client in a session, there is not that energy. Also, in a one-hour session, there are so many other things you need to have time for. You need to have time for pre-talk, to find out where the client is, what has happened since the last time. You will need to have time for the relaxation to go into the meditative state. After the breathing, you will paint the breathing mandala, and then you will have to talk about it. If you think about all these elements, only 8-10 minutes are left for the music itself.

Angela: That is why you suggest 8–10 minutes for Music Breathing?

Dr. Körlin: For a one-hour session. I think that if you have a longer time, you could do up to 20 minutes. You can use between one and three pieces of music. You can extend the session up to one and a half hours.

Angela: So, it depends on the needs of the client whether you lengthen the time for listening to the music?

Dr. Körlin: Yes. It is also for economic constraints as well. Also, I think it is difficult to do more than 20 minutes using music having classical features where the music changes a lot. For example, Holotropic Breathwork uses music that is not so changing, it is more static, not so many things happening in the music.

Angela: May I get back to the choice of music again? Do you use classical music mostly, or do you use nonclassical music? How would you differentiate when to use classical?

Dr. Körlin: It has to do with the concepts of level of Activation and level of Modulation. Clients have limits, levels of tolerance, low or high degrees of those two. Some clients cannot tolerate going to the full level of activation or listening to very complex music that changes every second.

Angela: When you say Activation and Modulation, I know Modulation means the level of variation and change in the music. Can you clarify what you mean by Activation?

Dr. Körlin: Activation—you can see it as a gliding scale between very low and very high [autonomic] bodily activity. Low is when you are resting as much as you can, lying on the bed, not moving. Just letting yourself sink into the bed, maybe getting a little bit drowsy. That is a very low state of activation and consumption of energy. Because the heart is calm, the circulation is slow.

Angela: So, it is more like a bodily state, the level of activation?

Dr. Körlin: Yes, right. So, the high level of activation approaches an alarm state, when you are running from something, or fighting something, you need to mobilize the whole body. The heart beats faster, blood vessels expand to get blood out to the body. You need to bring more oxygen to the body. When you think of the fight or flight response, the high level of activation is when you are in danger, you run like hell, you must climb a tree, or fight somebody.

Angela: I understand it more.

Dr. Körlin: So, it is like a gliding scale. And there is modulation. Low modulation is simple music, consists of few notes, not doing much, maybe just a stroll. The highest degree of modulation would be a symphony by, for example, Brahms or Mahler.

Angela: In that case, do you use the music to match the client’s state or do you always bring them to a low activation state?

Dr. Körlin: I want them to start with the low activation state. Then, increase the activation and modulation to a level that they can tolerate, and then go back to the low activation again at the end. It is like a curve, begin at zero, then go up and go back again. It is a bit like Helen Bonny’s graph of the intensity of the music over a program.

Angela: My question is, it would be hard to get one piece of music that will do everything together, right? Do you use many pieces of music? Or how do you just do one?

Dr. Körlin: If you want to do that, you can do that within a piece of music. You choose a piece of music that has a bit of intensity in the middle; it fades out and diminishes as the music ends. Most music pieces have that structure. In Western classical music, we have ABA, where B is more alien. Lisa Summer said it is more “not me.” It has more disharmony. It is more challenging in the B part, then you go back to the A part, which is by now the home that you left when you went into the B part. Back in the A part, the music diminishes the activity before it ends. That is the way most [Western classical] compositions are.

Angela: In that way, is it more appropriate to use classical music, because neoclassical music piece probably will not have such a dramatic change in music form?

Dr. Körlin: Both can be used, depending on the level of modulation you want to have. You listen to them beforehand, you will notice the level of complication and intensity, activation, and choose something that is suitable for this client. In the beginning of the Music Breathing session, you go for the low level of activation and low level of modulation. Like the client you reported to me, maybe you go a bit too far with the degree of modulation and drama. But, the client might have managed that at a later stage, if he had had more sessions and learned more on how to handle the tension that was produced by the music.

Angela: I am just curious, will there be any side effects from doing Music Breathing? You have clients who practice at home, right? If the person somehow forgets what he is supposed to do, will that have any impact?

Dr. Körlin: I think you have to know the client well enough, so that you can be sure if s/he can manage certain levels of music. Then, you take the next step. You see if the client can manage that. Of course, the client has to come back, otherwise you don’t have the data to choose the next piece of music. So, for example, Bach is generally predictable, the safest of all the composers. If you stay with Bach, you can be more certain not to exceed the limits.

Angela: I see. So, when do you use GIM, how do you choose between Music Imagery and Music Breathing? Do you use Music Breathing when people cannot handle GIM? How do you decide when to use what?

Dr. Körlin: As Music Breathing was developed, it was invented in situations where people could not handle their images in GIM. They either had autonomic over-reaction, with panic and excitation, or they were overwhelmed by a lot of images. There were so many images that they could not integrate them. When too much happened, they could not make any order of it. They may be in an alarm state, or [alternately] get shut down. If they cannot “hear” and feel the music, they cannot use it either.

Angela: Some people would use Music Imagery instead of GIM, right? What is the difference between Music Imagery and Music Breathing?

Dr. Körlin: One difference is that clients can do Music Breathing by [themself]. You can also “prescribe” to train Music Breathing by yourself. That means that you don’t have to have a therapist in the room every time. You can do it by yourself, and then you can do it more times. Music Imagery is a single session that you do once a week. Then, you have to wait until the next week when you get back to the therapist. The next week, you will do it again. But, you cannot work with the music as much as you can with Music Breathing, where you don’t need the therapist in the room every time. You just need breathing and the music.

Angela: I see what you mean. It sounds like Music Breathing can be a complement to Music Imagery.

Dr. Körlin: And Music Breathing is the safest one.

Angela: The safest one? Even safer than music imagery?

Dr. Körlin: Yes, because music imagery can also have a very strong effect while the client is in the music listening state, when you have no verbal contact. The client has directions before, but no tools when something unexpected happens in the music that [the client] cannot manage. But in Music Breathing, the client will have the breathing as a tool.

Angela: May I ask you about Music Breathing’s processing of the imagery afterwards, with mandala drawing? Do you instruct them to draw this bodily sensation from breathing while listening to music? What happens if they draw something that is not related to that, or something not within your expected impact from that?

Dr. Körlin: It is part of the training of the client, to not forget the breathing. You process the mandala and its content, as you would do in Music Imagery. You also bring in the breathing in the processing. If you notice that the client doesn’t try to adapt the breathing to the music, you should be persistent and ask the client to do that.

Angela: So, in that case, the drawing itself is almost like an assessment of their experience as a result of breathing to the music, not something that goes into the subconscious mind and provokes lots of memories or images, am I right?

Dr. Körlin: That is right. For some clients, there is no obvious connection between the images and the experience of the breathing volume, which is a body image. But the expectation is that the images somehow should be related to the breathing. Sometimes, it isn’t. Sometimes, it is. If clients have a lot on [their] minds, are very troubled by something, or trying to find a solution, then the content of that situation and the emotions would be stronger and take over. Then, you allow that.

Angela: So, it is more than just a body scan kind of image; it could be something else. And it is still acceptable?

Dr. Körlin: Right. What you do, you ask the client to note the connection between the images and the breathing and the music. It is a triad that your clients do all the time. For some sessions, you can’t. In some sessions, you have only the experience of the body space. In other sessions, you have only emotions and problems.

Angela: Are you saying that they can practice this Music Breathing at home as much as they want?

Dr. Körlin: No. Not as much as they want. Three to five times a week.

Angela: Three to five times a week. Do you recommend that they do the drawing or just listen to the music while breathing?

Dr. Körlin: I recommend them to do the drawing also, to do at least one drawing in the meantime, between this session and the next session. They can do a drawing after every session by themselves at home if they want.

Angela: But do you recommend them to do one?

Dr. Körlin: I demand at least one because there should be one. It is also the fact that the painting becomes a sort of memory, a sort of notebook. When you look at the painting, you remember the session and the experience. It is like a hook that brings back the process. Otherwise, you can just forget the experience until the next time.

Angela: How long does it take for people to experience the benefit of Music Breathing?

Dr. Körlin: You experience some benefits after 4 weeks, but this requires that you work at home both with the Silent Breathing and with the Music Breathing, and at the same time, you will see the therapist as indicated.

Angela: May I clarify with you again about the Silent Breathing? You start with the triangular breathing, breathing out, then holding, and then in. Then you go with the exercise from an enlarged breathing space enlarged, which gradually becomes a smaller breathing volume. This is what you call the Silent Breathing exercise?

Dr. Körlin: Yes. The purpose of triangular breathing is just to find the breathing center. After a while, you don’t need triangular breathing to find the center. You can find it with ordinary breathing.

Angela: Is that why you usually teach the triangular breathing for the first two times? Then go to the other biphasic one…

Dr. Körlin: The first two or three times, you will try both triangular breathing and biphasic.

Angela: Then do you gradually phase out the triangular breathing, and just focus on the biphasic?

Dr. Körlin: Yes. You will go into the music with the biphasic breathing. If you try for yourself to do the triangular breathing with music, you will find that it consumes a lot of attention. You don’t have so much space left for imagery. It is such a complex, gymnastic exercise for the brain.

Angela: Do you think it consumes more energy, when you practice the Music Breathing—consciously thinking of the breathing while listening to the music listening, versus just breathing normally?

Dr. Körlin: Yes, the least energy is consumed by breathing normally without thinking about it. I think that when you do it as an intentional activity, in the beginning, it consumes some energy because you have to consciously think and predict what the music is going to do and how you are going to follow with the breathing. After a while, you forget that. And you will do it automatically.

Angela: What do you think is the impact of Music Breathing on a person in the long run?

Dr. Körlin: In the long run, you learn to lower the stress level, lower the amount of energy that you consume in an everyday state. You are doing Silent Breathing a lot and will start doing it without thinking about it.

Angela: Thanks very much for your time.

Conclusion

After the interview, the author realized that SB is truly a very focus-oriented approach grounded in one’s bodily felt senses from the breathing mechanism. It re-strengthens the parasympathetic system of a person. Often, if one is doing SB correctly, the drawings from practicing SB usually contain supportive images, reaffirming a strong grounding sensation of a person. This grounding experience certainly explains why MB can offer a strong sense of safety, particularly if the client can intentionally dwell in the process of imaging breathing activity when accompanied by appropriately selected music. SB therefore provides a somewhat similar support level to MI. SB is definitely a good resource for many therapists. As a result, one can gain more understanding of and be clearer on the concepts of both SB and MB, particularly in the identification of the degree of activation from the music selection to regulate the WoT of the clients. One merit of MB is its accessibility, which allows clients to take more control of their own recovery. MB clients can do in-home practice that other modified GIM therapies do not offer. This in-home practice of MB is certainly good news for people with chronic illness.

A short 3–minute video clip of an interview with Dr. Körlin prior to this in-depth one was recorded and uploaded as a reference. This video clip serves as a means of promoting MB to clinicians and the general public. One can access it at this YouTube web link: https://youtu.be/FdHNfQ0mrcM. None of this short version is transcribed nor included in this article.

About the Author

Angela Shum has been a registered nurse for more than 10 years, working in health care setting across different countries and cities, including Hong Kong, Canada, and the US. Her nursing clinical experience has been extensive in various settings, including hospital, nursing home, and university.

After she earned her master’s degree in expressive therapy (specializing in music therapy and mental health counseling), she worked as a music/rehabilitation therapist at the Provincial/State hospitals in both Canada and the US. She has experiences working with clients with dementia, gambling addictions, stroke/traumatic brain injury, developmental disabilities, and in forensic psychiatry. Presently, she is residing in Hong Kong doing private practice, with her passion of promoting Focused Music Imagery, Music Breathing, GIM and Focusing Oriented Expressive Arts (FOAT®), and educating health care professionals, particularly psychiatric nursing about using these approaches for wellness.