Breathlessness is a highly aversive symptom which elicits strong emotions for most people. This naturally impacts upon relationship dynamics and is influenced by sociocultural context. The meaning of breathlessness and the diagnosis of asthma is heterogeneous and a systemic approach can be invaluable. There is limited literature related to the psychological demands of breathing difficulties. This chapter, from the perspective of a respiratory clinical psychologist, explores some key issues when working systemically with people with breathing difficulties and their loved ones. Some patients discover after detailed medical assessment that symptoms previously attributed to asthma are driven by other factors and non-pharmacological approaches may be recommended such as respiratory physiotherapy, psychology, speech and language therapy and lifestyle changes. This reconceptualization can be psychologically demanding and can trigger feelings related to stigma and a worry that clinicians might be viewing the symptoms as ‘all in their head’. This chapter summarises existing literature and uses clinical examples to discuss some key issues for clinical practice. Recommendations are then shared, including the need for clinicians to strive for safe uncertainty and cohesive interdisciplinary care, for research focussing on relationships and for political change to support effective services.