Trauma-sensitive yoga

Trauma-sensitive yoga is yoga as exercise, adapted from 2002 onwards for work with individuals affected by psychological trauma.[1][2] Its goal is to help trauma survivors to develop a greater sense of mind-body connection,[3] to ease their physiological experiences of trauma,[3] to gain a greater sense of ownership over their bodies,[2] and to augment their overall well-being.[3] However, a 2019 systematic review found that the studies to date were not sufficiently robustly designed to provide strong evidence of yoga's effectiveness as a therapy; it called for further research.[4]

Background

Psychological trauma and the body
Psychological trauma can follow from the experience of a traumatic event.

Psychological trauma occurs when an individual has experienced a traumatic event which becomes lived and relived in the body and the mind.[5][6] Trauma can trigger a chronic stress response in the body,[7][8] which may manifest as an uncontrollable and constant state of heightened arousal and fear.[3][7][9] Those with a history of trauma may also interpret this chronic stress response as a threat to their sense of self and relation to the world.[5][6][10][11] Traumatized individuals often have difficulty soothing their overactive internal sensations without relying on external stimuli, such as food, substances, or self-harm.[7][12][13] Therefore, psychological trauma is not only associated with psychological disorders such as post-traumatic stress disorder (PTSD), depression, and anxiety,[4] but also with somatic disorders.[4][14]

Though most evidence-based treatments focus on the psychological effects of trauma first and foremost,[4][5] attrition rates are still high, possibly due to heightened physiological arousal during the initial stages of exposure therapy.[4][15] Mind-body approaches offer a complementary method to traditional psychotherapy, allowing traumatized individuals to reconnect with and identify their own physical sensations.[4][13] Mind-body approaches allow participants to work through their somatic trauma memories and feel safe enough to emotionally and verbally process their traumatic memories.[4][13] Such approaches involve increasing awareness of, and attention to, bodily sensations, while emphasizing present-moment experience. In this way, they seek to counteract dissociative responses.[16][17] Finally, mind-body approaches attempt to help traumatized individuals to nurture their bodies.[7] In this way, messages from the physical body may provide information for traumatized individuals about their identities and help individuals regain ownership over their internal responses.[7][18]

Postural yoga
Postural yoga teachers may respectfully adjust a pupil's body hands-on, whereas trauma-sensitive yoga requires giving space to participants.

Postural yoga is a mind-body practice with many forms and styles. It typically includes physical postures called asanas, breathing exercises (pranayama), mindfulness, and meditation.[4][19] Postural yoga can reduce stress,[2] enhance physical health,[2][20] and heighten one's sense of self.[7]

Physiological effects

The techniques of yoga alleviate effects on the body's nervous system.[7] The mindfulness and meditation aspect of yoga allows the mind to maintain objective awareness on the body's physical sensations, while maintaining a state of calm.[7][21] The aspect of yoga geared toward breath manipulation helps to enhance capacity for emotion regulation.[7][22][23] Thus, yoga reduces the overall intensity of the stress response and improves the ability to self-soothe.[7][24]

Yoga is associated with a reduction in physiological and somatic complaints often attributable to post-traumatic stress disorder, such as pain and anxiety.[25] Research also suggests that yoga produces psychological benefits for individuals with post-traumatic stress disorder such as reduction of stress,[25][21] a decrease in depression as associated with the mindfulness component,[25][26] a greater sense of interconnectedness with others when practiced in group settings,[25][27][28] enhanced self-efficacy and self-esteem,[25] and a feeling of overall empowerment.[25][29]

Description

Trauma-sensitive yoga is a form of yoga as therapy, adapted from modern postural yoga. It was developed at the Justice Resource Institute's Trauma Center in Brookline, Massachusetts, in 2002 by David Emerson and colleagues. It was designed to promote an enhanced feeling of safety for traumatised individuals as they engage in an exercise that is focused on body awareness, which might otherwise be overwhelming for them.[2][1] It addresses the need for a trauma-informed yoga practice able to identify and mitigate potentially triggering environmental and physiological circumstances,[1][30] while still providing the psychological and physical benefits that typical yoga practice offers.

Trauma-sensitive yoga has been formulated from five core domains which if nonoptimal could produce adverse side effects among a traumatized population by reminding them of their traumas:[30]

Five Core Domains[30]Trauma-sensitive yogaModern postural yoga
EnvironmentSpace is welcoming, safe, comfortable for vulnerable studentsAny suitable space
Physical exerciseInternal sensations important, for feelings of safety, self-acceptanceAchieve particular postures
AssistsAllow space between teacher and pupilPolite hands-on acceptable
Teacher qualitiesGentle, students stay in controlOften directive
LanguageNon-directive instructionsDirective language acceptable

Key features

Themes

David Emerson has identified four clinically informed key themes in trauma informed yoga practice that have been beneficial for the trauma survivors. These include: 1) experiencing the present moment (which addresses the trauma survivors' predicament of being unable to be fully present in the moment or in their bodies); 2) making choices (which addresses the issue of lack of choice and helplessness that trauma survivors experience during a traumatic event); 3) effective action taking (which addresses the inability to escape the traumatic event that trauma survivors have experienced during the trauma incident), and 4) creating rhythms (which addresses the issue of feeling disconnected that trauma survivors continue to experience in relation to others and themselves). These themes can be integrated by the teacher all in one class, or may be used individually as a focal point of a particular class.[31]

Approach

Trauma-sensitive yoga is designed to begin gently, with a seated breathing exercise, followed by light movements.[2] While adhering to the conditions of the five core domains (i.e., physical environment, exercises, teaching style, adjustments, and language),[30] the instructor guides the class through a series of physical postures at a level of difficulty fitting the abilities of the participants.[2] In each posture, instructors encourage students to observe their internal sensations, without judgment, and to respond to them compassionately.[3] Throughout, participants are encouraged to make choices for themselves about what feels comfortable and safe in their bodies, and instructors spaciously invite students to modify any posture as needed.[2] The class ends similarly to ordinary postural yoga in a resting pose (Savasana).[2]

Certain conditions remain constant to ensure that participants feel safe, including consistency of room appearance and class structure, instructors' reminders to participants of where the exits are located, and bright lighting so that participants can see their surroundings.[32]

Mechanisms

Individuals who have experienced psychological trauma often view their internal body sensations as dangerous and foreign, and form destructive habits as a means of coping with their internal experiences.[3] Therefore, instructors strive throughout to create an environment that feels both physically and emotionally safe for the participants, thereby facilitating a healing atmosphere for traumatised individuals.[30] When students feel increased levels of safety and groundedness in their environment, they are said to be at an appropriate mid-range level of arousal for working with their traumas effectively.[6][30] In that state, they can learn to work with the physiological experiences of trauma in a more adaptive and less destructive manner.[3]

Confidentiality

Consumers of trauma-sensitive yoga may need to consider the matter of confidentiality as it differs between trauma-sensitive yoga instructors and mental health professionals.[30] Though instructors are most often required to complete at least 200 hours of yoga teacher training with a focus on trauma, confidentiality is typically not the focus of training.[30]

Evidence

Trauma-sensitive yoga is effective for improving the psychological symptoms for women who have survived interpersonal violence.[15][30] Improvements may include a reduction in symptom severity of post-traumatic stress disorder,[30][32] reduction in severity of symptoms of depression and anxiety.[2][30] Survivors of interpersonal violence who engage in trauma-sensitive yoga have reported increased feelings of safety and agency,[2][15] higher self-esteem and self-compassion, decreased feelings of isolation, greater feelings of relaxation, and a greater sense of agency over their own bodies.[25]

Practitioners state that trauma-sensitive yoga should be used only as an alternative and complementary treatment to other evidence-based treatments (e.g., psychotherapy, medication) for trauma.[16][19] Classes are designed to vary, and thus efficacy has not been established.[16] Trauma-sensitive yoga can be used as a primer to individual psychotherapy, as a means of preparing and grounding the body before uncovering stored traumatic memories,[3][19][21] and establishing a traumatized individual's buy-in for treatment.[19]

A systematic review in 2019 failed to find strong evidence that yoga was effective in PTSD, depression, or anxiety after trauma, as the studies examined were of low quality with a "high risk of bias"; they provided what would if confirmed be strongly beneficial effects with effect sizes in the range of ds=0.40—1.06. The reviewers called for further studies with "more rigorous design".[4]

References
  1. Emerson, D.; Sharma, R.; Chaudhry, S.; Turner, J. (2009). "Trauma-sensitive yoga: principles, practice, and research". International Journal of Yoga Therapy. 19: 123–128.
  2. Nolan, C. R. (2016). "Bending without breaking: a narrative review of trauma-sensitive yoga for women with PTSD". Complementary Therapies in Clinical Practice. 24: 32–40. doi:10.1016/j.ctcp.2016.05.006. PMID 27502798.
  3. Spinazzola, J.; Rhodes, A. M.; Emerson, D.; Earle, E.; Monroe, K. (2011). "Application of yoga in residential treatment of traumatized youth". Journal of the American Psychiatric Nurses Association. 17: 431–444. doi:10.1177/1078390311418359.
  4. Nguyen-Feng, Viann N.; Clark, Cari J.; Butler, Mary E. (August 2019). "Yoga as an intervention for psychological symptoms following trauma: A systematic review and quantitative synthesis". Psychological Services. American Psychological Association. 16 (3): 513–523. doi:10.1037/ser0000191. ISSN 1939-148X. PMID 29620390.
  5. Tzu, G.; Bannerman, B. (2017). "Transforming trauma into healing and being: a non-dual therapy approach". International Journal of Mental Health and Addiction. 15: 63–79. doi:10.1007/s11469-016-9659-1.
  6. Ogden, P.; Minton, K.; Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York: W. W. Norton.
  7. Caplan, Mariana; Portillo, Adriana; Seely, Lynsie (2013). "Yoga Psychotherapy: the integration of western psychological theory and ancient yogic wisdom" (PDF). The Journal of Transpersonal Psychology. 45: 139–158.
  8. Christopher, Michael (March 2004). "A broader view of trauma: A biopsychosocial-evolutionary view of the role of the traumatic stress response in the emergence of pathology and/or growth". Clinical Psychology Review. 24 (1): 75–98. doi:10.1016/j.cpr.2003.12.003. PMID 14992807.
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  16. Pradhan, B.; Kluewer, J. D.; Makani, R.; Parikh, T. (2016). "Nonconventional interventions for chronic post-traumatic stress disorder: ketamine, repetitive trans-cranial magnetic stimulation (rTMS), and alternative approaches". Journal of Trauma & Dissociation. 17: 35–54. doi:10.1080/15299732.2015.1046101. PMID 26162001.
  17. Pradhan, B. K. (2014). Yoga and mindfulness based cognitive therapy--A clinical guide. Switzerland: Springer International.
  18. Berg, A. L.; Sandahl, C.; Bullington, J. (2010). "Patients' perspective of change processes in affect-focused body psychotherapy for generalised anxiety disorder". Body, Movement and Dance in Psychotherapy. 5: 151–169. doi:10.1080/17432979.2010.494853.
  19. Macy, R. J.; Jones, E.; Graham, L. M.; Roach, L. (2018). "Yoga for trauma and related mental health problems: a meta-review with clinical and service recommendations". Trauma, Violence, and Abuse. 18: 35–57.
  20. Ross, Alyson; Friedmann, Erika; Bevans, Margaret; Thomas, Sue (August 2013). "National survey of yoga practitioners: Mental and physical health benefits". Complementary Therapies in Medicine. 21 (4): 313–323. doi:10.1016/j.ctim.2013.04.001. PMC 3721070. PMID 23876562.
  21. Follette, Victoria; Palm, Kathleen M.; Pearson, Adria N. (March 2006). "Mindfulness and trauma: implications for treatment". Journal of Rational-Emotive & Cognitive-Behavior Therapy. 24 (1): 45–61. doi:10.1007/s10942-006-0025-2.
  22. Granath, Jens; Ingvarsson, Sara; von Thiele, Ulrica; Lundberg, Ulf (March 2006). "Stress Management: A Randomized Study of Cognitive Behavioural Therapy and Yoga". Cognitive Behaviour Therapy. 35 (1): 3–10. doi:10.1080/16506070500401292.
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  25. West, J.; Liang, B.; Spinazzola, J. (2017). "Trauma sensitive yoga as a complementary treatment for posttraumatic stress disorder: a qualitative descriptive analysis". International Journal of Stress Management. 24 (2): 173–195. doi:10.1037/str0000040. PMC 5404814. PMID 28458503.
  26. Schreiner, Istvan; Malcolm, James P. (September 2008). "The Benefits of Mindfulness Meditation: Changes in Emotional States of Depression, Anxiety, and Stress". Behaviour Change. 25 (3): 156–168. CiteSeerX 10.1.1.452.7892. doi:10.1375/bech.25.3.156.
  27. Berrol, Cynthia F. (1992). "The neurophysiologic basis of the mind-body connection in dance/movement therapy". American Journal of Dance Therapy. 14 (1): 19–29. doi:10.1007/bf00844132.
  28. Macy, Robert D.; Johnson Macy, Dicki; Gross, Steven I.; Brighton, Pamela (2003). "Healing in familiar settings: Support for children and youth in the classroom and community". New Directions for Youth Development. 2003 (98): 51–79. doi:10.1002/yd.44. PMID 12970987.
  29. Cloitre, M.; Courtois, C.; Ford, J.; Green, B.; Alexander, P.; Briere, J.; van der Hart, O. (2012). "The ISTSS expert consensus treatment guidelines for complex PTSD in adults". ISTSS. Archived from the original on 2015-02-15. Retrieved 2018-10-17.
  30. Nguyen-Feng, V. N.; Morrissette, J.; Lewis-Dmello, A.; Michel, H.; Anders, D.; Wagner, C.; Clark, C. J. (2018). "Trauma-sensitive yoga as an adjunctive mental health treatment for survivors of intimate partner violence: a qualitative examination". Spirituality in Clinical Practice. 6 (1): 27–43. doi:10.1037/scp0000177.
  31. Emerson, David; Hopper, Elizabeth (2011). Overcoming trauma through yoga: Reclaiming your body. Berkeley, California: North Atlantic Books. pp. 192–259. ISBN 978-1-58394-533-9.
  32. Price, M.; Spinazzola, J.; Musicaro, R.; Turner, J.; Suvak, M.; Emerson, D.; van der Kolk, B. (2017). "Effectiveness of an extended yoga treatment for women with chronic posttraumatic stress disorder". The Journal of Alternative and Complementary Medicine. 23: 300–309. doi:10.1089/acm.2015.0266. PMC 5393408. PMID 28121466.
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