Trauma Sensitive Yoga in Therapy Bringing the Body into
Treatment
Visit the link below to download the full version of this book:
https://medipdf.com/product/trauma-sensitive-yoga-in-therapy-bringing-the-body-i
nto-treatment/
Click Download Now
FOREWORD
Originally, in the first couple sessions, part of me was hyper-alert of being
in the space and distrustful of yoga, ya know, what is this really going to
do for me? I was very skeptical. . . .
[Over time], I know it’s kind of strange, but it’s almost as if my mind
became more connected to my thoughts and what I did to my body. . . .
[Yoga] gave me structure, like a place to start building or become more
aware. I think it gave me a starting place.
—Trauma-sensitive yoga research participant
AS A HELPING PROFESSIONAL, EVEN IF YOU HAVE NEVER used
yoga with a client before, you can likely imagine a reaction such as the one
depicted above. In fact, you may even share some of the skepticism
described in the first part or have similar questions about the use of yoga in
treatment. Common questions I have been asked include the following: If
other forms of therapy have not successfully eliminated symptoms, how is
yoga going to be any different? How can yoga help in healing the deep
wounds of trauma? How can yoga supplement, or be integrated in, the
psychotherapy process? Is yoga a worthy compliment to psychotherapy? By
way of introducing David Emerson’s practical and creative ideas on how to
integrate yoga into the therapy room, I will attempt to answer these
questions and offer my thoughts on how and why yoga is an important and
useful adjunct to therapy. My perspective and ideas are based on my clinical
experiences and research with adult female survivors of childhood
interpersonal trauma, referred to as complex trauma.
My journey into yoga began in 2004 after a significant personal loss.
Practicing yoga became a source of hope and healing during a time of
turmoil. Like many of the clients I now work with, I found a physical,
psychological, and emotional outlet through yoga, and my personal journey
quickly became an integral part of my professional practice. As a
counseling psychologist who studies posttrauma recovery and healing, I
always look for ways to help my clients decrease symptoms and improve
overall health and wellness. After noticing yoga’s profound effects on my
own emotional well-being and recovery, I began to wonder how people
struggling with complex trauma might respond to yoga. Indeed, a growing
body of literature has unequivocally shown the benefits of yoga for many
medical problems (e.g., diabetes, arthritis, fibromyalgia, cancer) and mental
health issues (e.g., depression, anxiety), so it seemed reasonable to imagine
possible benefits for trauma survivors.
As I ventured toward using yoga as a therapeutic outlet, I took yoga
teacher training to educate myself further and began researching yoga as a
treatment for posttraumatic stress disorder (PTSD).. In collaboration with
Bessel van der Kolk’s Trauma Center, I focused my research on examining
the effects of TSY) on adult survivors of complex trauma.
What we know about complex trauma is that the symptoms that arise in
the aftermath can disrupt functioning well into adulthood and pervade all
domains of a person’s life. When our self-protective capacities are
consistently overwhelmed by repeated exposure to trauma it can be toxic to
our bodies, and survivors often find themselves in a cycle of hyperarousal
and dissociative numbing. The experience of complex trauma and resulting
autonomic instability can lead to a feeling of being out of control within
one’s own body and life. Trauma survivors describe intolerable physical
sensations and somatic complaints, problems with affect and impulse
regulation, deficits in attentional capacities, poor interoceptive awareness,
and negative self-perception.
This complex array of symptoms can pose significant challenges in
treatment. After all, how can we expect clients to successfully engage in
talk therapy when they disconnect from inner experiences, struggle to stay
connected to their present experiences, and lack the skills to tolerate affect
elicited by trauma-related stimuli, such as when asked to process traumatic
memories? Psychotherapy can be effective in treating various aspects of
PTSD, such as confronting relational difficulties in a supportive
environment, identifying unhealthy patterns, and setting goals for engaging
in self-care. However, physiological symptoms, somatic complaints, and a
lack of interoceptive awareness may be more difficult to treat with “top-
down approaches” (i.e., cognitively oriented treatments focusing on
thoughts and emotions). This leads us back to the question about how yoga
can help.
How is yoga going to be any different from other treatments?
Yoga—defined here as a combination of physical forms, focused breathing,
and purposeful attention or mindfulness—seems to be a useful complement
to trauma treatment because it directly targets the very symptoms that other
approaches struggle to address by using the body purposefully (i.e., a
bottom-up approach). TSY in particular aims to cultivate awareness of the
mind-body connection and to build self-regulation skills to address the
ways in which trauma is held in the body.
A randomized controlled trial (RCT), conducted by Bessel van der Kolk
and colleagues (van der Kolk et al., 2014), examined the effects of TSY on
women with complex trauma who were unresponsive to traditional
psychotherapy. Women in the 10-week TSY course were more likely than
women in the control group to no longer meet criteria for PTSD
posttreatment. The TSY group also showed significant decreases in
depressive symptoms and negative tension- reduction behaviors (e.g., self-
injury). Furthermore, a long-term follow-up conducted by Alison Rhodes
(2014) found that the frequency of continuing yoga practice, regardless of
group assignment in the study, was a significant predictor of long-term
outcomes. At 1 to 3 years posttreatment, women who practiced yoga
following the study were more likely to show a loss of a PTSD diagnosis
and greater reductions in PTSD and depressive symptoms (Rhodes, 2014).
These studies suggest that the addition of TSY to treatment may lead to
long-term improvement in symptoms that had previously been considered
unresponsive to other interventions.
How can yoga help to heal the deep wounds of trauma?
While past research has demonstrated the profound effects of TSY as an
effective complement to traditional psychotherapy, the specific mechanisms
by which TSY generates such change were still unclear. In an attempt to
gain some understanding, I talked with participants 2 months after they
completed the 10 weeks of TSY. Using semistructured interviews in a one-
on-one setting, I asked the women to share their personal experiences of
TSY and the perceived changes in their lives due to their use of TSY.
Throughout the interviews, the women attested to the tenaciousness of
complex trauma symptoms and their nonresponsiveness to years of
treatment. Through their experiences with TSY, they reported symptom
reduction, improved quality of life, and personal empowerment. Through
the sharing of their stories, the women provide some answers to this
question about how yoga can help in healing the deep wounds of trauma. I
outline some of their insights below.
Consistent with typical symptoms of complex trauma, participants in
the study described how, prior to the TSY program, they often felt
disconnected or dissociated from their present reality. However, the
integration of purposeful attention with physical postures and focused
breathing seemed to improve participants’ capacity for present-moment
awareness. They became increasingly able and willing to notice how they
were feeling in their body and formed greater tolerance for emotional states
and bodily sensations, as they could experience them in a safe way, rather
than from the lens of past trauma. One participant said she “started to be
able to recognize emotions . . . feel what’s inside . . . instead of just trying to
get rid of it.”
In addition to greater interoceptive awareness and tolerance of inner
sensations, TSY also instilled a sense of ownership over one’s physical
body that many women had lost through their traumatic experiences.
Women started to recognize that their bodies belong to them, that their
bodies were under their control, and that they could be safe in their bodies.
This involved a literal awareness of an embodied self, an acceptance of
one’s body with less judgment and criticism, as well as a sense of being in
charge of how to move, use, and treat one’s body. For many of the
participants, a growing awareness of ownership and control over one’s body
also led to appreciation for one’s body, including a deeper sense of
responsibility for self-care and the tendency to “listen to [my body] a lot
more now.” Similarly, participants said they began to feel more confident in
identifying and employing appropriate behavioral responses in emotionally
difficult situations, including when they triggered or experienced
flashbacks. Through TSY they were able to build skills for emotion
regulation through the use of physical postures and breath, and “have these
ways to soothe and comfort myself, and I don’t have to be stuck in the
flashbacks.”
The increased ability for regulation of internal states also inspired a
sense of control in one’s life and, in turn, hopes for new possibilities in the
future. For some, this included willingness to take action to improve their
health (e.g., stop smoking or drinking) and for others this consisted of
making changes to improve quality of life (e.g., pursuing professional
passions).
Like many survivors of complex trauma, the women also experienced
long-lasting damage to their sense of self, such as feelings of shame,
hopelessness, and worthlessness. However, through TSY, participants began
to change their language about themselves, express less self-judgment, and
even cultivate self-acceptance. Likewise, participants acknowledged an
appreciation for all they had been through.
Issues of interpersonal functioning (e.g., isolation, lack of trust,
unhealthy boundaries) resulting from complex trauma caused some of the
most significant pain for participants. However, as participants began to feel
more connected to, and accepting of, themselves they also began feeling
more comfortable engaging authentically in relationships and setting
healthy boundaries.
While the TSY classes focused specifically on present-moment
experiences in the body, the women in the study described benefits both on
and off the mat. The women gained skills for finding a calm presence in and
out of class, they developed a stronger connection to themselves and to
other people in their lives, and they recognized their ability to choose how
to move their bodies and choose the direction of their lives.
How can TSY supplement, or be integrated in, the
psychotherapy process?
The impact of TSY on trauma survivors can clearly be quite significant.
Ideally, the integration of TSY with ongoing psychotherapy would allow for
the synthesis of top-down and bottom-up processing in the treatment
setting. Such an approach rests on the belief that a greater capacity for
emotion regulation, interoceptive awareness, and self-acceptance may
facilitate deeper interpersonal connections (including the therapy
relationship). Indeed, some participants expressed greater ability for
emotional expression and exploration in therapy for these reasons.
Integrating TSY into the therapy room may seem daunting at first. You
may wonder about space limitations or whether clients will feel comfortable
doing yoga forms in the therapy room. While this book will walk you
through all the ins and outs and address these curiosities in detail, here are
some brief thoughts regarding such concerns.
From a practical standpoint, many of the movements and forms in TSY
are done in a chair, making this approach easily adaptable to the individual
therapy room. The information contained in this book will provide you with
many examples. Additionally, some of the study participants offered insight
into specific attributes of the teacher and environment that made them feel
comfortable and able to fully engage in moving their bodies in a therapeutic
setting. I would suggest that these characteristics (outlined below) would
also be important for a therapist in a clinical setting.
The tone of the teacher’s voice as well as the words the teacher chose
were quite important to the facilitation of a sense of safety and comfort.
More specifically, a gentle tone and environment of acceptance was
appreciated as the teacher was perceived as “extraordinarily kind and
patient” and never asked the women to “do more than we could.”
Another important aspect was the use of invitatory language (e.g., “if
you like” or “when you feel ready”), which highlights choice, presence, and
awareness of the body. Furthermore, providing verbal modifications and
alternative forms was an important facet to emphasizing choice and
reminding the women to pay attention to what feels right in their body.
Using invitatory language and emphasizing choice are often helpful in a
psychotherapy setting, and this is certainly the case when incorporating
TSY. This may be particularly important if and when a client is not ready to
verbally address trauma-related material, as we can offer helpful
alternatives and “ ‘meet clients where they are.’ ”
A sense of safety in the room was another critical aspect as it allowed
participants to more easily remain engaged in the TSY classes. For
example, most participants were grateful for the lights being on, the private
room, and the focus on verbal assists versus physical assists. Given the
boundaries typically adhered to in therapy, these are likely good guidelines
for a psychotherapy setting as well.
Is yoga a worthy complement to psychotherapy?
The information shared above reflects the valuable role that TSY may have
in the treatment of complex trauma. The focus on bottom-up processing in
TSY and the emphasis on movement, breath, and bodily sensations seem to
help survivors learn to regulate affective arousal by raising awareness of
internal states and reorganizing the physiological responses connected to
symptoms. Survivors are then more able to experience emotions safely in
the present moment. Whereas recalling the trauma may have elicited
reactions such as hyperarousal or dissociation in the past, with these
physiological changes and skills for self-regulation, participants are able to
manage the trauma-related physical sensations or feelings as they arise.
Furthermore, for a number of participants, a greater ability to tolerate
trauma-related stimuli also meant greater ease in verbally expressing and
processing their experiences in psychotherapy.
While complex trauma has posed some very difficult challenges for
treatment, TSY offers an additional approach for working with symptoms of
complex trauma and creates new pathways for healing and personal growth.
I hope that this book offers hope and inspiration to you. Remember that
yoga is a practice of living the process, and David Emerson is a wonderful
guide to have on this journey. Enjoy. You are in good hands.
—Jennifer West, PhD
INTRODUCTION
AT THIS POINT IN HISTORY, THANKS TO THE WORK OF
MANY great practitioners and scientists, we have collectively developed a
solid understanding about how traumatic experiences affect human beings.
The picture developed by such luminaries as John Eric Erichsen, Jean-
Martin Charcot, Pierre Janet, John Bowlby, Mary Ainsworth, Lenore Terr,
Judith Herman, Rachel Yehuda, Bessel van der Kolk, and many other
pioneers reveals the devastating impacts of trauma on our minds, our
bodies, and our relationships. Thanks to continued research in such fields as
human development, neurobiology, and epigenetics, our understanding of
trauma and its impacts continues to deepen and expand. However, because
of the degree of suffering that trauma represents in human terms, from
survivors of war, violence, torture, human trafficking, and terror to
survivors of chronic childhood abuse and neglect to victims of domestic
violence and sexual assault all across the globe, the time has come for us to
pivot from our understanding of trauma toward developing and
implementing new, effective treatments. Too many studies that indicate the
impacts of trauma tend to resort to the hope of a psychopharmacological
solution; while perhaps drugs can take the edge off of symptoms (and may
even one day erase memories), it is extremely doubtful that they will ever
truly heal people from the most insidious reality of relational trauma: that
we were deliberately hurt and betrayed by our fellow human beings (most
egregiously, by those who were supposed to protect us). TSY is intended
most pointedly for people who have experienced this kind of interpersonal
trauma and, though I allude to it here, I will explain the rationale in detail.
My basic argument throughout this book is that if we want to treat
people who have experienced interpersonal trauma effectively we must use
the clinical knowledge available to us and be open to new interventions that
recognize the deep and complex nature of these traumatic experiences and
not reduce trauma to a set of symptoms that can be medicated away, or for
which a simple change in cognitive frame or behavioral patterns will
suffice. Our treatments must match the complexity and nuance of trauma
itself, and one aspect of the whole person that must not be overlooked or
minimized is the experience of being embodied. For it is the body, the result
of billions of years of evolution, that ultimately defines us as being human.
In this book I explain the fundamentals of trauma-sensitive yoga (TSY),
an intervention based in and completely reliant on the body, as an
adjunctive treatment for individuals impacted by trauma. My intention is to
offer a rationale for its use, describe the evidence accumulated on its behalf
so far, and provide specific techniques and practices that can be utilized by
clinicians and clients as they work together to heal one of the most insidious
wounds a human being can experience.
In 2003 yoga was first used as an adjunctive treatment for trauma at the
Trauma Center in Brookline, Massachusetts. From its beginning, the
Trauma Center Yoga Program has been a collaborative effort among yoga
teachers, clinicians, neuroscientists, and our clients. In keeping with our
desire to accumulate objective data as to the efficacy of our intervention,
one of the first steps we took was to create a small pilot study to measure in
a clinical setting the impact of yoga on adult survivors of chronic childhood
abuse and neglect. Our concern was that our clients as a group reported
explicitly or demonstrated in various ways a deep and abiding hatred for
their bodies, and we did not see a talk-based approach to therapy as being
an adequate way to engage such visceral self-hatred. We thought we could
use yoga as a way to help people to befriend their bodies and that this
newfound friendliness would contribute to positive therapeutic outcomes.
Therefore, as a team, the first measurement we came up with was a body
awareness scale that we could use to measure trauma sufferers’ sense of
themselves and relationship to their physical beings. This instrument was
proprietary so it had never been used or tested in any other study, but we
wanted to see if doing yoga could indeed change a traumatized person’s
perceptions of her body. In addition we decided to compare our yoga group
to a dialectical behavior therapy (DBT) group that was ongoing in our
clinic. We chose DBT for comparison because it is a treatment often used
for trauma survivors and it is primarily a cognitive approach as opposed to
our use of yoga, which is primarily physical. I should say that, at this point
in our work, we referred to our intervention simply as “yoga” or “gentle
yoga.” It wasn’t until we really started to establish the theoretical
underpinnings and specific methodology behind our approach that we
coined the specific term trauma-sensitive yoga.
What did we learn as a result of this simple survey and comparison?
The yoga group did indeed feel much better about their bodies, and the
DBT group felt the same or worse about theirs (van der Kolk, 2006). This
simple result in our small pilot study encouraged us to look further into the
possibilities of yoga as a beneficial intervention within the context of
trauma treatment.
After a few years we were able to conduct another, slightly larger pilot
study that was also positive in terms of body perception, this time
comparing our group of trauma survivors with a group without a significant
trauma history. Then, in 2009, we were fortunate enough to receive the first
grant ever awarded by the National Institutes of Health (NIH) to study the
use of yoga for trauma. For the purposes of this study, in order to generate
some empirically sound data, we needed to study the effects of our yoga
protocol on symptoms associated with posttraumatic stress disorder
(PTSD). In this book I discuss some of the differences between PTSD and
other trauma frameworks that, while not officially diagnostic at the time of
this writing, nonetheless, more accurately describe the clients for which
TSY was developed. These phenomena include complex posttraumatic
stress disorder (CPTSD), complex trauma, and developmental trauma, all of
which imply a more prolonged exposure to interpersonal trauma, such as a
child growing up in an abusive home, as opposed to a single incident, like a
car accident, which might result in a PTSD diagnosis. So, while the subjects
in our study were survivors of multiple, interpersonal traumas, usually
beginning in early childhood, everyone also had to qualify for a PTSD
diagnosis in order for us to be able to measure any clinically relevant
changes that might result after 10 weeks of TSY. Our hypothesis was that
TSY participants would show a clinically significant reduction in PTSD
symptomology and this is, in fact, what we found (van der Kolk et al.,
2014). As a result we are now able to say that TSY is a promising
intervention that has clinical relevance for people in treatment for PTSD.
However, as I indicated, there is more to the story because our study
also included in-depth interviews with TSY participants that were intended
to address the deeper meaning of the TSY experience in relation to the
impacts of the complex, long-term, interpersonal trauma that our study
subjects had experienced. These qualitative interviews, designed and
implemented by Jennifer West (West, 2011) and written about by her in the
foreword to this book, indeed revealed a more complex picture. PTSD
symptoms in particular were positively affected after 10 weeks of TSY and
participants also reported that the TSY practice had an impact on their lives
beyond the PTSD symptom set; that is, not just symptoms were affected but
also participants experienced themselves in the world and in relation to
other people in profoundly new ways.
So we concluded that TSY is a relevant intervention for people with
PTSD who also have complex trauma histories. This indication, which was
revealed in our clinical trials, also aligns with our personal experience of
using TSY with complexly traumatized individuals, both male and female,
youths and adults, in a wide variety of settings. As a result of our clinical
trials, the Trauma Center Yoga Program developed a team of qualified yoga
teachers who have collectively taught thousands of TSY sessions since
2003 to groups and individuals suffering from complex trauma, including
men and women who grew up in abusive or neglectful environments, as
well as survivors of interpersonal violence, sexual assault, war, torture, and
more. Over the course of this book, I will share examples of some of these
stories with you (please note that all names used in the stories throughout
are pseudonyms, and all of the case stories are composites based on clinical
experiences). Ultimately, this book is intended to equip you with
information and techniques that you can use in your therapy work; it should
not simply serve as an interesting read, though I hope it is that as well.
I begin in Chapter 1 by exploring the principles and parameters of TSY,
including how it differs from traditional yoga and other somatic (or body-
based) models of therapy; what its theoretical underpinnings are; which
clients can benefit from it most; and who might not be best suited to take
advantage of the therapeutic qualities of TSY.
The remaining chapters highlight the core aspects of TSY methodology.
I will introduce the key concepts of interoception, choice making, and
action taking, and I examine how to use TSY for such therapeutic goals as
working with rhythm and movement, being present, and sensing muscle
dynamics. Throughout, I offer a look at both why and how to use various
aspects of the treatment under different conditions and with different
clients, in order to maximize the results. While by no means being
exhaustive, the book will end with a “portfolio” chapter that presents a
number of illustrated yoga forms that readers can use as soon as they and
their clients feel ready to do so.
Before we delve into the rest of the book, I’d like to highlight an
important, foundational concept of TSY: you do not need to be a yoga
teacher, or really have any prior experience with yoga for that matter, in
order to incorporate TSY into your practice. In fact, this book assumes that
most readers are not yoga teachers but are approaching the material as
qualified mental health clinicians or the equivalent. You will rely first and
foremost on your clinical training in order to help you establish when TSY
might be appropriate for a given client and then to be able to titrate its use,
depending on your assessment of its efficacy. That said, the more familiarity
you develop with the contents of this book and with specific TSY practices,
the more integrity the intervention will have. My assumption is that if you
conclude TSY is good for your client you will also notice that in many
fundamental ways it is also good for you so you will be interested in
practicing it for yourself, and thereby strengthen your effectiveness as a
facilitator!
My hope is that this book, while providing some insight into the nature
and impacts of trauma exposure, will be a useful guide to a new treatment
modality that has the potential to increase the benefits of your clinical work.
Interlude
When the truth is finally recognized, survivors can
begin their recovery.
—Judith Herman, M.D.
Historical truth is established by what gets told, not by
what actually happened.
—Daniel N. Stern
Judith Herman, a pioneer in the field of modern trauma study and treatment,
suggests that “when the truth is finally recognized, survivors can begin their
recovery.” But what does it mean to “recognize truth”? What is truth? It
may be that the truth Dr. Herman is pointing to here is what one remembers
about the past. Indeed, many trauma-informed therapists believe that it is
critical for survivors to have access to this kind of truth: that which we
remember. However, Daniel N. Stern, a pioneer in the field of
developmental psychology, an expert in infant development, and the author
of the book The Interpersonal World of the Infant, says that the “historical
truth is established by what gets told, not by what actually happened.” Now
we have to consider our relationship to the truth: is it something we know
or is it something we tell? In fact, with trauma, there has historically existed
a tension between what actually happened and what is told about it. One
way to resolve this tension would be to decide what is more important: what
is told or what actually happened. TSY was developed in a context where
what actually happened matters more than what is told about it. Further, the
truth of “what actually happened,” which Stern calls our attention to, may
not be something carried in our explicit memory and therefore may not be
something we can either fully recall or tell someone else about. It may be
something that only our body knows and remembers. In fact, it may be
something that we cannot speak of but that we can feel with great clarity
right now in our bodies: the eloquence of what we feel but cannot tell. So
the truth of memory and cognition is not the only kind of truth that is
important to trauma healing. What I feel in my body right now, in the
present moment, is at least as important as what I remember about the past
and what I tell about it.
This book demonstrates that it would be equally valid in the context of
trauma treatment to say that, when the truth is finally felt and acknowledged
in the body, survivors can begin their recovery.
