WHAT IS TRAUMA-SENSITIVE YOGA?
THIS CHAPTER WILL INTRODUCE TRAUMA-SENSITIVE YOGA (TSY) as a clinical intervention. In order to give as full a picture as possible, I will explore both how TSY differs from mainstream yoga and other somatic models of trauma treatment as well as the theoretical underpinnings of TSY within which I provide an overview of the condition that it is intended to treat (called complex trauma). In order to define complex trauma, I will need to review some of the clinical work that has led to the specific framework as well as some other pertinent clinical material. My presentation of the clinical material is by no means intended to be a complete survey of the literature on trauma. Readers interested in more in-depth works on the subject will find a good place to start within the references section. In defining complex trauma, I begin at a very particular historical point and focus only on what has led me to develop this approach to treatment.
Let’s begin by investigating some ways in which TSY differs from more mainstream yoga.
How does TSY differ from regular yoga?
Yoga is composed of a vast multitude of practices that have a rich, complex, and ancient history. Because yoga as a phenomenon is so convoluted it would be folly to attempt a concise definition. It is more accurate to say that yoga is supple enough to be many different things to many different people. However, in an effort to find a common denominator, I would suggest that people practice yoga because they want to live more fully. Yoga practitioners are curious about the potential that being alive affords them. So whether the practices are more mystical and esoteric in nature or are more grounded and physical, those who take up a yoga practice, whether they are seekers in ancient India or young women in modern-day New York City, share a common bond, which is to know more about themselves and about what it means to be human. Because it is well outside of the scope of this book to go into the historical record in any detail, readers who are interested can find many great resources that investigate the origins and philosophy of yoga as it has existed and evolved over the millennia (one place to start is Feuerstein, 1998).
So, while we have narrowed a definition of yoga down to practices undertaken through a desire to live life more fully, we must next consider the current historical period and how yoga has generally come to be practiced. In that regard, as of the writing of this book, yoga is primarily practiced as a physical discipline that utilizes various body forms in order to strengthen and stretch muscles. In addition to the physical emphasis, other common aspects of yoga in its current iteration are breathing practices and, one of the key buzzwords of our time, mindfulness, which is essentially synonymous with purposeful attention (more on this in Chapter 2). TSY borrows from all of these components: there is an overarching implication that people engaged in TSY want more from life than is currently available to them; we focus on physical forms; we use some simple breathing practices; and we purposefully direct our attention. In these ways TSY is similar to most yoga classes that exist today. However, it is not primarily the external characteristics that distinguish TSY from other types of yoga (though there are a few worth examining), but rather how the material is presented; whether or not yoga becomes a treatment for complex trauma hinges on the presentation.
While the bulk of this book focuses on how to present yoga so that it can become a treatment for complex trauma, let’s begin by looking at some general principles of TSY that make it distinct. I will present these principles in contrast to what is typical in what I call a “regular” yoga class, which is my shorthand for a yoga class you are most likely to find in an average Western city. I do recognize that in reality not all yoga classes are the same. Along with the way that forms, breath, and mindfulness are presented in regular yoga versus TSY, I will also consider how language is used in both contexts.
Forms
In most regular yoga classes the term “pose” is used to refer to each of the postural exercises: that is, Tree Pose, Happy Baby Pose, Eagle Pose, and so on. Because we work with many people who have been made to literally pose for an abuser in either a sexual or exploitative way we realized we had to find another term. Even for our clients who have not experienced sexual exploitation, like some of our war veterans, the term “pose” implies an externalization of the process that implies that what we are doing is more about what it looks like from the outside rather than what it feels like. For these reasons in particular we settled on the term “form” to describe the postural exercises so I use this term going forward.
While TSY uses yoga forms that may show up in any yoga class anywhere, the emphasis is not on the form itself. That is, the focus is not on the external expression of the form but rather on the internal experience of the practitioner. There is no emphasis on “getting a form right” or on pleasing some external authority (namely, the yoga teacher or the clinician). The focus is instead on the practitioners’ experiences with the given form as they perceive it. This kind of orientation, from the external to the internal, is one of the key shifts that makes TSY a treatment for complex trauma, and we will come back to this in many ways throughout the book. By valuing the internal perspective over the external in everything we do and say, we send a clear message about power dynamics: with TSY, power resides within the subjective purview of each individual and is not externalized or centralized in the teacher.
So we experiment with different ways of moving our bodies and different shapes that our bodies can make but only so that we have an opportunity to feel something, not so that we can try to mold ourselves to someone else’s idea of a form.
The form-based, or body-based, quality of TSY is, however, critically important to the whole project. I would speculate that it is the very fact that we are always working within the context of a yoga form, something visceral and body-based and not in the context of cognition, that gives TSY its particular value as part of the therapeutic process for trauma survivors. For example, imagine that your client tells you that for the past several months when she had her lunch break during work she couldn’t feel whether or not she was hungry and this has caused her a great deal of anxiety. Furthermore, your client might tell you that her consternation around food reminds her of never having enough to eat as a child. It would be possible to spend the therapy session talking about that past experience, trying to make sense out of it in some way. It would also be possible to use the therapy session to plan for what to do the next time she has a lunch break and can’t feel whether or not she is hungry. A third option would be to spend the session talking about the meaning of food for your client and wondering if perhaps the idea of nourishment is a fundamental traumatic experience. Each of these possibilities may have therapeutic value but they are all indisputably abstract, theoretical, cognition-based exercises: contemplating the past, planning for the future, or trying to create meaning, in this case connecting an inability to recognize what kind of food would be satiating to past trauma.
TSY offers another possibility that also addresses some core issues but in a different way. The client and therapist might employ part of the session to experiment with using a yoga form to practice feeling something like having feet on the ground or contracting or lengthening a muscle. While your client may have told you about her distress at not being able to feel hunger with TSY you and your client will get to practice feeling something in the body right in the moment and choosing what to do about it in real time. In order for this kind of intervention or practice to make sense, we need to understand the problem as one of not being able to feel any internal state and not just specifically hunger. If that is the case, we can use a yoga form to practice feeling and choosing what to do in the body with the understanding that it might impact the very same mechanisms that allow us to feel and respond to hunger. In fact, in our experience with TSY at the Trauma Center, feeling a muscle do something is as valid and equally as important as feeling hunger.
I explore this idea in more detail in Chapter 2 but for now we are recognizing that the forms themselves are not important but rather it is the opportunities they offer to have felt experiences in our body that make forms meaningful in the context of TSY. In most regular yoga classes there are goals related to the forms themselves, like holding a form longer or stretching further or making your body conform more fully to the teacher’s ideal.
Breath
In TSY, we experiment with breath but we do not prescribe a way to breathe. In other words, the facilitator does not assume that one way of breathing is inherently better than another way of breathing and, therefore, does not present the material that way. In most regular yoga classes, breath is highly prescriptive, where one way of breathing is presented as “better” than another and the goal is to breathe in the “better” way. For example, it is common to go to a yoga class and hear the teacher say something like, “Extend your out breath; this will help you stay calm.” Therefore, it is clear to the student that a long out breath is better than a short one. Once a clinician at the Trauma Center was doing TSY with a war veteran and he invited him to try to extend his out breath a little bit. The veteran became very upset and said that, in the Marines, you were taught to pull the trigger of your gun on the out breath. He was a sniper and had killed many people on an out breath. In this case, simply exhaling for a longer period was not calming or soothing, no matter what the yoga teacher (or clinician) says. For this veteran, a long exhale caused him a great deal of anxiety. For us this was an important lesson in complex trauma treatment: the client’s subjective experience is more important than any external idea of how the practice is or “should be.” Breath, like form, is presented as an opportunity to experiment with options without any coercion or expectation of outcome (more on breath in Chapters 6 and 7).
Mindfulness
One simple definition of mindfulness is that it is the purposeful direction of attention toward an object (i.e., a sound, a smell, a taste, an emotion, or a body experience). Jon Kabat-Zinn, a modern proponent and popularizer of mindfulness, says, “Mindfulness means paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994, p.4). When mindfulness comes up in a regular yoga class, it could be anything from paying attention to what you are doing with your body to what you are thinking or what kinds of emotions are coming up. In TSY we also experiment with the purposeful direction of attention but the object of mindfulness is always the same: the body experience. We are not interested in any other objects: not thoughts, feelings, emotions, sights, sounds, or smells. With TSY, any time the facilitator invites the direction of attention, it is toward what is felt in the body. There is a word for this kind of attention to felt experience in the body that is probably the single most important word in this entire book: interoception. There will be much more on this in the next chapter and the chapters that follow but, for now, please consider that when we talk about mindfulness in TSY it is always connected to interoception.
Language
The language of the TSY facilitator is critically important and must be chosen with great care and precision. In most regular yoga classes it is common to hear the frequent use of instructions or commands like “raise your right arm” or “place your right foot forward and your left foot back.” With TSY we never speak in commands and instead shift entirely to what we call invitatory language. Invitatory language requires that everything you do with TSY is an invitation to your client, including whether or not they do any yoga at all! So “would you like to try a little bit of yoga?” would be an appropriate way to introduce TSY. Then you need to respond to your client’s choice: yes or no. They may very well say, “I don’t know,” because not knowing what to do with the body is a common phenomenon with complex trauma as we will see. In that case you could offer to look at this book together or give them a chapter or two to take home and read if they are interested. The key point is that nothing you do with TSY is a command.
Once you get into the forms themselves, the encouragement for the facilitator is to precede every cue with an invitatory phrase such as “if you like” or “when you are ready.” For example, “If you like, you could experiment with lifting one leg” or “When you are ready, you may wish to experiment with lifting your arms.” When presented in this way, every action becomes an opportunity for the student to ask herself, “Do I want to lift my leg?” or “Am I ready to lift my arms?” Maybe she decides she is not ready to lift her arms and she pauses for a moment. For traumatized people who may not be used to making these kinds of decisions about what to do with their bodies, invitatory language may be very difficult to deal with because they may not know what they want to do; this is very common. But giving your clients real invitations and allowing them opportunities to consider what they want to do and when they want to do it are also key parts of the treatment.
When you set this kind of invitatory tone and stick with it, your client will learn that he is in charge of what he does with his body. This includes the fact that he can always stop doing TSY at any time for any reason (you can remind him of this possibility). You are not telling your client what to do with his body: he is figuring it out for himself with your support. If you, as the TSY facilitator, notice that your client is becoming frustrated or upset in some way by the practice (or he tells you so) perhaps ask if he would like to stop the practice for now so that he has a chance to decide for himself. He is still able to keep that element of control though you may offer options. The encouragement is that once you introduce TSY everything that your client does with his body is invitational and under his control.
How TSY differs from other somatic models
Now that we have defined some ways in which TSY differs from regular yoga practice, I would like to shift toward the clinical domain and explain how TSY fits in among other body-based interventions for trauma that have arisen over the past few decades. Though the field of trauma treatment is still primarily anchored in the psychodynamic, psychotherapeutic model that emphasizes cognition (that is, centered on what is spoken between the therapist and client and on helping clients expose and change what are perceived as faulty thought patterns), somatic interventions have become more prominent. By “somatic” I mean any clinical intervention that includes, indicates, or acknowledges the body in some way. Because some of the more elegantly conceived somatic techniques are used exclusively for the alleviation of physical pain (like the work of Thomas Hanna) and others (like the work of Don Hanlon Johnson) are so broad and far-reaching that they don’t articulate specific technique but rather act as a more descriptive paradigm for an entire field called “somatics,” I will focus on only three widely known interventions that contain within their framework specific techniques that are intended to be utilized in the treatment of psychological trauma.
The Hakomi method. Described primarily as a mindfulness practice by its founder, Ron Kurtz, this method also undeniably works with the body (Kurtz, 1990). Kurtz describes how a client will often exhibit a physical gesture in connection with an emotion like lifting the shoulders when afraid. He refers to these physical gestures that accompany emotion as “spontaneous management behavior.” From Kurtz’s perspective, spontaneous management behavior is not something to judge or even to change but rather something to notice, something to make conscious and even embrace. Though TSY shares aspects of this nonjudgmental awareness, our focus is on the body and not on any meaning making associated with the body experience.
Sensorimotor psychotherapy. Its founder, Pat Ogden, describes sensorimotor psychotherapy as “body oriented talk therapy.” Ogden has a background in yoga and dance, and she brought that sensibility to her clinical work with trauma survivors. Like the Hakomi method (Ogden was a cofounder with Ron Kurtz of the Hakomi Institute in 1981), a significant amount of time is devoted to working with the physical representation of emotional experiences: how the body contains and expresses emotional valence associated with trauma and how we can use the body to mediate that emotional suffering through the guidance of a qualified clinician (Ogden, Minton, & Pain, 2006).
Somatic experiencing (SE). Its founder, Peter Levine, describes SE as having evolved from his observations of prey animals who, in his estimation, though they are chronically exposed to stress, rarely exhibit symptoms of trauma. He believes that prey animals literally use their bodies to move the stress out of their system through actions like shaking. Levine believes that many traumatized people, though in possession of the same physical resources that prey animals have, are, for whatever reason, not able to access them, and therefore the trauma remains stuck physically in the organism. The intention of SE is to help clients gain access to the healing potential inherent in their bodies. SE, like TSY, does not require people to talk about their trauma and relies heavily on the body to facilitate healing (Levine, 1997).
Each of these somatic or body-conscious techniques, to one degree or another, considers the body experience of the client to contain information that is useful to the therapeutic process and makes an attempt to access that information. Whether a matter of identifying and acting out physical gestures that have heretofore been stuck in the body, unable to be expressed (as in Pat Ogden’s work), or figuring out ways the body can move to release the imprint that trauma has left on the nervous system (as in Peter Levine’s work), clearly the body is central to these therapeutic techniques.
Because of the centrality of the body in the process, TSY is part of what I would call the somatic movement in trauma treatment. However, it is useful to draw some distinctions between these other somatic approaches to trauma treatment and TSY. In my opinion, all three of the methods indicated above attempt, ultimately, to make meaning out of body experiences or to place body experiences in the context of memories or experiences from that past that remain in some way unprocessed. When we talk about memory in the context of trauma, it is often more appropriate to discuss emotion. In other words, Kurtz, Ogden, and Levine all suggest that traumatic memory is primarily encoded as emotion and that these emotions are mediated by the body. In this way, body experiences are important because of their connection to emotional content, and the treatment, in all three cases, is mostly about using your body to change your relationship to emotions: I do something with my body in order to express or relieve emotional content. Importantly, the three methods named above were founded by people trained in Western psychotherapy or psychology, which has an unyielding emphasis on the preeminence of cognition: if I can recognize my emotional state, I can have control over it and if I have some control over it I won’t suffer. In other words, these treatments access the body, not as an end in and of itself but rather as a doorway to a cognitive understanding of the emotional valence associated with trauma. This is not to say that these somatic methods are not incredibly beneficial. They have made great contributions to the work of trauma treatment and healing. However, they are ultimately meaning-making paradigms: I shrug my shoulders because I am scared; I want to hit you because I never hit my perpetrator and that act of not hitting is stuck in my body; my back is tight because I have not released the traumatic memory that is stuck there. Other than sharing a focus on the body as part of treatment, TSY is fundamentally different.
In TSY there is no attempt to make meaning out of a body experience; we are not interested in the emotional content associated with a bodily form. In other words, there is no “because” (as in I shrug my shoulders because I am scared). The point is simply to have and to notice the body experience as it is right now, to choose what to do with it once it is felt, and then to take action based on your choice. There is much more on the dynamics of feeling, choosing, and acting to come but for now it is enough to know that, with TSY, we are not “processing” the emotional content of trauma or trying to “understand” trauma in the usual sense of the word. The suggestion is that there may be great therapeutic value in not turning what is felt in the body into a story or into an emotion. In this way, the somatic techniques I have presented all end up turning body experiences into cognitive ones where the end result involves understanding what we do with our body now in relation to the trauma we experienced in the past. With TSY, we offer our clients the opportunity to do something different, namely, instead of meaning making in our head, we are after having an experience in our body. What I invite readers to consider is whether there is room in trauma treatment for body experiences that we don’t have to make meaning out of but simply notice and interact with. Our work with TSY suggests that there is and that such experiences may significantly add to the process of recovery and healing.
Theoretical underpinnings of TSY
TSY is not based simply on the intuition that having body experiences may be helpful as part of trauma treatment. Three theoretical underpinnings to TSY-trauma theory, neuroscience, and attachment theory-come directly from the clinical literature. Let’s look at each one in some detail.
Trauma theory
Like yoga, trauma also has an ancient tradition. It has been written about and speculated upon within cultures all around the globe for millennia: from ancient epic poems, to philosophical speculation, to treatment interventions. It has been called many things and understood in many ways but surely, since the beginning of history, humans have experienced trauma in the form of overwhelming, terrifying, and life-altering experiences. For our purposes, while it is useful to consider the fact that our forebears have been dealing with trauma forever and that it is not a new phenomenon by any means, we can skip ahead to the modern medical model that began to distinguish trauma as a treatable, psychological disorder, which occurred in the late 1970s. Specifically, we will be concerned with the following iterations of trauma: posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder (CPTSD), disorders of extreme stress not otherwise specified (DESNOS), complex trauma, and developmental trauma disorder (DTD). My argument will be that all of these classifications of trauma are interrelated, build on and inform one another, and point in the direction of a similar phenomenon: trauma that occurs within the context of relationships is especially devastating to human beings and, because of its multifaceted impacts, requires a broad matrix of healing modalities.
PTSD IS JUST THE BEGINNING
The modern understanding of trauma starts with PTSD so let’s begin there. PTSD is currently the most common terminology associated with psychological trauma because, as of the writing of this book, it is the only official diagnosis directly associated with trauma as indicated by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or the Physicians’ Desk Reference. PTSD is, therefore, the only diagnosis directly associated with psychological trauma that is presently recognized by insurance companies so it is the only trauma-related condition that can be directly billed for by clinicians. Pausing to note this monetary correlation is important, though I will not extrapolate further.
The PTSD diagnosis itself was conceived in the United States in the late 1970s and codified in the DSM-III in 1980 by clinicians who were mostly treating male combat veterans of the war in Vietnam (Andreasen, 2010). For our purposes the most notable component of PTSD is that the diagnosis is based on symptoms (e.g., recurring flashbacks, avoidance of memories associated with the events, etc.) and does not consider the specific circumstances of a survivor other than that he or she perceived a direct threat to personal safety or witnessed someone else in a life-threatening situation. In other words, whether the triggering event was a tornado, a car accident, a physical assault, or domestic violence doesn’t matter from the viewpoint of the PTSD diagnosis.
After the diagnosis was established, a new door was opened for people who were suffering greatly to receive treatment, which is undoubtedly good. But the story didn’t end there. Astute therapists like Lenore Terr and Judith Herman and their contemporaries noticed differences between the official diagnosis that was supported by the medical establishment and the people they actually saw in their offices. Specifically, what seemed to be missing was context. That is, a patient who had experienced a single car accident may qualify for PTSD but she had different symptoms than either patients who had been repeatedly abused within the context of relationships or survivors of repeated torture at the hands of other people. Judith Herman in particular began to call attention to trauma that occurs within the context of relationships and also has a longitudinal quality to it (there is more than one traumatic event). Herman used the word “captivity” to describe such conditions and she pointed out that people who were traumatized in captivity displayed particular symptoms, such as self-injury, explosive anger, amnesia for traumatic events, shame, preoccupation with relationship with the perpetrator, repeated failures of self-protection, and alterations in systems of meaning. Most of these symptoms that Herman saw in her experience as a psychiatrist were not described under PTSD in the DSM. In order to account for her actual experience in her office, Judith Herman needed to come up with a new framework, which she called Complex Posttraumatic Stress Disorder (CPTSD) (Herman, 1992).
BEYOND PTSD
The next evolution in terms of the classification of psychological trauma came because clinicians began to see a connection between complex symptoms in adulthood and traumatic experiences in childhood. The clinical observation of these consistent yet very broad symptoms led to a classification called Disorders of Extreme Stress Not Otherwise Specific (DESNOS). Again, like CPTSD, DESNOS was not an official diagnosis but rather a phenomenon that grew out of the actual experience of clinicians treating traumatized people. Eventually, there was a DESNOS symptom set developed that in some cases overlapped with that of CPTSD, but it also added some new dimensions to the literature that have bearing on the development of TSY like self-destructive behavior and chronic pain (both symptoms that play themselves out within the body) (Luxenberg, Spinazzola, & van der Kolk, 2001).
Over the next several years, DESNOS was studied, written about, expanded on, and eventually absorbed into the clinical milieu under a new name: complex trauma. Complex trauma added another important clinical observation to the mix that was referred to as “the cascading interplay between trauma exposure, impact and (mal)adaptation” (Spinazzola, Habib, et al., 2013). That is, one traumatic experience had a tendency to snowball and lead to more traumatic experiences. The cascading effect of trauma could be understood in the case of a child who was chronically physically abused at home and skipped school regularly because he didn’t want anyone to see his bruises and as a result is held back a year or placed in a remedial program because he is so far behind his peers. Being in remedial programs may lead to ostracization by peers and judgment from adults, which in turn may lead to more antisocial behavior and so on. In addition to the very important concept of the cascading effect, complex trauma also arrived at a consistent and very detailed symptom array that applied to adult survivors of chronic childhood abuse and neglect, including, to name just a few, social isolation, difficulty localizing skin contact, problems knowing and describing internal states, distinct alteration in states of consciousness, substance abuse, acoustic and visual perception problems, and shame and guilt (Cook, Spinazzola, et al., 2005). These symptoms, which expand on DESNOS, add to the increasingly nuanced understanding of psychological trauma that has evolved since the late 1970s, when PTSD was first indoctrinated into medical parlance.
The final, and most current, iteration of psychological trauma that is relevant to the development of TSY is Developmental Trauma Disorder (DTD). DTD is a diagnostic framework that focuses attention on people who are exposed to trauma in the context of relationships, like CPTSD, but specifically refers to the experiences of children, like DESNOS and complex trauma. Specifically, DTD is a proposed diagnosis that would apply to children and would be entered into the DSM. The symptom array is based on the literature from DESNOS and complex trauma, and this clinical understanding would inform the treatment protocol (Ford, Grasso, et al., 2013). The symptoms, which will now sound familiar, that are cited by experts wishing to include DTD as an official diagnosis include dysregulation of affect and behavior, disturbances of attention and consciousness, distortions of self-perception, and interpersonal difficulties, along with some still inconsistent but notable changes in the brain (D’Andrea, Ford, et al., 2012). In addition, the DTD framework would presuppose the interrelational aspect of trauma because these kinds of traumas always occur within the context of relationships: specifically, adults with power and children without power.
I consider the iteration of trauma first presented by Judith Herman right up through to DTD as ultimately attempting to characterize one phenomenon, which consists of several parts where each part ends up supporting and informing the whole. Therefore, I specifically use the term complex trauma from here on out to represent this integrated phenomenon because the term seems to have, more or less, encompassed all of the other frameworks in the current clinical literature.
The neuroscience of trauma
One thing was clear: the rational, executive brain, the mind, the part that needs to be functional in order to engage in the process of psychotherapy, has very limited capacity to squelch sensations, control emotional arousal, or change fixed action patterns.
—Bessel van der Kolk, 2006, p. 5
A large part of the story of the development of TSY involves current directions in neuroscience. Although the field is still in its very early stages, researchers are developing a picture of what happens to the mammalian brain as a result of exposure to traumatic experiences and it is quite devastating (Bossini, Tavanti, Calossi, et al., 2008; Long, Duan, Xie, et al., 2013). While significant impacts are being observed on many regions of the brain as a result of trauma exposure, the most important neurophysiological support for TSY is found in a set of brain regions collectively referred to in the literature as “the pathways of interoceptive awareness,” or the “interoceptive pathways,” which include parts of the insular cortex and the anterior cingulate cortex among others (Khalsa, Rudrauf, Feinstein, & Tranel, 2009). The term interoception will figure predominantly throughout the rest of this book and will be examined in detail in Chapter 2 but, for the moment, consider interoception as an attentional praxis that centers on our ability to feel the activity of our interior self, that is, the self contained within our skin. For example, it is interoception to feel our heartbeat, our stomach grumble, or a muscle stretch. One interesting way to understand interoception comes from the neuroscientist A. D. (Bud) Craig, who writes that it is interoceptive information that helps us develop an experience of what he calls our “sentient self” (Craig, 2010). Interoception gives us a cortical representation of our embodied self. Of particular importance to trauma treatment, researchers are finding that parts of the brain associated with our ability to interocept are deeply compromised by trauma. For example, in a script-driven, symptom-provocation study, the neuroscientist Ruth Lanius and her colleagues found that “subjects with PTSD showed lower levels of brain activation than comparison subjects in the thalamus, the medial prefrontal cortex and the anterior cingulate gyrus [parts of the interoceptive pathways]” (Lanius, Williamson, Densmore, et al., 2001, p. 1921). In another study involving combat veterans, it was found that the group with PTSD had less volume of gray matter in the left insula and the anterior cingulate than their non-PTSD counterparts (Herringa, Phillips, Insana, & Germain, 2012). This and other research are pointing to the fact that trauma survivors are deeply disconnected from their core being-the feeling of being embodied-and this seems to be a great source of the suffering associated with complex trauma and PTSD. In essence, this research on the brain suggests that traumatized people do not have a reliable self, a feel-able self, a foundation from which to safely experience themselves, relationships, and the world around them. What is it like to live in a body that is unfeel-able and therefore unpredictable? I would suggest that living with an unfeel-able and unpredictable body is one valid way to explain what complex trauma is.
Another piece of relevant neuroscience research comes from Bessel van der Kolk’s lab where trauma patients were exposed to traumatic reminders and researchers found “a relative deactivation in the left anterior prefrontal cortex, specifically in Broca’s area, the expressive speech center in the brain, the area necessary to communicate what one is thinking and feeling” (van der Kolk, 2006, p. 2). So, neuroscience not only presents a picture of traumatized people being alienated from their bodies but also indicates that they may be unable to talk about their experience because of the impact to Broca’s area. The suggestion here is twofold: we need to pay more attention to what it really feels like to live in a traumatized body and we need a broader range of treatments for traumatized people other than those that are talk-based or strictly cognitive.
At the Trauma Center in 2011, under the direction of Bessel van der Kolk, we conducted a 20-week trial with a small group of eight adults with complex trauma. All of our subjects underwent a functional magnetic resonance imaging (fMRI) scan and then six people participated in 20 weeks of TSY. After 20 weeks, all eight participated in another fMRI scan and indications were that the group that received TSY had more activity in parts of the interoceptive pathways (left insula, right thalamus, and right dorsomedial prefrontal cortex) than their counterparts. This is an intriguing early step that we hope to investigate further.
Attachment theory
An infant whose mother’s responsiveness helps him to achieve his ends develops confidence in his own ability to control what happens to him.
—Mary Ainsworth, 1979, p. 933
The final theoretical underpinning of TSY comes from attachment theory, a framework that is particularly attuned to the role of relationships both in creating complex trauma in the first place and in the possibilities relationships provide in terms of healing. In a way, attachment theory developed on a parallel track to trauma theory but at some point along the way these two tracks have intersected and, in many ways, merged. Attachment theory describes a specific way of understanding the importance of relationships that has made its way directly into the treatment of complex trauma (Blaustein & Kinniburgh, 2010; Kinniburgh, Blaustein, & Spinazzola, 2005). One aspect of attachment theory that will ring a clear associative bell with complex trauma is that it seeks to understand behavior in adulthood as being directly related to the experience one has in their primary relationships in infancy and childhood. Pioneers in the field, particularly Mary Ainsworth and John Bowlby, focused mostly on the relationship between mother and child though, since their work, the understanding of “primary” relationships has expanded beyond just the biological mother (Karen, 1998). Colleagues at the Trauma Center and others who focus on attachment in the context of trauma suggest that, as helpless infants, human beings rely completely on the relationships with their primary caregivers for creating the safety that will allow them both to survive and, critically, to fully develop their capacities. Without this relational safety and stability, a human being needs to use all of his or her energy purely for survival and will therefore end up sacrificing a significant amount of normal, healthy development (Kinniburgh, Blaustein, & Spinazzola, 2005). Studies have shown that, as a result of this tradeoff-healthy development for survival-the adolescent or adult survivor will experience devastating impacts that will affect their health and well-being on many levels unless attended to effectively (see the Adverse Childhood Experiences (ACE) study data for some examples, which can be found at www.cdc.gov/ace/).
So how does TSY correspond to attachment theory? First, the trauma-informed clinical community, part of the environment from which TSY sprung, has been deeply concerned with treating the impacts of disturbed, or insecure, attachment for years (among other examples previously cited, see Courtois & Ford, 2012). Everything that happens in TSY happens within the context of a relationship-that is, the relationship between the facilitator/clinician/therapist and the student/client/patient. TSY offers many unique relational opportunities that are particularly apropos to treating attachment-based, complex trauma. First and foremost, the student is in charge of what he is doing with his body at all times so, even though the facilitator may offer some yoga-based invitations, the student can always say “yes” or “no” at any point in the process. Being in control of what you do with your body in the context of a relationship is particularly important in the treatment of complex trauma because the dysregulation associated with early childhood trauma is primarily body based. That is, when an infant or child is neglected or abused, those experiences are absorbed by the body, especially if they occur prior to the ability to verbalize (van der Kolk, 2006). For example, when the infant is hungry and the parent is repeatedly unable to supply nourishment (for whatever reason), the infant experiences an unmet body need; when the child is physically and/or sexually abused by the person she wants and needs to trust above all others to keep her safe, the body absorbs the impact of these extremely confusing messages. Pain, pleasure, terror, and a desire to please may be all mixed up and experienced within the body (consciously or unconsciously). It may be that these body feelings become so overwhelming or confusing or disorganized that eventually they become intolerable and therefore banished to the realm of the unfelt and unknown.
With TSY, we focus on using the relationship to give our clients a safe space to begin to feel their body again and begin to notice what they want to do with their body in a given situation. The facilitator supports their clients as they learn to trust what they feel, make their own choices about what to do based on what they feel, and take action based on what they choose to do. Facilitators also invite clients to notice how it feels once they take that action and then repeat the process. This is, after all, the work of a good parent or primary attachment figure: helping children notice what they feel; figure out how to act on what they feel; take action; and then help them notice how the result of their action feels. I am not suggesting that the TSY facilitator is positioning himself or herself in the role of a parent, but we should borrow from the understanding that a healthy relationship, which supports inquiry, making choices, and learning from the actions that we take, is a good paradigm to begin with when facilitating TSY.
Critically, in our experience, for most of the people we work with, this process is broken down at some stage and it is the job of any helper-including a therapist or a TSY facilitator-to assist people back into the flow, so to speak. To be out of the flow, to not know what we feel, what we want, or what to do about it is a very frightening and painful way to live. With TSY, we are always working with body sensation and dynamics and not feelings of hunger or thirst (also feel-able things), for example, but researchers hypothesize that the interoceptive pathways that allow me to feel that I am hungry are more or less the same that help me feel my leg muscles contract or extend (Craig, 2003). If this is the case, then when I practice feeling my leg muscles I am toning my ability to feel/sense myself in other ways. If practitioners are aware of attachment theory, they can use the relationship to create a safe space where the client’s experience is validated and supported and not coerced, manipulated, judged, or neglected.
Try an exercise: The Seated Mountain Form
Perhaps it’s best to try an exercise at this point as a way of bringing together several of the concepts that have been discussed thus far, because TSY is, ultimately, an experiential practice. If you like, we can experiment with the Seated Mountain as an example.
In order to create a form like the one pictured in Figure 1.1, the facilitator could say “sit up tall.” That could be the end of it. But what would that mean in the context of trauma treatment? Perhaps the student’s experience of such an instruction would be, “Well, here we go again. I am being told what to do with my body. That’s familiar territory.” This kind of “instruction” effectively mimics and may reinforce the trauma paradigm that was learned, maybe through the primary relationship, namely, “You are helpless to affect your circumstances, don’t bother to try” or “Do what I say or else,” and so on. I would suggest, based on the theoretical underpinnings presented above, that talking to one’s client like this is traumatizing him or her. If we respect the impacts of complex trauma, including neuroscience, as well as the power of attachment, of the relationship, we might think differently about how we organize our presentation of the Seated Mountain Form. We might notice that, through this yoga form, we have an opportunity to establish a new kind of relationship, one where the person in charge (the facilitator) turns over control to the person with less power (the client). What happens when what the client feels in the body during a yoga form is immediately validated by the therapist/facilitator? Where the client’s experience is not manipulated or coerced, just validated? What happens when the client gets to make real choices about what to do with the body and is then supported in this process by the facilitator?
Figure 1.1. Seated Mountain form
How might this look for our example above? The facilitator might say, “If you like, you could experiment with sitting up tall. Perhaps you might investigate lengthening up gently through the top of your head.” At the same time as the facilitator is giving this invitation to the client, she is also experimenting with the same dynamics and having her own genuine experience. The process begins as an invitation, not as a command, and both parties are immediately engaged on equal footing. The facilitator might then invite her student to notice what it feels like to sit up tall: “you may feel some of the muscles that you are using to create this ‘tallness’ in your body.” The door is immediately opened for the client to have an interoceptive experience, to feel something. Subsequently, he may or may not tell the facilitator about his experience. The important thing in the moment is that the facilitator is inviting experience, not commanding it. It would be perfectly fine, within the context of TSY, to directly ask the client some questions like “Do you feel some muscles that you are using to help yourself sit up tall?” or, even more pointedly, “Do you feel some stomach muscles engaged here?” as long as answers are not demanded, anticipated, or required. These kinds of direct questions may be helpful with some clients to, in effect, jump-start interoception but they run the risk of being coercive, so the encouragement is to proceed with caution and to always make space for the client to feel something totally different than what you are inquiring about or nothing at all without any judgment on your part.
Bringing together trauma theory, neuroscience, and attachment theory
To wrap up this discussion of the theoretical underpinnings of TSY, I would suggest that the word that underlies trauma theory, neuroscience, and attachment theory is relationship- relationship with the other and relationship with the self. When you consider the implications of neuroscience, for example, and the impact that trauma seems to have on the pathways of interoception in particular, it is clear that, with regards to complex trauma, we are dealing with a damaged relationship to the self. Through the lens of attachment theory we recognize the impact of relationships with others both in the process of creating trauma and in the process of healing it. In this regard, I like to view Judith Herman’s emphasis on empowerment in trauma healing as a bridge from neuroscience to attachment theory: how do our relationships with others impact our relationships with ourself? Do we learn to be disempowered through our dysfunctional early relationships and then re-create that dysfunction through our relationships to ourself going forward? Might this be another way to understand complex trauma? The literature around complex trauma and attachment theory suggests exactly this: it is within the context of our early relationships that we lay out a roadmap for how to relate to ourselves for a lifetime; the suffering associated with abusive or neglectful early relationships is perpetuated, ad infinitum, through the relationships with ourself. Unless we do something about it.
Nowhere is the relationship between early relational trauma and later life dysfunction more apparent than in the work of the ACE study. (To date, there have been dozens of research papers generated from the ACE data set. Interested readers can visit www.cdc.gov/ace/ to view papers.) This collaboration between the Centers for Disease Control and Prevention, and Kaiser Permanente in California clearly indicates that the more someone is exposed to chaos in childhood—violence, abuse, drugs, alcohol, neglect, and so forth—the more likely he or she will experience cognitive impairment, higher risk behaviors, heart disease, and even early death. These adverse health outcomes can be understood, when coupled with our growing knowledge of the neurophysiological impacts of trauma, as resulting from an inability for survivors to be interoceptive and to therefore be able to make informed choices about what to do with their bodies. The only way to have our needs met, whether it’s medical care, nutrition, or healthy affection, is for us to be able to sense the messages from our bodies; TSY offers a starting point for that kind of interoceptive practice. With TSY we want to attend to relational dynamics-both with the other and with the self-at all times and we want to do our best to purposefully relate to our students/clients in a way that helps them build safer, more satisfying relationships to their core selves and thereby make healthier choices that result in more positive outcomes. The way we do this is by never telling our students what to do with their bodies, focusing on interoception, always using invitations instead of commands, and giving genuine options and choices within forms.
Finally, it is important to note that there are indications that while relationships can be the problem they can also be part of the solution. In a highly relevant study with foster children who showed signs of insecure attachment, foster parents were taught relational techniques like following a child’s lead (very much like the TSY approach of never telling people what to do and emphasizing invitation and choice). The children who experienced these kinds of nurturing techniques from their foster parents showed lower levels of blood cortisol (a stress hormone) and improved behavioral outcomes as opposed to the control group (Dozier, Peloso, Lindhiem, et al., 2006). However, this study involved infants and toddlers while TSY is developed primarily for adolescents and adults, and it also included some age-appropriate hugging and cuddling from the caregivers (not from a third party, like a therapist or yoga teacher) and this likely had an effect on the outcomes. Still, indications are that even if insecure attachment is the first experience, humans can adapt and heal when given appropriate relational encounters later in life.
Another study examined a treatment for children and adolescents that emphasized one particular aspect of a relationship that involves the person with the most power trying to sense the emotional state of the person with less power and honoring that state rather than attempting to change it (Becker-Weidman 2006). The emphasis is again placed on the dyadic relationship, in this case between the therapist and client, and indications were that children who experienced this kind of intentional attunement from their therapist showed improvement in both affect regulation and the ability to form new social relationships. With TSY, even though our emphasis is not on the emotional state but rather on our interoceptive awareness, because the teacher is following the lead of the client, there is a type of attunement at the core of the experience (I will discuss the kind of attunement that TSY emphasizes in more detail in Chapter 6).
Important note on the role of the facilitator
Though the role of the TSY facilitator will become more clear as you read on, I feel it is important for readers to begin to think about the practical side of using this material right at the outset. Ultimately, in order to be effective for your clients, you must have enough comfort and familiarity with the material to facilitate a coherent experience. To that end, I devote Chapter 8 to specific practices that can be used either exactly as they are presented or can be modified to suit your own experience. It will help immensely if prospective TSY facilitators practice this material themselves as well as practice teaching friends, family, and/or colleagues as often as possible. You do not have to be a yoga teacher in order to successfully use TSY as part of a therapy practice but you do need to have a practiced facility with the material. The more experience you have, the more effective you will be.
Additionally, being a facilitator for your client’s body experience may be a very different role than what you are used to as a therapist so it is worth taking some time to reflect on where you are coming from. Were you trained in a very strict psychoanalytic or psychodynamic, talk-oriented approach that centers on meaning making? Are you based in a more cognitive-behavioral understanding of trauma treatment, which emphasizes the analysis of thinking and/or behavioral patterns and then an attempt to change them? Do you have some kind of somatic training? Have you ever facilitated any kind of body experience with students or clients? Are you a yoga teacher or do you have some other kind of similar training? All of these questions are important ones to consider as you contemplate how TSY might fit into your particular clinical practice.
Shared, Authentic Experience
One critically important aspect of your role as a TSY facilitator is that you are entering into a shared, authentic experience with your client. That is, with any TSY exercise, the facilitator and the student are both doing the activity and it is not a situation where the facilitator is prescribing something and then standing outside of it to observe or interpret the outcome. TSY involves both parties engaging simultaneously with the material. We encountered some of the aspects of this dynamic when we discussed attachment theory. John Bowlby, the “grandfather” of attachment theory, referred to a concept that he termed mutual enjoyment as being a critical part of successful relationships. Though he referred specifically to an aspect of the mother-child relationship, I would suggest that we can broaden this understanding to consider certain aspects of any successful therapeutic relationship as well, including that between the TSY facilitator and student. In the domain of TSY, mutual enjoyment means that both parties are actively involved in the process together. So, for example, if the exercise is a Gentle Spinal Twist (see Figure 8.4 in Chapter 8), you are both doing the form at the same time. Even more important, when the facilitator invites the student to notice what he feels in his body, to practice making choices, or to experiment with taking actions (more to come on these topics in later chapters), the facilitator is also doing these things. This kind of approach adds an integrity to the practice that goes beyond words. By engaging with your client like this, you are letting her know that she is not alone, that you are both human beings with bodies that can move in some way. When you authentically model this attention to your own internal experience and do not attempt to control or coerce the experience of your client, you are letting her know that she doesn’t have to “perform” for you; that she doesn’t have to “get a form right” in order to please some external authority; and that she can risk being authentic in her relationship with you and her relationship with herself.
A further challenge for you is to recognize and to trust your own actual experience, as it is, without imposing it on the client. As you practice recognizing and trusting your own felt experience, you simultaneously support clients by example as they practice recognizing and trusting theirs. You share this investigation but not the outcome. You may feel one thing while they feel something else. You honor both of your experiences as equally valid. To me this coincides, a little abstrusely but none the less, with Bowlby’s assertion that successful relationships contain mutual enjoyment. Complex trauma is a phenomenon of having one’s experience held hostage to the whims of an external force, namely, another person. Power is largely externalized in the form of that other person. Healing trauma involves reclaiming the locus of control and, therefore, the validity of one’s own felt experience. TSY is a process of internalizing power because both parties are involved in a relationship where each gets to have his or her own experience validated without imposing it on the other. To be sure, as the clinician, you are not asking for your client to validate your experience but you don’t have to because you are validating it for yourself. Ultimately, your student does not need to refer to you for validation, but can instead find validation from within.
Conclusions
To this point, I have written some about who will benefit most from TSY but it is also useful to remind readers who TSY might not be for. Though I am not a diagnostician and do not suggest that TSY be ruled out completely, this treatment was not developed for people who experienced a single-incident trauma like a car accident or a natural disaster (some exceptions might be single-incident sexual assault or any circumstance where one person purposefully hurts another). In general, single incidents are cases where techniques like eye movement desensitization and reprocessing (EMDR) may be far more effective and appropriate (Shapiro, 2001).
TSY is especially for people with complex trauma, for people who were hurt and abused continually within relationships. While our empirical data for TSY to date has focused on adult women who experienced chronic childhood abuse and neglect, we also use TSY with men with a similar background, with younger children and teens with a similar background, and with war veterans because there seem to be many similarities between these groups in terms of symptoms (see, for example, the detailed report by Davy, Dobson, et al. [2012] on the effects of combat exposure in the Australian Defense Forces, which indicates symptoms similar to some of those found in the complex trauma literature). We are not the first to observe these similarities. Judith Herman, in her seminal book, focuses on both women trapped in abusive relationships as well as war veterans and survivors of torture. Similarly, Lenore Terr, another pioneer in the field of trauma studies, concentrated on children who experienced captivity by people other than primary caregivers (Terr, 1992). For his part, Ed Tick investigates how deeply combat experiences have affected veterans of modern war since Vietnam (Tick, 2005).
Finally, consider the image of “the yoga guru” perched on an elevated platform, in front of a room full of students, calling out directions to his rapt novitiates; students diligently follow orders as they move their bodies from one form to the next based on each successive command. This image is the antithesis of TSY because complex trauma can be similarly understood as an experience, in one way or another, of being told what to do (and what to feel) by some externalized authority, of subjugating your will to the will of another over and over again. Imagine being in these life situations: a baby born to a drug-addicted parent who is unable to meet the complex physical and emotional needs of an infant; an adult trapped in an abusive relationship; a soldier pinned down behind a wall while people try to kill him and his friends in a hail of bullets and bombs, while amid this chaos he pulls the trigger and people die. In each case, you are exposed to actions perpetrated upon, through, or withheld from your body by an external force over which you have no control. People who are steeped in chaotic environments like this learn that they are never safe in relation to other people because other people are not safe; most insidiously, as a result of these kinds of traumas, people learn that they are never safe in relation to themselves, in their own skin. Those people are who TSY is for.
Now that we have established some foundations of TSY in comparison to regular yoga and to other somatic models for trauma treatment, and investigated the theoretical underpinnings of the intervention, let’s turn our attention to the methodology: how it’s actually done.