Trauma-Sensitive Yoga In Therapy

NOTE: Chapters 2 through 7 will begin with practice examples.

CINDY IS 39 YEARS OLD, AND SHE GREW UP IN AN AFFLUENT suburb. Her trauma history includes significant, sustained sexual and verbal abuse from her biological father, who was a very powerful, prominent public figure in town. The abuse began in very early childhood and continued into her early teens until her father committed suicide. As a child, Cindy was told over and over by her father that she or her mother would be killed if she ever told anyone about what was happening. When Cindy began to practice trauma-sensitive yoga (TSY) she had been in therapy for two decades and, although very successful in her professional life, still suffered tremendously from, among other things, an inability to sleep without intrusive nightmares, binge eating followed by prolonged periods of self-imposed starvation, cutting and burning her arms and legs, and severe dissociation that would often end up leading to major alcohol binges where she would wind up in unwanted sexual relationships with strangers. Cindy had told her therapist that she was “terrified of her body” and that she felt like her body was “only there to cause . . . pain” and many other similar things over the years. TSY was a last resort for Cindy (“I’ve tried everything else, why not!”) and was undertaken with her therapist with whom she had a very good relationship for the prior 5 years. Cindy and her therapist decided to use TSY as a 15-minute practice at the start of each session and then they moved into the talking process that they had established over the years. During the fourth session that included TSY, Cindy and her therapist were experimenting with flexing and extending their fingers (making fists and then alternately spreading out their fingers) and noticing what that felt like. As soon as the therapist invited Cindy to notice if she felt her hands in any way, Cindy became very distressed. She said in a panic, “I can’t feel anything! These hands don’t seem to belong to me. There is no connection. This is really disturbing.” The therapist invited Cindy to look at her hands if she wanted and to continue to experiment with moving her fingers and notice if this helped her be aware of her hands at all but Cindy said she still couldn’t feel anything and was clearly still very distressed. At that point, Cindy said, in a very childlike voice, “It may be because I was tied down by my wrists so many times as part of my abuse.” At this point, the therapist could have stopped the TSY altogether and shifted into another mode, possibly talking about this memory and processing it in some way. Cindy also could have called it off right there either explicitly or implicitly—she could have dissociated, for example, which would have required a shift in dynamics. But what the therapist decided to do, and what seemed acceptable to Cindy on this occasion, was to stay with TSY but shift away from the hand movements to something else. The therapist used the following language: “Would you like to experiment with a different movement?” Cindy said, “Yes, let’s try the neck movements.” Cindy had found over the previous few months that moving her neck had been soothing in some way and, remembering that, she initiated a shift to the neck movements in this moment of distress. So, following Cindy’s lead, they began some gentle neck circles together and after a few seconds the therapist asked, “Do you feel this movement around your neck?” and Cindy said, noticeably relieved, “Yes, I can feel that.” They stayed with the neck movements for a few minutes and then ended with some shoulder movements, which Cindy, again to her relief, noticed she could feel. After about 10 minutes of neck and shoulder movements they shifted into their talk therapy.

When asked later to explain her thinking during this process, the therapist said, “I was trying to give Cindy an opportunity to feel something in her body and she came up with the neck movements herself! I just felt like the most important thing at that moment was to not abandon the body if it was tolerable and for Cindy to have an opportunity to find something that was feel-able. The goal was not even to feel ‘good’ or to ‘calm down’ but just for Cindy to have an opportunity to feel something if she could tolerate that. I felt like it was more important to make available an opportunity for her to feel her body than to process a memory at that moment as long as it was okay for her.”

What is interoception?

One of the most important concepts in TSY, and one of the most important but least-known words in the English language, is interoception. In 1906, the Nobel laureate Charles Scott Sherrington introduced three terms into medical parlance: “proprioception,” “exteroception,” and “interoception.” Of the three, perhaps proprioception, which is basically the awareness of one’s body in relation to external objects, is the most familiar. (Proprioception is why we don’t constantly walk into walls or get into car accidents.) Exteroception refers to awareness of any stimuli coming at us from the outside (sights, sounds, smells, etc.). Interoception is our awareness of what is going on within the boundary of our own skin; it is intra-organismic awareness. One researcher who has devoted a good deal of his career to studying interoception is Alan (Bud) Craig (he coined the term “the sentient self” in this context). As a neuroscientist, Craig has developed a picture of interoception that is in most ways too complex for our purposes but, basically, he and others have identified nerve fibers that run from all tissues of the body to the brain. These fibers are called “afferent” because their direction is from the viscera (the body) to the brain as opposed to efferent fibers, which run from the central nervous system outward to the tissues of the body. Of these afferent nerve fibers, Craig says, “Such fibers conduct information regarding all manner of physiological conditions, including mechanical, thermal, chemical, metabolic and hormonal status of skin, muscle, joints, teeth and viscera [internal organs]” (Craig, 2003, p. 500). Importantly, this afferent information does not have to enter conscious awareness to be considered interoception. It is possible for information (like a certain chemical deficiency) from a group of muscle cells, myocytes, to reach the brain and cause a behavioral reaction (like eating protein) without that initial information becoming conscious. With TSY, however, we are always dealing with conscious processes; therefore, for us, we are concerned with feeling dynamics within muscles, as opposed to something that is arguably not directly accessible to consciousness like an object’s specific chemical content. The latter would be considered “metabolic” information and the former “mechanical,” according to Craig’s definition but the important thing is that both are interoception.

For another good definition of interoception, we can turn to a 2002 review written by Clare J. Fowler in the journal Brain about a book called Visceral Sensory Neuroscience by Oliver G. Cameron. Ms. Fowler writes, “As originally defined interoception encompassed just visceral sensations but now the term is used to include the physiological condition of the entire body and the ability of visceral afferent information to reach awareness and effect behavior, either directly or indirectly. The system of interoception as a whole constitutes the material me and relates to how we perceive feelings from our bodies that determine our mood, sense of well-being and emotions” (Fowler, 2002, p. 1505). Ms. Fowler’s definition of interoception encompasses three components that we will need to deal with: the visceral experience of feeling something in my body (from a muscle contracting or lengthening, to my heart beating, to my stomach grumbling); the motivation to act that the visceral feeling may initiate; and the effect of our visceral experience on our mood and emotions. Again, with TSY, we focus primarily on what Ms. Fowler calls the original definition of interoception, visceral experience, but, first, let’s take a look at the other two components.

After the visceral quality of interoception there is a reference to the effect of our visceral awareness on our behavior. The suggestion is that when we feel a muscle dynamic or we feel our stomach grumble we take an action in response: we stretch a muscle if it feels tight or we go and get food. Therefore, interoceptive awareness has a purpose, namely, to get us to act. While in TSY we certainly practice receiving information (see Chapter 4) from our body and then acting based on that information, however, we also practice interoception for its own sake even if that awareness does not lead to an action outcome. Our understanding of the neuroscience of complex trauma indicates that just the practice of feeling our body experience, even if we do nothing further, has specific therapeutic value for complex trauma treatment. In other words, although in upcoming chapters I will show how to connect interoception to an action outcome, our primary approach to interoception as a critical part of trauma treatment remains visceral awareness, whether or not a subsequent action is taken.

The third element of Fowler’s definition of interoception involves the emotional valence of visceral experiences. Reflecting on the example of Cindy above, interoception may have some emotional content associates with it. For Cindy, noticing that she could not feel her hands was distressing while noticing that she could feel her neck was calming. In a sense, we can understand the perceived emotional content as an interpretation of the visceral experience. This gives me an opportunity to make a clear distinction regarding the methodology of TSY. While in the therapeutic process writ large there is clearly space for the exploration of emotional valence, with TSY, as a component of treatment, we stay with the visceral experience alone. In that regard, Cindy’s therapist simply invited her to notice what she felt in her hands and around her neck; she did not ask Cindy to interpret what she felt in emotional terms—that interpretation came from Cindy. In TSY, our work is to strengthen the visceral, nonemotional aspect of our interoceptive capacity, not our capacity to transform body experiences into emotions.

Evidence for the benefits of interoception from mindfulness/meditation research

At present, almost all of the evidence (aside from our small pilot study that I referenced in Chapter 1) we have for the benefits of practicing interoception on actually changing parts of the interoceptive pathways in the brain must be extrapolated from work done in the field of mindfulness or meditation by researchers like Richard Davidson (Davidson & McEwen, 2012; Lutz, McFarlin, Perlman, Salomons, & Davidson, 2013), folks associated with the Mindfulness Based Stress Reduction Program (MBSR) in Massachusetts (Davidson & Kabat-Zinn, 2003; Holzel, et al. 2011) and Sarah Lazar (Lazar, Kerr, et al. 2005). These researchers have focused their attention on contemplative practices, such as various forms of meditation that involve the use of focused attention. The interoceptive practice within TSY is also, in this way, a contemplative practice, where the object of contemplation or focused attention is the body experience (the visceral component of interoception). It is possible to extrapolate from the findings of the meditation research that it is the practice of attentional control, regardless of whether the object of one’s attention is a thought, an emotion, a sound, or a body feeling, that may have an effect on the workings of neurons and therefore brain regions associated with trauma. While this is a speculative stretch at this point, it is by no means a radical one and would surely be an area ripe for further research. Why, you may ask, if meditation has shown such promising results, do we need TSY as another option for traumatized people? Because, ultimately, meditation is a cognitive process and TSY is an interoceptive one. With meditation the body is held in a rather passive state and most of the work is done with the mind: either observing thoughts and emotions or intentionally creating certain cerebral or emotional states. In order to do meditation one must have a robust-enough frontal lobe (the executive part of the brain) in the first place to know that thoughts and feelings are just thoughts and feelings and that they will come and go or they can be changed at will. For our complexly traumatized clients, thoughts and feelings are experienced as trauma all over again and not as phenomena that can be observed without emotional and visceral reactivity (van der Kolk, 2006). Meditation, like any other kind of cognitive treatment that doesn’t take self-regulation into account, is actually retraumatizing for complexly traumatized clients (for more, see the section below about interoception and self-regulation). In contrast to meditation, with TSY, the body, not the mind, is the center of activity. The conceptualization of trauma that undergirds TSY considers the problem to be more an experience of what is happening right now in the body—what it feels like to exist in this body right now—and less about thoughts about trauma or thoughts about the past or the future. Ultimately, this treatment attempts to go directly to where trauma lives: in the body.

Practicing interoception using TSY

Now that we have an understanding of what interoception is and the framework for why we should bring it into treatment for complex trauma, let’s turn our attention to ways in which we can use TSY and actually practice the sense of interoception.

Language of interoception

In order to bring interoception into the therapeutic milieu, the facilitator has one very important tool: language. The most important interoceptive word is notice, as in if you like, you can tilt your head to one side and when you do this you may notice a feeling in the side of your neck or if you like, notice how it feels in your lower back when you fold forward. The general encouragement is to use the word notice as often as possible as long as it is tolerable to your clients. What is it that you are inviting your clients to notice? Anything that is feel-able in their body. Because it is possible to notice all kinds of things like thoughts and emotions, for example, and our focus is always on the felt experience in the body, it is important that we look a little closer at how we use language to make interoception available.

Consider again the invitation if you like, you can tilt your head to one side and when you do this you may notice a feeling in the side of your neck. Figure 2.1 depicts this action.

For the purpose of this chapter, let’s focus on the interoceptive language (I’ve already talked about invitatory language in Chapter 1): you may notice a feeling in the side of your neck. While notice is the key interoceptive word it is not able to stand alone—we can’t just randomly tell (or even invite) our clients to “notice without suggesting something to notice.” There has to be an object of awareness and, most of the time, we need to make that object very clear. In our example the object is the side of your neck. Now your client has something to hold onto—somewhere to direct attention. (In the larger picture of TSY, we also want to make it clear to our clients that they may not feel anything and that that’s perfectly ok. We are not requiring that they feel anything; we are just making the possibility of feeling something available to them.) So, now that we have established an object (the side of your neck) and an initial impetus to interoception (notice), we are still missing something. Imagine if the sentence was you may notice the side of your neck. While it works as a sentence, that is, it has a subject (you), a verb (notice), and a noun (neck), it seems incomplete for our purposes, doesn’t it? Notice what about the side of my neck? I have nothing specific to notice yet (or maybe I have too much and I get overwhelmed). In our use, the word notice is a verb but if it stands alone in this sentence it is very weak, especially if we are trying to practice interoception. We need to strengthen this sentence so that our clients know what it is we are inviting them to notice: hence the additional words a feeling. Now, notice is still the verb but a feeling becomes the subject and in the side of your neck stands as the object.

You may notice a feeling in the muscles at the top of your legs.

You may notice a feeling in your hand.

You may notice a feeling in your lower back.

The encouragement is to use some iteration of notice a feeling as often as possible in a TSY session because this is how you can most directly bring up the practice of interoception. Also the word notice is not replaceable in our sentences above, but the word feeling is. You could, for example, invite people to notice a sensation in the side of your neck and this would still be interoceptive practice. One final caution when it comes to language and TSY is to avoid the use of adjectives and adverbs. These two sentences are examples:

Head Tilt

You may notice a good feeling in the side of your neck.

You may notice that the side of your neck feels good when you tilt to one side.

In both cases, by using a feeling word (“good”) in the context of TSY, we end up coercing our clients into having a certain kind of experience (or putting our client in a position where she may feel something that she does not experience as good and is therefore in conflict, which can also damage the relationship); such coercion is antithetical to trauma treatment. Additionally, our work is to make interoception available to our clients and interoception has nothing to do with adverbs or adjectives. If your client wishes to interpret a feeling in his body as good or bad, that is fine but it is not the point of TSY, nor is it part of the role of the facilitator for reasons that I hope are becoming more clear to readers.

No coercion

As we begin to introduce TSY into the therapeutic process it is very important that we remain conscious of one pitfall that is lurking around the edges of each yoga form: the impulse to influence your client’s experience in a coercive or manipulative way. I brought up this issue in Chapter 1, and again above, but I would like to expand on it here. I call it an impulse because we want to help the people we are serving, we want them to get better, and any new tool, like TSY, that purports to help traumatized people get better can cause us to be a little overzealous. The key is that in order for TSY to work the facilitator must absolutely never, under any circumstances, coerce their client into doing some yoga form or another or into having a particular experience with a yoga form that the facilitator thinks will be beneficial in some way. It is very tempting as a facilitator to place external value on a form like, this form will help you relax or this form will help you feel happier or this form will help you to feel strong. What happens if your client doesn’t feel relaxed or happy or strong in the given form? What happens to the role of interoception? There is a shift away from the internal experience and toward an external one where someone else’s value of the yoga form begins to dominate. Under these circumstances it becomes unclear what our focus is in practicing TSY and in a worst-case scenario the client’s actual experience with interoception is totally neglected. What the client feels in his body is devalued in favor of the expectations placed on him by the facilitator. Consider, for example, what this does to the power dynamics in the relationship. In effect, the teacher is short-circuiting the interoceptive process of the student by stepping in and saying, implicitly or explicitly, just feel what I want you to feel or, further, what you actually feel is not as valid as what I suggest that you feel. This sounds rather extreme but, I would argue, is not far off from what happens in many yoga classes that are taking place every day in health clubs, yoga studios, and ashrams around the world. Also, critically, this sounds a lot like a trauma paradigm, doesn’t it? When we bring yoga into the domain of trauma treatment we must not tell people what to do or what to feel. Essentially, we are careful not to make feeling something particular the goal of TSY. Actually it is very important that we don’t make feeling anything the ultimate goal of TSY because it is in the nature of complex trauma that there will be many times when our clients will not be able to feel certain parts of their bodies. That is totally and completely ok. In fact, please remind your client (and yourself) from time to time, “You may not feel anything in this form and that’s ok.” We want to make interoception explicitly available, help people discover it where they can, but we don’t want to present interoception like it’s required and we don’t want our clients to feel in any way like they have failed if they don’t feel something.

Focus on the internal experience

To be traumatized is to live in a body with which you have an unreliable and unpredictable relationship. Where does that unreliability and unpredictability come from? In large part from our inability to interocept. As discussed in Chapter 1, we know that parts of the brain, collectively referred to as the pathways of interoception, are affected by trauma. This means that we know our traumatized clients have particular difficulty feeling their internal states and this fundamental disconnection contributes in large part to the suffering associated with trauma. If you practice TSY with your traumatized clients you present them with an opportunity to feel and sense themselves. Without a somatic intervention like this, all you can do is talk about what it is like to feel estranged from your body; you talk about someone’s very real and immediate experience as an abstract cognition. These kinds of conversations may be useful at times but they are no substitute for interacting in some way with the body that is the cause of such consternation and the seat of the actual experiences! TSY gives you and your client a way to have these kinds of interactions based on the actual experience of feeling something. This is exactly what happened in our practice example with Cindy. Her therapist, sensing the benefit of staying with the body, if tolerable, so that Cindy could have a direct, feel-able experience, decided not to shut down TSY and move into a more abstract, cognitive process. Instead, Cindy’s therapist kept the focus on the internal experience as it was in the moment. By staying with the internal experience, Cindy was able to discover that parts of her body were indeed feel-able and that everything that occurred within her own skin wasn’t mysterious or painful.

As we introduce TSY to our clients, we seek to give them access to their bodies, knowing that their bodies are often the most frightening place of all for them. The work is to experiment with different yoga forms, as long as it is tolerable for the client, until a part of the body is revealed as accessible and feel-able.

One extra challenge in practicing interoception is that so many traumatic memories seem to be stored in the body, just outside of conscious awareness, and your clients have probably developed a keen physical infrastructure around protecting themselves from these implicit memories (Rothschild, 2000; van der Kolk, 1994, 2006). When you invite them to feel their bodies, it may be a very dysregulating experience even if it may be an essential part of trauma treatment to eventually be safe sensing your body. By using TSY to invite the body into the therapeutic milieu you will be exposing your clients to some very painful terrain, perhaps the thing they are trying most determinedly to avoid: awareness of the body. Because of these challenges, it is useful to approach interoception as a dosage issue: that is, how much interoceptive practice can my client tolerate? How much is too much? When is interoception appropriate and when is it better to talk or to use some other kind of intervention?

Interoception and self-regulation

Self-regulation is fine as long as it does not interfere with interoception. What does this mean? Self-regulation is, simply put, our ability to calm ourselves down when we are agitated. Survivors of traumatic experiences, especially complex trauma, very often have difficulty regulating emotional and behavioral arousal (Kinniburgh, Blaustein, & Spinazzola, 2005). Therefore, many therapists believe that it is essential to help clients find ways to self-regulate. There are three big problems with self-regulation in terms of TSY methodology.

First, in most clinical contexts, self-regulation involves emotions and not visceral feelings in the body. With TSY, we are not facilitating emotional experiences; while we do not want to avoid them if they come up, we, as TSY facilitators, do not want to bring them up ourselves. Consider our case example. Cindy’s therapist does not invite her to stop moving her hands because it is emotionally distressing but primarily because she couldn’t feel anything; it was an interoceptive dead end. Their work was to find a part of the body that Cindy could feel.

Second, a belief like “my client needs to learn to calm themselves down when they get upset” can easily lead to a prescription like “my client needs to learn how to use his breath to self-regulate” or “my client will feel more calm if they do a forward fold.” This is another trap. We always want to avoid the urge to prescribe when using TSY. TSY may offer some opportunities to practice self-regulation but it is not the most important part of the practice nor is it even necessary. Another way to say this is that self-regulation is fine as long as it is not prescribed. As TSY facilitators, our commitment to not telling people what to do or feel trumps our ideas about self-regulation. If your client notices that something she does helps her feel more calm, like taking a deep breath or moving into a certain yoga form (like Cindy in our example with the neck movements), that is fine and it is certainly reasonable for you, the facilitator, to reflect back to your client how great it is that she found something that helped her feel more calm. But our work is not about making ourselves feel calmer: it is first and foremost about learning to feel our bodies and the things that our bodies can do. If you as the clinician feel that the most important thing for your client right now is that he calm down, you will use a technique other than TSY (i.e., there is literature available on using breath and posture to change cortisol and testosterone levels in the body in order to calm down and feel more competent). In terms of TSY, however, feeling calm is perfectly acceptable as long as it does not trump interoception; to put it another way, feeling calm is fine as long as it comes from interoception and is not a prescription.

The third big problem with self-regulation is that if we get too side-tracked by emotions the process can quickly veer off into cognitive territory where we become hung up on interpreting body experiences through an emotional/cognitive framework: this is not TSY. While we recognize that emotional interpretation of interoceptive experiences will happen from time to time, we do not want to encourage it.

My suggestion is that if you use TSY you will create an environment where the emphasis is on interoception and where your client is in charge of his body (more on this in the next two chapters) and he will discover self-regulation techniques for himself. Critically, all of what he discovers will belong to him and will be embodied by him for the very fact that it was not prescribed. It will not be something external to be doled out like medication according to the benevolence of some “expert.” Your client becomes the expert. The truth is, there will be plenty of room in therapy for talking about emotions; there will probably also be plenty of room in treatment for prescribing self-regulation techniques. You are bringing TSY in as a way to do something new, which is to practice the visceral aspect of interoception, that is, to have unmitigated, uninterpreted body experiences.