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