AT THIS POINT IN HISTORY, THANKS TO THE WORK OF MANY great practitioners and scientists, we have collectively developed a solid understanding about how traumatic experiences affect human beings. The picture developed by such luminaries as John Eric Erichsen, Jean-Martin Charcot, Pierre Janet, John Bowlby, Mary Ainsworth, Lenore Terr, Judith Herman, Rachel Yehuda, Bessel van der Kolk, and many other pioneers reveals the devastating impacts of trauma on our minds, our bodies, and our relationships. Thanks to continued research in such fields as human development, neurobiology, and epigenetics, our understanding of trauma and its impacts continues to deepen and expand. However, because of the degree of suffering that trauma represents in human terms, from survivors of war, violence, torture, human trafficking, and terror to survivors of chronic childhood abuse and neglect to victims of domestic violence and sexual assault all across the globe, the time has come for us to pivot from our understanding of trauma toward developing and implementing new, effective treatments. Too many studies that indicate the impacts of trauma tend to resort to the hope of a psychopharmacological solution; while perhaps drugs can take the edge off of symptoms (and may even one day erase memories), it is extremely doubtful that they will ever truly heal people from the most insidious reality of relational trauma: that we were deliberately hurt and betrayed by our fellow human beings (most egregiously, by those who were supposed to protect us). TSY is intended most pointedly for people who have experienced this kind of interpersonal trauma and, though I allude to it here, I will explain the rationale in detail.
My basic argument throughout this book is that if we want to treat people who have experienced interpersonal trauma effectively we must use the clinical knowledge available to us and be open to new interventions that recognize the deep and complex nature of these traumatic experiences and not reduce trauma to a set of symptoms that can be medicated away, or for which a simple change in cognitive frame or behavioral patterns will suffice. Our treatments must match the complexity and nuance of trauma itself, and one aspect of the whole person that must not be overlooked or minimized is the experience of being embodied. For it is the body, the result of billions of years of evolution, that ultimately defines us as being human.
In this book I explain the fundamentals of trauma-sensitive yoga (TSY), an intervention based in and completely reliant on the body, as an adjunctive treatment for individuals impacted by trauma. My intention is to offer a rationale for its use, describe the evidence accumulated on its behalf so far, and provide specific techniques and practices that can be utilized by clinicians and clients as they work together to heal one of the most insidious wounds a human being can experience.
In 2003 yoga was first used as an adjunctive treatment for trauma at the Trauma Center in Brookline, Massachusetts. From its beginning, the Trauma Center Yoga Program has been a collaborative effort among yoga teachers, clinicians, neuroscientists, and our clients. In keeping with our desire to accumulate objective data as to the efficacy of our intervention, one of the first steps we took was to create a small pilot study to measure in a clinical setting the impact of yoga on adult survivors of chronic childhood abuse and neglect. Our concern was that our clients as a group reported explicitly or demonstrated in various ways a deep and abiding hatred for their bodies, and we did not see a talk-based approach to therapy as being an adequate way to engage such visceral self-hatred. We thought we could use yoga as a way to help people to befriend their bodies and that this newfound friendliness would contribute to positive therapeutic outcomes. Therefore, as a team, the first measurement we came up with was a body awareness scale that we could use to measure trauma sufferers’ sense of themselves and relationship to their physical beings. This instrument was proprietary so it had never been used or tested in any other study, but we wanted to see if doing yoga could indeed change a traumatized person’s perceptions of her body. In addition we decided to compare our yoga group to a dialectical behavior therapy (DBT) group that was ongoing in our clinic. We chose DBT for comparison because it is a treatment often used for trauma survivors and it is primarily a cognitive approach as opposed to our use of yoga, which is primarily physical. I should say that, at this point in our work, we referred to our intervention simply as “yoga” or “gentle yoga.” It wasn’t until we really started to establish the theoretical underpinnings and specific methodology behind our approach that we coined the specific term trauma-sensitive yoga.
What did we learn as a result of this simple survey and comparison? The yoga group did indeed feel much better about their bodies, and the DBT group felt the same or worse about theirs (van der Kolk, 2006). This simple result in our small pilot study encouraged us to look further into the possibilities of yoga as a beneficial intervention within the context of trauma treatment.
After a few years we were able to conduct another, slightly larger pilot study that was also positive in terms of body perception, this time comparing our group of trauma survivors with a group without a significant trauma history. Then, in 2009, we were fortunate enough to receive the first grant ever awarded by the National Institutes of Health (NIH) to study the use of yoga for trauma. For the purposes of this study, in order to generate some empirically sound data, we needed to study the effects of our yoga protocol on symptoms associated with posttraumatic stress disorder (PTSD). In this book I discuss some of the differences between PTSD and other trauma frameworks that, while not officially diagnostic at the time of this writing, nonetheless, more accurately describe the clients for which TSY was developed. These phenomena include complex posttraumatic stress disorder (CPTSD), complex trauma, and developmental trauma, all of which imply a more prolonged exposure to interpersonal trauma, such as a child growing up in an abusive home, as opposed to a single incident, like a car accident, which might result in a PTSD diagnosis. So, while the subjects in our study were survivors of multiple, interpersonal traumas, usually beginning in early childhood, everyone also had to qualify for a PTSD diagnosis in order for us to be able to measure any clinically relevant changes that might result after 10 weeks of TSY. Our hypothesis was that TSY participants would show a clinically significant reduction in PTSD symptomology and this is, in fact, what we found (van der Kolk et al., 2014). As a result we are now able to say that TSY is a promising intervention that has clinical relevance for people in treatment for PTSD.
However, as I indicated, there is more to the story because our study also included in-depth interviews with TSY participants that were intended to address the deeper meaning of the TSY experience in relation to the impacts of the complex, long-term, interpersonal trauma that our study subjects had experienced. These qualitative interviews, designed and implemented by Jennifer West (West, 2011) and written about by her in the foreword to this book, indeed revealed a more complex picture. PTSD symptoms in particular were positively affected after 10 weeks of TSY and participants also reported that the TSY practice had an impact on their lives beyond the PTSD symptom set; that is, not just symptoms were affected but also participants experienced themselves in the world and in relation to other people in profoundly new ways.
So we concluded that TSY is a relevant intervention for people with PTSD who also have complex trauma histories. This indication, which was revealed in our clinical trials, also aligns with our personal experience of using TSY with complexly traumatized individuals, both male and female, youths and adults, in a wide variety of settings. As a result of our clinical trials, the Trauma Center Yoga Program developed a team of qualified yoga teachers who have collectively taught thousands of TSY sessions since 2003 to groups and individuals suffering from complex trauma, including men and women who grew up in abusive or neglectful environments, as well as survivors of interpersonal violence, sexual assault, war, torture, and more. Over the course of this book, I will share examples of some of these stories with you (please note that all names used in the stories throughout are pseudonyms, and all of the case stories are composites based on clinical experiences). Ultimately, this book is intended to equip you with information and techniques that you can use in your therapy work; it should not simply serve as an interesting read, though I hope it is that as well.
I begin in Chapter 1 by exploring the principles and parameters of TSY, including how it differs from traditional yoga and other somatic (or body-based) models of therapy; what its theoretical underpinnings are; which clients can benefit from it most; and who might not be best suited to take advantage of the therapeutic qualities of TSY.
The remaining chapters highlight the core aspects of TSY methodology. I will introduce the key concepts of interoception, choice making, and action taking, and I examine how to use TSY for such therapeutic goals as working with rhythm and movement, being present, and sensing muscle dynamics. Throughout, I offer a look at both why and how to use various aspects of the treatment under different conditions and with different clients, in order to maximize the results. While by no means being exhaustive, the book will end with a “portfolio” chapter that presents a number of illustrated yoga forms that readers can use as soon as they and their clients feel ready to do so.
Before we delve into the rest of the book, I’d like to highlight an important, foundational concept of TSY: you do not need to be a yoga teacher, or really have any prior experience with yoga for that matter, in order to incorporate TSY into your practice. In fact, this book assumes that most readers are not yoga teachers but are approaching the material as qualified mental health clinicians or the equivalent. You will rely first and foremost on your clinical training in order to help you establish when TSY might be appropriate for a given client and then to be able to titrate its use, depending on your assessment of its efficacy. That said, the more familiarity you develop with the contents of this book and with specific TSY practices, the more integrity the intervention will have. My assumption is that if you conclude TSY is good for your client you will also notice that in many fundamental ways it is also good for you so you will be interested in practicing it for yourself, and thereby strengthen your effectiveness as a facilitator!
My hope is that this book, while providing some insight into the nature and impacts of trauma exposure, will be a useful guide to a new treatment modality that has the potential to increase the benefits of your clinical work.
Interlude
When the truth is finally recognized, survivors can begin their recovery.
—Judith Herman, M.D.
Historical truth is established by what gets told, not by what actually happened.
—Daniel N. Stern
Judith Herman, a pioneer in the field of modern trauma study and treatment, suggests that “when the truth is finally recognized, survivors can begin their recovery.” But what does it mean to “recognize truth”? What is truth? It may be that the truth Dr. Herman is pointing to here is what one remembers about the past. Indeed, many trauma-informed therapists believe that it is critical for survivors to have access to this kind of truth: that which we remember. However, Daniel N. Stern, a pioneer in the field of developmental psychology, an expert in infant development, and the author of the book The Interpersonal World of the Infant, says that the “historical truth is established by what gets told, not by what actually happened.” Now we have to consider our relationship to the truth: is it something we know or is it something we tell? In fact, with trauma, there has historically existed a tension between what actually happened and what is told about it. One way to resolve this tension would be to decide what is more important: what is told or what actually happened. TSY was developed in a context where what actually happened matters more than what is told about it. Further, the truth of “what actually happened,” which Stern calls our attention to, may not be something carried in our explicit memory and therefore may not be something we can either fully recall or tell someone else about. It may be something that only our body knows and remembers. In fact, it may be something that we cannot speak of but that we can feel with great clarity right now in our bodies: the eloquence of what we feel but cannot tell. So the truth of memory and cognition is not the only kind of truth that is important to trauma healing. What I feel in my body right now, in the present moment, is at least as important as what I remember about the past and what I tell about it.
This book demonstrates that it would be equally valid in the context of trauma treatment to say that, when the truth is finally felt and acknowledged in the body, survivors can begin their recovery.