Relatively speaking, Posttraumatic Stress Disorder is still a diagnostic adolescent. Not officially recognized until 1980s in DSM III and driven by reactions to combat, we are still learning so much and yet so many questions remain. One thing that is clear, the prevalence of those who have experienced trauma is much higher than previously thought and affects more than just veterans. To complicate matters, like all mental health treatment, one size does not fit all. In recent years, research has been exploding on the integration of bodywork into or as an adjunct treatment to therapy.
As a Psychologist, I have been studying and integrating yoga and yoga theory into work with clients with many different diagnoses, including PTSD. Yoga is a benefit-packed practice that is receiving a significant amount of attention from the trauma world. The Trauma Center, in Brookline MA1, has created a new style of yoga called Trauma-Sensitive Yoga (TSY)2. This practice differs from your standard yoga class in many ways and emphasizes one very important piece of the puzzle: choice. Typically, yoga classes are prescriptive in that they direct yogis from pose to pose. Variations and modifications are usually offered but for the most part, all students do as they are told. The option of choice can be very powerful for a survivor of interpersonal violence as they typically have long histories of being told what to do, how to do it, and how to feel about it.
Standard treatment is also often instructive: “Take this medication to help your nightmares,” “Be sure to practice your deep breathing,” and “even though it’s difficult, it’s important to talk about what happened.” In our kindest and most competent effort, we tell our clients what they can do to feel better. This perspective is not meant to discredit any of the evidence-based practice used to treat trauma today as TSY is not considered a replacement. In fact, TSY requires participants to be involved in therapy. Again, TSY provides a choice for clients. I recently had a particularly intense session with a survivor and she opted to end with a brief TSY chair practice to “help her relax” (her words, not mine). As she sat in her chair, I sat in mine, going through the practice. At one point, she simply chose not to do any of the movements offered. At the end of the practice, she provided an unsolicited explanation saying she noticed that a particular movement caused pain in her back. She said she chose to just sit and breathe which ultimately relaxed her. This may seem so trivial but if we think of the therapy office as a micro chasm of the real world, what if this client could always choose not to do something that hurt her? What if she could dictate what she did with her body? What if she could feel safe in her own body? What if she saw an opportunity to break a pattern?
As therapists, we are mindful not to re-traumatize clients but merely taking away a choice, could have a negative impact. Some clients have become so disconnected from their bodies that just recognizing that their body needs something is a challenge. Trauma-Sensitive Yoga offers clients an opportunity to restore that connection and to be the one who chooses how to meet those needs.
Can “Regular” Yoga Help?
The simple answer is, yes. There is an abundance of research available on the use of yoga for anxiety, depression, and other medical and mental health issues. A “regular” yoga class still provides all of those benefits to someone with PTSD/Complex Trauma. However, it would not be considered “trauma-sensitive.” This may be a barrier for some.
The image of a “good yogi” is a petite, toned, young woman in skin tight clothing, effortlessly bending her body into precarious poses all while balancing on one toe. Now for a moment, imagine sending a client with PTSD to a yoga class filled with fitness models who are able to stand on their heads, look good doing it with a teacher who scripts their movements and even adjusts their poses by placing his or her hands on the students’ hips. One might argue that this class would be difficult for anyone to attend. Anyone who has been to a yoga class knows this is not your typical student or class makeup. Classes usually run the age spectrum, a mix of people who are fit and those working to be fit, mismatched workout clothes, and a plethora of skill levels. This is important to keep in mind when making a recommendation for a client to try yoga. If a client cannot get the first image out of their head, they are likely not to attend.
For the client with PTSD, or any mental health issue, yoga can be a wonderful complement. Some of the physical benefits include increased mobility, increased agility, better balance, less muscle fatigue, better breathing, decreased risk of injury, increased core strength, and increased joint stability. Some of the mental benefits would be improved focus, improved concentration, reduced anxiety, improved mood, and better sleep. Yoga can also be more emotionally provoking, releasing, and awakening than a therapy session. People can be flooded with painful, and blissful, emotions during any yoga practice. I am willing to bet anyone reading this article who teaches yoga or attends classes has witnessed someone in tears during a class for no apparent reason. Like therapy, this can lead to healing. However, the client must be prepared to handle this kind of a reaction or risk decompensating or terminating both yoga and therapy. Not preparing a client for this possible response would be comparable to not building coping skills with a client before doing a narrative.
Knowing that yoga can be helpful to those with PTSD is good but one might ask how it can be used with clients. The answer to this is a really big and complex one. Technically, I would suspect that all therapists are using some yogic techniques in therapy already. Anyone use diaphragmatic breathing with clients? Meditation? Relaxation? Often, therapists receive training in these techniques and they come out of the yoga tradition. (I would offer a cautionary statement here with using meditation with clients who have complex trauma as being alone with one’s thoughts may be an awful place to be, guided meditation is perhaps a better option). I believe it is always best to have foundational knowledge of yoga before making recommendations to clients. Certainly, a therapist could receive additional training to become a yoga teacher. If that is not of interest or an option, there are trainings available that provide a basis for integrating this work into therapy. It should be noted that it would not be appropriate to bill insurance for a yoga class in session. These techniques are merely introduced and practiced much like a mindfulness exercise or role playing interpersonal effectiveness skills.
Regarding making referrals to yoga, the majority of studios are not going to offer TSY classes so this begs us to be a little creative and collaborative. Get to know your local studios, classes, and teachers. Develop personal relationships with them so you feel safe sending some of the most vulnerable clients to them. This offers clients a safe continuum of care and this IS our responsibility.
Practicing yoga can also help the therapist. Self-care has gone from progressive idea to an absolute necessity when providing therapy, particularly to clients with trauma histories. As therapists, we are exposed to accounts of people doing unthinkable things to each other. Without taking time to care for oneself, the therapist is at risk. Despite all the education, training, and supervision, we are all still people who are susceptible to the same things as our clients. If we do not take care of ourselves, we limit our ability to care for our clients. All the benefits of yoga to clients also extend to therapists. I am certainly not saying “therapists must do yoga,” I am offering it as a choice.
1 - For more information on Trauma-Sensitive Yoga, visit traumacenter.org.
2 - Resource: "Trauma-Sensitive Yoga in Therapy: Bringing the Body into Treatment” by David Emerson.
For more information on integrating yoga in psychotherapy, visit Replenishonrainylake.com for details on Integrating Yoga into Psychotherapy: Exploring the Research & Practical Applications retreat.