Monday, May 2, 2011

A Victim's Treatment: Yoga as a Therapeutic Approach to Trauma

In America’s violent culture today, trauma is something that anyone can endure at any time. Everyday many people suffer trauma of all intensities in many places of the world. Unfortunately, many people do not or are not able to receive the therapy and the help that they need. Many people do not enjoy having to sit and talk about their feelings to a complete stranger. When trauma becomes overwhelming for an individual, that individual may develop what is called posttraumatic stress disorder. It is a psychiatric disorder that affects daily life and has long-term effects on an individual’s mental health. Although there is help for people with this disorder, not a lot of the interventions are effective for all the symptoms of posttraumatic stress disorder. However, one effective intervention, the use of yoga in therapy, is seen to be quite an effective and successful intervention that works well with posttraumatic stress disorder victims and it seems that this therapeutic technique works wonders with clients.
Trauma and Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is “the most common and carefully delineated psychiatric disorder found in trauma survivors” (T. Muser, H. Rosenberg, S. Rosenberg, 2009, p. 37). It was first observed by researchers of war trauma during the years of World War 1, II, and the Korean War (Courtois, 2008). Trauma survivors include those who suffer the trauma directly or those who have witnessed traumatizing events. Trauma can be experienced by any person at any age, in any setting, in any culture, and anywhere in the world. The populations that typically experience posttraumatic stress disorder due to prior trauma are victims of abuse, whether it’s sexual, physical, or emotional, victims of natural and man-made disasters, those who have served in combat and war, or people who have lived or were exposed to traumatizing events, such as homicide, serious car accidents, sudden life-threatening illnesses, or death (Flannery, 1992). However, it has been seen that not all events or occurrences that cause an individual to endure an overwhelming amount of stress are considered traumatic events. According to the DSM–IV diagnostic requirements for posttraumatic stress disorder, the “characteristics of the precipitating traumatic event, according to the DSM–IV, require “experiencing, witnessing or being confronted by an event . . . that involves actual or threatened death or serious injury, or a threat to the physical integrity of self or others” (T. Mueser, H. Rosenberg, S. Rosenberg, 2009, p. 42). There is no telling whether or not someone will suffer from posttraumatic stress disorder after a traumatizing event; however, therapists look for signs and symptoms that have appeared longer than one month because it allows the therapist to correctly diagnose it. Unfortunately, many people do not get the help that they need because of fear, denial, or they are unable to. Sadly, the people who do not receive some type of therapeutic help are often swallowed by their traumas and their lives are completely affected in a very detrimental way.
According to Flannery (1992), there is a reported over two and one-half to five million Americans who suffer every day from the damaging effects that occur with posttraumatic stress disorder.
“The severity of the trauma, the number of traumas the person has been exposed to in a lifetime, the nature of social supports available, and the quality known as psychological hardiness or resilience all influence the likelihood of developing PTSD following exposure, as well as influencing the severity and chronicity of this disorder” (T. Mueser, H. Rosenberg, S. Rosenberg, 2009, p. 38).
In other words, trauma can range in all levels of intensities and posttraumatic stress disorder can result from just one traumatic episode, such a home robbery, or repeated traumatic episodes, such as repeated accounts of sexual abuse by a family friend. “As described in the DSM-IV-TR, PTSD is characterized by persistent reexperiencing of the traumatic event (intrusions), persistent avoidance of stimuli associated with the trauma, numbing of general re¬sponsiveness, and persistent symptoms of increased physi¬ological arousal” (Emerson, Sharma, Chaudhry, Turner, 2009, p. 123). These symptoms worsen as time goes on, especially if the victim doesn’t allow themselves to receive therapeutic help. Individuals with posttraumatic stress disorder often have difficulty calming themselves down and allowing themselves to self-regulate, which leads to a decrease in heart rate variability and increased activation of the sympathetic nervous system (Emerson, Sharma, Chaudhry, Turner, 2009). If the victims of posstraumatic stress disorder don’t allow themselves to discuss their traumatic event or their history of traumatic events, they will most likely repress their thoughts, feelings, and memories of the event or events. Regrettably, this only worsens their condition because repression only leads to a larger amount of deep psychological distress that causes very damaging problems such as psychotic distortions or delusions that surround the topic of the trauma that the individual experienced or is experiencing.
Trauma has long-lasting effects on the mental health of an individual and the unfortunate aspect of it is that it can often be resistant to treatment (Emerson, Sharma, Chaudhry, Turner, 2009). The initial reaction for people who are victims or who witness traumatic events is shock that leads to having feelings of fright, and possibly leading to anger (Flannery, 1992). Those who experience or witness a traumatizing event can often be enmeshed in the trauma and become so overwhelmed by their thoughts and feelings so much that they may become constantly anxious, worried, paranoid, and depressed. “Victims can be in acute crises anywhere from a few days to a month. The fear and anger may be followed by confusion and withdrawal from others. Some victims have trouble sleeping and many have recurrent memories of the event” (Flannery, 1992, p. 7). Surprisingly, these are symptoms of less severity than other symptoms such as flashbacks, which puts the victim right back into the “heart” of the traumatic event. This happens because according to Krishnamurti (1999), we are very attached to our thinking, obsess over the process of thinking, and seem to worship ideas and things that have been put together by our thoughts, especially in western culture. When victims become so wrapped up in their trauma, it creates psychiatric problems and when those problems are not attended to right away, they become worse.
To think about the trauma that people undergo everyday in America is extremely disheartening. People have called America the place where dreams come true and yet great violence, destruction, crime, and natural disasters occur here every single day. According to Flannery (1992), “thirty percent of all combat victims have been psychologically traumatized, and one hundred children die every month from abuse and neglect” (p. 6). These are just two pieces of the many statistics that Flannery (1992) covered in his book, which also included statistics that discussed batterers, abuse of men, women, and the elderly, sexual abuse, violent crimes, the development of disorders that result from the occurrence of abuse, and addictions that potentially lead to abuse. Not only did these statistics not include the people who were traumatized by directly witnessing traumatic events such as these, but these statistics most likely have increased.
These statistics are absolutely earth shattering. Although not everyone becomes completely traumatized by being exposed to or by witnessing stressful life events, but it is extremely important that these people seek professional help from a psychologist or mental health clinician specializing in trauma cases because not having the opportunity to process the feelings that the person holds in relation to the traumatic event or occurrence would most likely increase the person’s risk of developing posttraumatic stress disorder. What can also help a person who is experiencing psychological trauma is being supported by family and friends and living in a positive environment.
“Following certain traumas (e.g., sexual assault), early intervention is considered critical as the level of distress immediately after the assault has a strong positive correlation with the development of future pathologies and PTSD. High distress levels at the time of assault significantly predicted increased levels of fear and anxiety in the following months. The authors suggested that since the level of distress is strongly correlated to PTSD symptoms, an attempt to decrease distress immediately following the event may result in a more positive treatment outcome” (Telles, S., Singh, N., Joshi, M., Balkrishna, A., 2010 p. 1).
As Emerson, Sharma, Chaudhry, & Turner (2009) have stated, treatment interventions are extremely important when it comes to individuals with posttraumatic stress disorder because as one can see, trauma is highly prevalent in our society. The development of an effective treatment intervention takes careful and continuous planning. However, not every type of therapy or intervention works with every individual that is diagnosed with posttraumatic stress disorder. The therapeutic approach must address the levels of the individual where posttraumatic stress disorders manifest themselves, which are affectively, cognitively, and biologically (T. Mueser, H. Rosenberg, S. Rosenberg, 2009). The most crucial factor for the treatment of an individual with posttraumatic stress disorder is education and knowledge. It allows clients to understand not only about the therapeutic process, but also about what posttraumatic stress disorder is and what can be done to help it. That is why it is very essential to have early intervention and a variety of treatments because everyone is an individual and their responses to therapy are most likely going to be dissimilar. In addition to talk therapy, an integration of yoga into therapeutic practice has been happening and it seems to be quite effective. It is great for those who feel that they’ve “lost their voice” to be able to use their body to relieve some of the frustration and their feelings toward a traumatic event.
Yoga and Therapy
“Following certain traumas (e.g., sexual assault), early intervention is considered critical as the level of distress immediately after the assault has a strong positive correlation with the development of future pathologies and PTSD. High distress levels at the time of assault significantly predicted increased levels of fear and anxiety in the following months. The authors suggested that since the level of distress is strongly correlated to PTSD symptoms, an attempt to decrease distress immediately following the event may result in a more positive treatment outcome” (Telles, S., Singh, N., Joshi, M., Balkrishna, A., 2010). What that may mean is that an essential factor in trying to relieve some of the stress an individual may have due to past trauma is integrating a therapeutic approach that may encourage the individual to appropriately control self-regulation and develop the ability to calm themselves in overwhelming situations. In my opinion, yoga can do just that because if one is focused they will be able to calm not only their bodies, but their minds as well. In addition to that, yoga is seen to reduce the activation of the sympathetic nervous system, emotional distress, and physical symptoms, while also increasing that quality of life (Emerson, Sharma, Chaudhry, Turner, 2009). According to Emerson, Sharma, Chaudhry, and Turner, (2009), “Yoga is a promising treatment or adjunctive therapy for addressing the cognitive, emotional, and physiological symptoms associated with trauma, and PTSD specifically” (p. 124). Yoga provides a holistic and therapeutic approach to treatment for individuals with posttraumatic stress disorder and from what is learned from the study of yoga is that meditative and relaxation types of yoga is a phenomenal approach when peace in the mind is greatly needed.
Sudarshan Kriya Yoga (SKY)
Through research, a common yogic technique that I have found is Sudarshan Kriya Yoga (SKY) which is a yogic technique that involves “rhythmic hyperventilation at different rates of breathing” (Telles, S., Singh, N., Joshi, M., Balkrishna, A., 2010, p. 2). One study that used this type of yoga was conducted on Bihar flood male survivors, a month after the natural disaster, in order to monitor the amount of posttraumatic stress following the use of yoga as an early alternative therapeutic technique and its effects on the flood survivors after one week of practicing. Another type of yogic technique that was used in this particular study was Siddha Samadhi Yoga which associates pranayama, or yoga breathing, with mindful meditation, and used “voluntary breath regulation” (Telles, S., Singh, N., Joshi, M., Balkrishna, A., 2010, p. 2). Both of these types of yoga would certainly work well, in my opinion. Not only are the victims of posttraumatic stress disorder able to try to quiet the mind, which I understand can be detrimental for some because they cannot handle the thoughts inside of their mind and they feel that they always must be thinking something or else the traumatic thoughts may appear, they are also able to practice their goal of self-regulation by learning to first regulate their breathing. These types of yoga were introduced to the experimental group and this group practiced yoga for at least an hour each morning.
“The yoga class included loosening exercises (sithilikarana vyayama) for ten minutes, physical postures (asanas) for twenty minutes and breathing techniques (pranayamas) for twenty five minutes. These practices were followed by five minutes of guided relaxation in shavasana (corpse pose). Loosening exercises (sithilikarana vyayama) are a set of techniques which involve repetitive movements of all joints from the toes up to the neck to increase mobility and to prepare for the practice of yoga postures”
(Telles, S., Singh, N., Joshi, M., Balkrishna, A., 2010, p. 4). None of the participants had any prior knowledge of yoga. At the end of the study, the autonomic and respiratory variables were assessed with the use of polygraphs, in addition to, emotional responses with the use of visual analog scales (Telles, S., Singh, N., Joshi, M., Balkrishna, A., 2010). It wasn’t surprising to find that there was a decrease in the psychological distress after the study because learning the postures and practicing the breathing techniques everyday is bound to relieve some stress the individual is regulating their whole being. In the end, the visual analog scale also showed a significant reduction in sadness within the yoga group.
Sudarshan Kriya Yoga (SKY) was also a yogic technique that was used for veterans the Vietnam War. Dissimilarly, the results of that particular study demonstrated that Sudarshan Kriya Yoga postures was more successful because it had been paired with Ujjayi , which is another form of a pranayama practice, and meditation (Brown, R. P., & Gerbarg, P. L, 2005). Studies have shown that it is more effective for the treatment of the individual if all three practices were integrated because it is the use of synergistic yoga which is found to be a highly effective approach for some of the individuals with posttraumatic stress disorder because the integration of too different breathing practices truly allows individuals reshape their lives with yoga being the first step towards treatment. “The overall effect is amelioration of feelings of fear, neglect, abuse, rejection, depression, isolation, and worthlessness” (Brown, R. P., & Gerbarg, P. L, 2005, p.713). Individuals are helped to focus their minds and at the same time are using yoga to help them accept who they are and to acknowledge the traumas of their lives, recognize that they are not their traumatic experience and that they are separate from that, and that they are able to move on from the past. Overall, I find Sudarshan Kriya Yoga (SKY) to be quite effective and as was seen previously, this type of yoga can be used for individuals who have experienced trauma on any level, at any intensity, and from any setting.
Hatha Yoga
Another yogic technique that was found to be helpful is hatha yoga. Hatha yoga is used for the trauma survivors enrolled in the Trauma Center Yoga Program. Their mission at the center is truly inspiring. They want to make sure that each individual is receiving holistic attention when practicing yoga for trauma because traumatic events affect the entire person, which includes body, mind, and spirit (Emerson, Sharma, Chaudhry, Turner, 2009). “Yoga, when skillfully employed, can uniquely address the physical needs of a trauma survivor, and provide a way for a trauma sur¬vivor to cultivate a friendly relationship to his or her body through gentle breath and movement practices” (Emerson, Sharma, Chaudhry, Turner, 2009, p. 124). They start the classes off slowly with warm-ups and stretches in order to establish a quiet, non-judgmental, and safe environment for them. Then it continues with yoga postures. Each class is focused on the individual or group of individuals that the instructor is working with. The individuals taking the class are not forced to do every pose or do all of the breathing practices. At the Trauma Center they encourage the individuals who are suffering from posttraumatic stress disorder to go at their own pace and to relax when they need to. This reminds me of how similar my class experience is to this experience, nice, quiet, and slow, where as power yoga is fast-paced and can be seen as somewhat chaotic to people who are suffering from posttraumatic stress disorder. This truly demonstrates that it is important for the body and mind to integrate. During my study of yoga I have come to realize that my body affects my mind, but my mind also affects my body. This type of yoga also shows to be very effective because the studies have shown that all of the symptoms of trauma were decreased, especially in the severity and the frequency of the posttraumatic stress disorder syndrome (Emerson, Sharma, Chaudhry, Turner, 2009, p. 124).
Conclusively, I strongly believe that yoga can be a very successful technique to use for professionals to use for their clients who suffer from posttraumatic stress due to being the victim or a witness to a traumatizing event and eventually developing post-traumatic stress disorder. The use of yoga breathing techniques can be very beneficial because it allows the diagnosed person to be able to calm the body, which in turn can calm the mind, as we have learned from Muktibodhananda’s Hatha Pradapika. “Through the breath, prana and consciousness are essentially linked; they can be separated by a scientific means which starts with the yogic technique of learning to retain the breath” (Muktibodhananda, 1998 p.157). By practicing to pay close attention to the breath, a person may be able to focus the mind, in order to break away form the stress that is inflicted on them. As van der Kolk (2009) states that when people endure posttraumatic stress disorder their bodies become enveloped in it, but yoga helps to build a strong and more comfortable body. I can understand how this yoga breathing technique might not be able to work for everyone because silence and focus might trigger something deep within them and cause them to bring themselves back to the traumatic event. However, this is often the goal of trauma psychotherapy because when a person is able to successfully process the traumatic event in a healthy way, they can lessen their intense reactions to the triggers that cause the posttraumatic stress. “A review article described breathing as fundamental for physical well-being as yoga breathing ‘can rapidly bring the mind to the present moment and reduce stress” (Telles, S., Singh, N., Joshi, M., Balkrishna, A., 2010, p.7). The loosening exercises and the relaxation techniques seemed to have worked well with the flood survivors, just as hatha yoga works with the clients of the Trauma Center. Singleton (2010) notes that asana and pranayama dominate the west’s popular cuture and I have to agree with that because we can see it everywhere, in the media, in every city, and now we see it for therapy. Honestly, I could definitely see myself using breathing techniques or possibly even poses in my work as a mental health counselor. I feel that this may not be for every client that may walk into my office, but I think it is a great and a very effective alternative that may be able to truly strengthen the therapeutic relationship with my clients as well as encourage the movement of growth and development for my client in the therapeutic process.

Mueser, K. T., Rosenberg, S. D., & Rosenberg, H. J. (2009). Assessment of trauma and posttraumatic disorders. In K. T. Mueser, S. D. Rosenberg, H. J. Rosenberg (Eds.) , Treatment of posttraumatic stress disorder in special populations: A cognitive restructuring program (pp. 37-52). American Psychological Association. doi:10.1037/11889-002
Muktibodhananda, S. (1998). Hatha Yoga Pradipika. Bihar, India: Yoga Publications Trust.
Telles, S., Singh, N., Joshi, M., & Balkrishna, A. (2010). Post traumatic stress symptoms and heart rate variability in Bihar flood survivors following yoga: a randomized controlled study. BMC Psychiatry, 1018-27. doi:10.1186/1471- 244X-10-18
Flannery, R.B. (1992). Post-Traumatic Stress Disorder. New York, NY: The Crossroads Publishing Company.
Brown, R. P., & Gerbarg, P. L. (2005). Sudarshan Kriya Yogic Breathing in the Treatment of Stress, Anxiety, and Depression: Part II—Clinical Applications and Guidelines. Journal of Alternative & Complementary Medicine, 11(4), 711-717. doi:10.1089/acm.2005.11.711
Emerson, D., Sharma, R., Chaudhry, S., Turner, J. (2009). Trauma-sensitive yoga: principals, practice, and research. International Journal of Yoga Therapy, (19). Retrieved from
Van Der Kolk, B. (2009). Yoga and posttraumatic stress disorder. Integral Yoga Magzine.
Singleton, M. (2010). Yoga body: the origins of modern posture practice. New York: Oxford Press.
Courtois, C. A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, and Policy, (1), 86-100. doi:10.1037/1942-9681.S.1.86
Krishnamurti, J. (1999). The light in oneself: True meditation. Boston: Shambala Press.

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