Yoga as a Treatment for People with Post Traumatic Stress Disorder: Has it been effective?

SHANNON REGAN

Lesley University: Yoga Culture, Theory and Practice

INTRODUCTION

Someone who experiences combat, abuse, sexual assault or severe accidents or loss can suffer from post-traumatic stress disorder (PTSD) (Foa, 2009). People who suffer from this disorder can experience life altering symptoms that may include severe anxiety, dissociation, flashbacks of the trauma and depression (Foa, 2009). “The U.S. National Comorbidity Survey7 found that an estimated 88% of people with PTSD had at least one other co-occurring psychiatric illness “(Emerson, Sharma, Chaudhry & Turner, 2006, p.123). Many people with PTSD have a form of anxiety, depression, or substance abuse problems (Cleveland Clinic, 2009). The intricacy of PTSD leads to the need for a well-rounded healing plan. Medication and coping skills are the main treatments for PTSD. The integration of yoga in clinical settings help people with PTSD have another way to cope with their traumas. 

I have had PTSD for about eight years and have tried numerous treatments. Until recently I never thought of mindfulness or yoga as a healing aid. Throughout the past nine years I have not been satisfied with the westernized approaches to healing. Many times I felt as though I was stripped of any human qualities and became my disorder. I was no longer “Shannon” I was depression, or anxiety. When I began my academic career at Lesley College I was exposed to a holistic approach to healing which included yoga. Integrating yoga into my life has helped me learn well rounded coping skills that I have incorporated into my treatment. This topic has sparked my own emotional growth which urged me to explore how much yoga is effectively being used in the treatment of PTSD.

THE CONNECTION BETWEEN MIND, BODY, AND HEALING

            For someone who suffers from PTSD it can be hard to want to be one with your body. Many people who suffer from trauma see “being grounded as literally feeling their feet on the floor; being present means knowing where they are and what’s going on around them” (Wills, 2009, para. 2).  The flashbacks and disorientation that comes along with PTSD makes it hard to find a sense of security or belonging mentally and physically. Mental health practitioners are starting to see this harmony as a key healing step in coping with PTSD.  Van der Kolk summarizes the importance of the mind body connection perfectly: “The memory of the trauma is imprinted on the human organism…you can’t overcome it unless you learn to have a friendly relationship with your body” (Wills, 2009, para. 9).  The effect of stress from traumatic events is literally imprinted in the body by chronic pain, elevated blood pressure, difficulty with breathing, increased heart rate, chest pain, migraines, and muscle tension. (Hewitt, 2009) It would make complete sense that someone with constant physical reminders and nagging pain would have a hard time finding peace with their body and allowing a healthy relationship to unfold. Physical pain is the easiest thing to focus on, and one signal of stress that is hard to ignore. Trying to quiet your mind when your body is constantly sending pain signals to the brain is both physically and mentally draining. To put effort into just feeling “normal” or “functional” drains your body and mind day after day.  Yoga may allow a person to pay attention on the effort they are putting into certain sensations and learn how to lessen that effort to create a healthy balance.

 Other treatments such as psychotherapy, cognitive behavioral therapy, or medicines such as Prozac are usually only one dimensional (Foa, 2009).  Many medications have severe side effects or their positive effects plateau after time. When you treat someone like a list of symptoms it does not allow someone to heal their actual emotions, only rearrange the chemicals in their body. While these therapies are useful for a large majority of people with PTSD, therapists, survivors, and the medical community are seeing the importance of covering the network of issues that arise from PTSD. "Traditional trauma therapy is talk-based and focuses on the mind, the story, tending to neglect the physical, visceral, and body-based dimension of trauma” (Emerson, Sharma, Chaudhry & Turner, 2006, p. 125). Complementary treatments, specifically yoga allow patients to create a well-rounded and multi-dimensional healing plan (Rosenberg, 2012). Yoga allows people to integrate their mind and body for a holistic healing. Yoga is something that patients could use for long term to help them heal through every stage of their lives. Too often than not in the Western medical treatments people are minimized down to a list of symptoms and all their human qualities are pushed away. The integration of complementary and alternative treatments such as yoga I believe is a response to the lack of lasting and wholesome healing.  In many other cultures the definitions of healing is much more holistic and looks at the root of a disease or issue. The integration of mind, body, and spirit is essential.

PTSD STATISTICS AND TREATMENT IN DIFFERENT POPULATIONS

            A large population of PTSD sufferers involves veterans. “According to a 2008 RAND Center for Military Health Policy Research study, nearly 20% of combat troops returning from Iraq or Afghanistan met criteria for either posttraumatic stress disorder (PTSD) or depression” (Stoller, 2012, p.59) Looking through a broader perspective, in the United States of America 6.8% of the population is struggling with PTSD. In other countries around the world that has more face to face combat, natural disasters or poverty the rate can reach up to thirty percent. (Brown, 2011).  Due to the fact that trauma is universal there is an increasing need for an effective treatment to this resistant psychological disorder.

            While trauma is seen in the majority of countries worldwide, coping mechanisms vary within cultures. One notable example of how certain cultures differ is explained in Crazy Like Us: The Globalization of the American Psyche. The author Ethan Watters describes how the people of Sri Lanka reacted to the tsunami that took place in 2004. Western psychologists thought that after the tsunami there would be a devastating amount of people with PTSD and it would be an optimal opportunity to study the effects of PTSD on a whole community.  When the psychologists got over to Sri Lanka they were “worried by the fact that the children in the village he was working in were more eager to get back to school than to talk about their frightening experiences. His explanation was that they were “clearly in denial” (Watters, 2010).  This event shows how out of touch traditional Western ideals are for the holistic healing of all humans. America has a superiority complex rooted in its beliefs and tends to overlook other cultures. I believe situations like this coupled with the growing frustration of the pushing of drugs in the West people have started to try many CIAM treatments, especially yoga as a way to deal with a number of disorders.

TRAINING

Another notable setback is the lack of teacher training for yoga concentrating on PTSD treatment. There was a study that involved one hundred and twenty-five Veteran PTSD treatment programs which took a part of an 81-idem survey that analyzed a multitude of aspects of complementary and alternative practices, including yoga.  One of the top complaints from the patients with PTSD that took part in the study was the lack of trained staff. (Libby, 2012) One of the most important things that teachers are made aware of is the comfort boundaries of the client and creating a healing environment. Teachers have to be hyperaware when working with people with PTSD because anything from breathing to a certain movement can be a trigger.

      One aspect that is important to the practice is the environment. Many people with PTSD do not feel safe within their own body so stepping into a new environment can cause heightened anxiety and symptoms. Some of the recommendations that the Trauma Center at Justice Resource Center in Brookline, MA gives is to have soft lighting, limit mirror use, try to create a silent practice room, and control entrances and exit use during the classes. (Emerson, Sharma, Chaudhry & Turner, 2006). Teachers should also not be a distraction throughout the practice but an aid. Their attire, voice, and movements should not draw attention or be too over bearing. They should be a guide but not overwhelm the patients. They should also use nurturing phrases and not get caught up with the technicalities but pay attention to their client’s ability level (Emerson, Sharma, Chaudhry & Turner, 2006)

Teachers are also urged to not touch their clients unless they are told it is okay to do so. Teachers also have to be aware that certain poses that can be triggering such as child pose. Kolk said that the most important thing a teacher is to do is “facilitate self-regulation techniques to help people use pranayama and movement to stay relaxed in the present moment” (Kolk, n.d)

      During a PTSD yoga session there are certain breathing practices to avoid or integrate. Slow and extended exhalations seem to be healing for trauma while kapalabhati can be triggering and cause hyper breathing and over stimulation (Karl, 2012).

CULTURE

            Hatha Yoga has three main components:  asana practice, pranayama breathing, and meditation/chanting.  A well balanced practice involved all three components and allows the individual an opportunity to be deeply immersed in their practice. In the West the focus is typically on asana practice and is seen as a form of exercise by the majority of the population. Although, in clinical settings the focus is centered on pranayama and meditation, while not really being supplemented with asana practice.  I think that asana is something that should be valued as much as pranayama or meditation.

I feel as though in the             West much of the population has a tendency to think that enlightenment and emotional healing can only be achieved with deep thought or meditation and this expectation has been adopted in the clinical world when working with clients with PTSD. Physical activity is tended to be seen as a health benefit separate from the mind. It is interesting that movement would not be incorporated seeing that someone with PTSD has a tendency to be anxious and applying physical movement may help quiet down their thinking. It may even be beneficial to start the healing program with a focus on more asana to try to focus their thoughts on the practice rather than their trauma or thoughts. As time goes on slowing down the practice and switching the focus on breathing and meditation may help the clients feel more ready and empowered to deal with the thoughts in their mind.

            One case where I found an emphasis on balance between asana and pranayama was the Trauma Center in Brookline, MA. Depending on the population a teacher is working with can change the activity level of the class. For example if the class is catered towards marines then there should be quicker movements and more action. If the class is for neglected children there may be more of a mix between strength poses and low impact, and slower movements. (Emerson, Sharma, Chaudhry & Turner, 2006).

POSSIBLE NEGITVE SIDE EFFECTS OF YOGA

            In the West it seems like yoga has been manipulated and tweaked to become a panacea. I feel as though it is a western behavior to generalize things as a miracle treatment. It can be dangerous for someone to stop medication or start yoga without making sure they are in a healthy physical condition. Yoga’s initial purpose was not to be used in clinical practices and to be molded into a Western medical model. Although yoga is still classified as a CIAM treatment, the West has stripped it of most, if not all its religious and philosophical principles. This manipulation can be dangerous for people who are in a broken state and looking for a way to end all their suffering. The religious and philosophical side of yoga could add another empowering element to patients. "People with high levels of existential well-being tend to have a good base, which makes them very centered emotionally” (Gipson, 2008, para. 3).  Understanding or following these existential principles may deepen the patient’s practice and understand why there is a variety of poses and breathing practices. I find it disheartening that the West has over looked a potential tool for patients with PTSD. From my perspective it seems that religion has a negative connotation in my generation. I feel as though the clinical world in the West overlooked these teachings because it does not follow the traditional colonial perspectives that the country was built on. To many patients introducing faith or a belief could be just another tool found through the integration of yoga. Yoga holds many impressive claims, yet generalizing the claims to all kinds of practices can lead to more suffering. Many times people see the negative side of medication, but not treatments such as yoga. Not being educated about yoga can be just as dangerous. For someone who is suffering from PTSD they have to be careful of what yoga classes they attend and find an educated teacher to help treat them in an effective manner where they will be safe. The teacher will help aid the creating of a safe environment for their clients which is important for healing. Someone who independently tries to deal with a serious case of trauma on their own by using only yoga can be dangerous as well. Certain moves can strain you physically and mentally if battling with a serious disorder such as PTSD.  It is important to learn how to make your practice work for your needs. Many people with serious disorders such as PTSD need the assistance of psychiatrist, medication, along with the assistance of complementary and alternative treatments.

PHYSICAL CHANGES THROUGH YOGA

            Not only does yoga help on a psychological level, it can help ease the stress on the body while living with PTSD. It has been found that people that have experienced trauma and experience post-traumatic stress symptoms tend to have lower heart rate variability. A lowered HRV can intensify PTSD symptoms and make it hard to lower anxiety and effects of stress. It has been suggested that HRV can be improved through yoga (Emerson, 2011).

            Stress responses involve the body’s main homeostasis maintaining systems. “Stress response involves two way communications between systems such as the brain, cardiovascular, immune, metabolic, nervous, and HPA axis (Streeter, 2012).  Elevated cortisol levels are also found in people with PTSD that causes a higher arousal of stress responses. With the integration of yoga poses and meditation it has been shown to lower cortisol levels which helps regulate the HPA axis and GABergic systems” (Streeter, 2012, p.1). It is important to acknowledge the physical effects of yoga while looking at a disorder such as PTSD, because healing does not just come from a healthy mind but a well-balanced body.

 While these findings are hopeful there are still other variables I think should be explained in the study. During many of these trails the participants are closely watched and receiving attention that most likely is not normal in daily life. It would be useful to know how much the relationship between the doctors, yoga teachers and the participants played a role in the healing process. In many complementary and alternative treatments many of the critical perspectives center on the placebo effect. While yoga holds many physical and physiological benefits, I believe there are some elements of the placebo effect playing a role in this treatment. In general many people start yoga with an intention, especially in a clinical setting where yoga is supposed to help heal a disorder. I think using yoga in a clinical setting aids the placebo effect because the population who is taking a part in the treatment is looking for something healing. The patients also have the support of a teacher, and the community of their yoga class. Having a supportive community can empower someone greatly. I think it would be interesting to compare someone continuing yoga alone to help their PTSD versus someone who continues to take specific yoga classes to help treat their PTSD.

 I came cross another common issue, which is most of the studies does not document what specific poses, or breathing techniques they are using.  I wonder how the different branches of yoga would hold up to these claims.

CONCLUSTION

            While there have been some impressive trials that support the use of yoga for the treatment of PTSD, there is still some major shortcomings that need to be taken care of. The programs that have been started and successfully integrated into therapeutic settings urges researchers to continue to study the benefits of yoga as a complementary practice while helping people with PTSD.

On a personal account I believe yoga can test you in ways you never thought was possible. When I began yoga, my intention was not about healing my disorder, but overtime I realized healing was happening under the surface. I found myself squirming during meditation and wondering why I couldn’t sit still. Over a couple of weeks I allowed myself to pay attention to my thoughts when I would feel uncomfortable and I found that I was uncomfortable in my own skin. I was not used to taking time for myself or paying attention to my body and mind connection. I found a lot of negativity in my thought throughout the practices. It amazed me how much I beat myself up. Through the couple months of practice my intention became clear. I worked on being kinder to myself and tried to redirect my negative thoughts about myself. My experience helped me cope with some of my emotional effects from my traumas.

Traumas and fears are the hardest things to not judge or silence. Being present in a moment is almost impossible for me because of the feelings of vulnerability. As with any new practice people can be apprehensive to partake in something that can make them focus on their struggles.

I found that a lot of the research on this topic is repetitive. It was hard to find case studies that took in account outside variables and showed the other forms of treatment they were receiving. Another limitation I came across was many of the studies only had on average a six week period of yoga that they were covering which made it hard to see if the integration of yoga in a residential environment would be more or less beneficial. I think they need to focus on longer trials that cover clinical and residential use of yoga in the treatment of PTSD. I also found that many of the studies centered on Veterans. On top of the Veterans I think it is important to see more studies incorporating a greater variety of people of different traumas and ages.

References:

Foa, E. (2009). Effective treatments for ptsd: Practice guidelines from the international. New York: Guilford Press.

Emerson, D., Sharma, R., Chaudhry, S., & Turner, J. (2006). Yoga therapy in practice trauma-sensitive yoga:principles, practice and research.

Stoller, C. (2012). Effects of sensory-enhanced yoga on symptoms of combat stress in deployed military personnel.

Brown, M. (2011). Today: Us national post-traumatic stress disorder awareness day. PLOS Medicine Community Blog,

Karl, Linda. (2012)  Compassionate Presence: Teaching Trauma-Sensitive Yoga. Insight

Streeter CC et al.(2012). Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy,depression, and post-traumatic stress disorder. Med Hypotheses

Emerson, David, and Elizabeth Hopper. (2011).Overcoming Trauma through Yoga: Reclaiming Your Body. Berkeley, CA: North Atlantic

Hewitt, Doug.(2009). "Physical Symptoms of PTSD." LIVESTRONG

Rosenberg, Tina. (2012). "For Veterans, a Surge of New Treatments for Trauma." Opinionator For Veterans a Surge of New Treatments for Trauma Comments. Opinionator

Kolk, Bessel Van Der. (n.d). "YOGA AND POST - TRAUMATIC STRESS DISORDER." Special Section I: Yoga & the Emotional Body

Wills, Denise. (2009) "Healing Life's Trauma." Yoga Journal

Watters, Ethan.(2010) Crazy like Us: The Globalization of the American Psyche. New York

Libby, Daniel J. "Issues in Yoga Therapy The Use of Yoga in Specialized VA PTSD Treatment Programs." INTERNATIONAL JOURNAL OF YOGA THERAPY (2012)

Gipson, A. (2008). Study finds link between faith, depression. USATODAY

Depression and other mental illnesses. (2009). Retrieved from http://my.clevelandclinic.org/disorders/depression/hic_depression_and_other_mental_illnesses.aspx