YTT 2020 Essay Assignment

Title: Trauma-Sensitive Yoga

Submitted by:  Kamila Gemin

Date: August 20, 2020

*Revised version for website (Nov 1, 2020)

                                                         

 Introduction

    This paper will explore how yoga can be a helpful adjunct to traditional trauma treatment.  It will discuss the relationship between trauma, suicide, self-harm behavior, and emotion dysregulation.  A history of trauma can increase the risk for suicidal behavior, as many individuals struggle to tolerate intense and uncomfortable emotions and therefore make desperate attempts to numb, cut off or avoid them, sometimes by using maladaptive self-harm behaviors.  While these are complex issues and several factors contribute, it appears that many people who attempt suicide or engage in self-harm have experienced one or more traumatic events.  Many trauma treatments require people to have emotion regulation skills, which include the ability to identify, experience, and manage intense emotions, without using maladaptive behaviors to cope.  Yoga can provide opportunities to experience emotions in a safe way; to reconnect with the physical body, thereby experiencing and tolerating uncomfortable emotions.  This paper will explore how yoga aids in recovery from trauma by outlining four key themes taken from the trauma-sensitive yoga literature: experiencing the present moment, making choices, taking effective action and creating rhythms.

Trauma and Post Traumatic Stress Disorder (PTSD)

“Trauma is the lasting emotional response that often results from living through a distressing event.  Experiencing a traumatic event can harm a person’s sense of safety, sense of self, and ability to regulate emotions and navigate relationships.” (Centre for Addiction and Mental Health, CAMH).  A traumatic event can be a recent or past single traumatic event such as an accident, being the victim of violence, or a sudden unexpected loss.  It could also be events such as living through natural disasters or war, or a long-term chronic situation such as abuse or neglect.  A person who has experienced a traumatic event might develop either simple or complex PTSD.  PTSD is defined as “a natural emotional response to frightening or dangerous experiences that involve actual or threatened serious harm to oneself or others.  However, for some people the thoughts or memories of these events seriously affect their lives, long after any real danger has passed.  These types of experiences are called ‘traumatic.’ ” (CAMH).  Common symptoms of PTSD include, but are not limited to, re-experiencing the traumatic event over and over, recurring nightmares, avoiding places and people that are reminders of the event, acting or feeling like the event is happening again, experiencing difficulty trusting others and having close meaningful relationships, having trouble sleeping, concentrating, losing interest in pleasurable activities, and getting angry easily.  Experiencing a single traumatic event is most likely to lead to simple PTSD.  Complex PTSD tends to result from long-term, chronic trauma and can affect a person’s’ ability to form healthy, trusting relationships.  Even years after the traumatic event occurred, people with trauma can still feel intense emotions such as shame, helplessness, powerlessness, and fear.  It is difficult to say what a traumatic event can be as each person has a unique reaction to distressing events; what is defined as traumatic for some may not be traumatic for others.  However, it is extremely common for traumatic events experienced early in life, such as abuse, neglect and abandonment, to be devastating for people throughout their life.  Also, traumatic events occurring later in life that are out of one’s control and are perceived as life threatening (e.g. accident, violence, war, loss), can also have a lasting impact on one’s mental health.  When thoughts and memories of the traumatic event don’t go away or get worse, they may lead to PTSD which can seriously disrupt a person’s ability to regulate their emotions and maintain healthy relationships.

Suicide

This essay will not do justice to the body of research and information that is available surrounding trauma, suicide and emotion dysregulation; it will simply provide a small window into how suicide can become an option to end pain, for many people suffering from various psychological issues. 

An average of ten people die by suicide each day in Canada and it is the ninth leading cause of death after serious illnesses such as cancer, heart disease, stroke and diabetes.  Across the life span, suicide is the second leading cause of death in children, youth and young adults aged 10 to 29 years; and the third leading cause of death in adults aged 30-44 years.  Suicide continues to carry a negative stigma which causes family members, health professionals, coroners and others to avoid labelling or reporting deaths as suicide.  As a result of this stigma, data may underestimate the actual total number of deaths by suicide and therefore not be an accurate reflection of the true impact of suicide on Canadians.

Suicide, and the factors that lead an individual to end their life, are very complex, which make predicting who will attempt and complete suicide, and treating suicidal behavior, very difficult.  Several risk factors have been shown to increase the imminent risk of suicide including: prior suicidal ideation, prior suicide attempt/behavior, history of deliberate self-harm, family history of suicide, exposure to others’ suicide, history of marginalization, chronic debilitating medical illness, and past and current psychiatric diagnosis.  Other risk factors include hopelessness, isolation, anger/aggression, panic attacks or anxiety, depressed mood, and substance use.  In addition, a non-modifiable risk factor, is the presence of trauma. 

The function of suicide is seen as a solution to ending unbearable psychological pain.  Extreme hopelessness and a belief that things can’t change for the better are also major drivers for suicidal behavior.  While much work still needs to be done to understand suicide, what researchers and clinicians do know, is that “most suicidal people do not want an end to their biological existence; rather, they want an end to their psychological pain and suffering.”  Most suicidal people express that suicide is the most “compelling option” for ending their pain (Jobes 2006).  In addition, most suicidal people have social and psychological issues and poor coping skills.

Attempts have been made to assess an individual’s level of imminent risk for suicide which then helps to lay a few starting points for treatment.  Jobes suggests that five areas can form a basis for exploring suicide risk and thereby creating a treatment plan to target the drivers of suicide for a given individual.  As previously mentioned, psychological pain, or a seemingly unbearable suffering as interpreted by the individual is one main driver for suicide.  He suggests that since this is an individual experience, a way to reduce the risk of suicide in this person, aside from removing the source of suffering, is to find ways to increase that person’s threshold for pain, thereby increasing their ability to tolerate psychological pain.  Secondly, the stress created by external pressures and demands on an individual, such as relationship conflicts, job loss, and other events that create a significant level of distress.  When an individual perceives this stress as exceeding their ability to cope, suicide risk increases.  A third area of focus is ‘agitation,’ the state of being emotionally upset and one’s impulsive need to do something to change their current unbearable situation.  Hopelessness is a significant risk factor for suicide, as hopelessness is “one’s expectation that a negative situation will not get better no matter what one does to change that situation” (Beck as cited in Jobes 2006).  It is suggested that hopelessness has been the most highly correlated risk factor for suicide.  Hopelessness is intimately linked to future thinking, about self, others and the future.  Finally, self-hate, or one’s negative view of self and self-loathing can become so extreme that suicide is seen as a way to escape the self.

Deliberate Self-Harm

Deliberate self-harm or “parasuicidal” behaviors are complex self-injury behaviors, that while highly destructive and dangerous, are not intended to end one’s life.  Examples may include cutting, burning, overdosing, substance use, unsafe sex, and reckless behavior.  These behaviors are often used as ways to cope with intense emotions and dissociation.  Dissociation is commonly experienced by trauma survivors and is described by some as feeling disconnected from reality, feeling unaware of time passing and not knowing what one was doing during that time.  Others described dissociation as feeling like people or things around them are unreal; feeling spaced out, numb or emotionally dead.  Self-harm in the form of cutting, for example, can rapidly reconnect the person with reality and get them out of a dissociative state.  Feeling unable to tolerate intense emotions in response to stress, is a major driver for self-harm behavior.  Unfortunately, this increases risk for a completed suicide when self-harm accidently leads to death.   

Emotion Dysregulation

The overlap between trauma, emotion dysregulation, self-harm and suicide risk creates a confusing and difficult scenario to treat.  Many treatments offered focus on building individuals’ emotion regulation skills in order to reduce risk of suicide, by learning to regulate emotions, improve quality of life, and prepare for trauma treatment.  Earlier this paper highlighted the role of self-harm behavior as a maladaptive emotion regulation strategy.  The example of cutting to reconnect with reality when one dissociates was offered.  Another example is overdosing on various substances as this usually leads to long periods of sleep, which is effective in avoiding the unbearable emotion(s).   Many people also report that thinking about dying and suicide planning, when accompanied by the belief that death will end suffering and pain, can bring feelings of calm and relief.  This type of suicidal ideation and accompanied self-harm behavior can also reduce painful emotions by providing a powerful distraction, especially when others become aware of one’s suicidal thoughts and actions.  Emotion dysregulation can affect individuals’ lives and their relationships as they often have sudden and rapid mood swings, feeling out of control, or feeling very angry and having angry outbursts.  Suicide attempts, threats and self-harm can be used as a way to communicate pain to others, and impulsivity is extremely high which increases the risk for actions such as substance use, unsafe sex, spending sprees, disordered eating, gambling and reckless driving.  The inability to regulate emotional arousal also interferes with the development and maintenance of a sense of self.  People who lack a sense of self describe a chronic sense of emptiness, an unstable identify (being unsure of who they are or their identity changes depending on the situation; going from feeling ok about themselves to feeling they are bad or evil).  The problem with these maladaptive coping strategies is that they work in the short-term by reducing the intense painful emotions that feel intolerable.  However, they create a variety of problems in the long-term and end up creating more suffering.

The Role of Yoga in Trauma Treatment – Four Yoga Themes

While yoga has been around for centuries, it is only recently that the Western world has started to take a closer look at how yoga can be helpful for a variety of physical and mental health challenges.  The authors used for this paper are studying the effects of yoga in trauma survivors and incorporating yoga into their psychotherapies.   The authors suggest that there are several key areas involved in recovering from trauma, including: sensing the body (interoception), learning self-regulation, sense of self, self-awareness, and learning to communicate.  They believe, and have seen in their research, that yoga has been an effective adjunct to traditional psychotherapy.  They suggest that four key themes can be explored in “trauma-sensitive yoga:” Experiencing the Present Moment; Making Choices; Taking Effective Action; and Creating Rhythms.

  1. Experiencing the Present Moment

Bessel A. van der Kolk refers to trauma as “a disease of not being able to be present.”  This is the focus of the first yoga theme, Experiencing the Present Moment.  So many people who have experienced trauma are separated from their bodies and their understanding of their bodies.  They are not able to be present and it is suggested that the inability to be present increases suffering.  The goal of PTSD treatment is to help people live in the present moment, without living the feelings and behaviors of the past trauma.  Yoga is seen by these authors as “an unparalleled practice for helping us to be somatically present.”  Yoga is interested in what is actually happening in this moment and that always involves the body.  Yoga invites the student to notice their bodies, learn to read their body cues and understand their reactions.  This sounds simple to many people, but for trauma survivors who are so separated from their bodies, this is a huge accomplishment.

Awareness of breath, practiced in yoga, is used to practice present moment awareness.  Many students in the authors’ clinics became aware of their breath for the first time.  An example shared was of a female student who realized she held her breath when she felt more anxious, and when she allowed herself to breathe more fully, her body began to relax.  This is an example of making a connection between a somatic experience and emotions.  Breathing awareness during yoga offers students a chance to have “a safe, positive, body-based present-moment experience” (Emerson 2011).  The implication for this in life, is that people can then learn to take this present-moment experience and apply it to stressful situations, especially ones that can be triggers for trauma survivors.  A trigger is something that reminds the person of the trauma and they are pulled away from the present and into the past trauma, leading to re-experiencing the feelings and behaviors as if the trauma were happening in that moment.  Yogis would call this “yoga off the mat” as students could use this skill to stay present and grounded in the face of triggers and stressful situations.

Practicing ‘experiencing the present’ can also be used as a healthy coping skill to manage dissociation by using physical cues to help survivors link to the present moment.  For example, in Mountain pose, the yoga teacher can invite students to bring their feet flat on the floor and then experiment with feeling their feet on the ground.  The teacher can offer suggestions to help students feel their feet, such as inviting them to move their toes or lift their heels.  The authors used an example of one student who had such deep somatic dissociation that he realized, through yoga, that he had been living his life completely cut off from his body.  When this student was invited to lift his leg, he didn’t notice he was lifting his leg unless he was looking at it.  Yoga teachers can use verbal cues such as, “What did you notice?  Are you aware of your body?  Can you feel yourself moving?  Do you feel disconnected from your physical self?”   Yoga offers a way for students to explore their relationship with their bodies, whereas traditional therapy is not oriented towards somatic experiences, rather it focuses on talking about events, thoughts, feelings, without actually “experiencing” movement and physical sensations in the moment.

In addition, once students were able to practice experiencing the present moment in their bodies, Bessel van der Kolk (2014) found that yoga improved arousal problems as it allowed for the awareness of tension and the choice to then release tension from the body.  Yoga was also shown to improve one’s relationship to their body, as people started to listen to their bodies and take care of themselves.

  1. Making Choices

Trauma is an experience that involves having no choice in what is happening to you.  This lack of choice is common among trauma survivors.  The trauma results in the person seriously questioning their sense of agency in the world and believing that they have no control over what happens to them in this world.   Therefore, hopelessness and fear become major barriers to people participating in their own lives.  Part of the process of healing from trauma is to help one regain a sense of agency and felt sense of control; to develop a sense of empowerment.  The authors believe that yoga can offer this as well as a profound ability to make choices.  Yoga offers a gentle and supportive way for students to make choices in relation to their bodies and to have experiences that invite a kind and caring way of treating oneself, all of the things that were missing during the trauma.   While it is difficult for many people to practice being kind to themselves, it is especially difficult, and important, for trauma survivors.  Yoga offers a chance to make small, manageable choices in relation to one’s body.  For example, when a teacher provides cues for neck rolls, they may point out that some muscles might be tight.  Students can then be invited to make choices once they notice this muscle tension – they could stop what they’re doing, which offers a chance to practice empowerment, as it implies that they are not stuck in this painful experience just because the teacher introduced neck rolls, that they have control and can stop if they choose.  The yoga teacher may also want to point out that other choices are also available.  The students may wish to experiment with smaller movements to see if that allows them to move without pain or discomfort, or alternately they may choose to explore the movement and make it bigger.   The teacher can reiterate many times throughout the class that students have choices with what they do with their bodies during their yoga practice.

The authors make note about other physical practices that can help trauma survivors cultivate a sense of empowerment, strength, and feeling of control, such as self-defense and combat training.  However, they have found that in order to benefit from these practices, people must be at a relatively advanced stage of recovery from trauma.  In contrast, they have seen that the majority of people who have experienced chronic maltreatment and neglect were unable to tolerate the violent and painful memories and associated thoughts, emotions and bodily responses, that get triggered during the aggressive nature of these self-defense type of activities. 

  1. Taking Effective Action

In addition to a lack of choice, traumatic events usually involve experiences where the individual must direct all their energy toward getting away from the threat.  However, as per the nature of trauma, despite their frantic efforts to get away, for some reason the person cannot escape.  The body enters its fight or flight response and yet it still cannot protect itself and bad things happen.  When an individual experiences this inability to escape and the body’s protective response as not being effective in helping itself, this has lasting consequences.  Even long after the traumatic event, many survivors find themselves in a frozen state where they are unable to get their bodies and minds to confront threatening or stressful situations.  For people who have experienced such severe states of helplessness, yoga can offer small, manageable moments of choice to take effective action, in the context of a yoga pose and even before they begin their yoga practice.  For example, the yoga teacher may ask students to take a moment to notice where they are right now.  To look around and observe some of the elements of their present experience – are they sitting in a chair?  Lying down?  Alone?  Is a window open?  Is there a lot of noise around them?  Teachers can ask a variety of questions to help students practice taking effective action, such as: “How do you feel in your body?  Do you feel hot or cold?  Do your arms and legs feel restless, heavy, tense, relaxed?  Take a moment to notice some of the characteristics of your current experience.  If you notice an area of discomfort, temperature, sensation in your lower back, too much noise, see if there is one thing you can do to make yourself feel better.  If possible, pick something simple and tangible that you can do like closing a window, moving out of the sun, shifting in your chair, or moving to a quieter space: just one thing you can do to make yourself feel better.  Are there any changes in your thoughts, your mood, your body?”  (Emerson 2011).  During a yoga class, students can be encouraged to ask the teacher to make changes in order to feel better, such as asking for the temperature in the room to be reduced or increased, or asking for a block, blanket or other prop.  Students can also be empowered to get these things for themselves; the teacher can make props easily accessible and inform the class they can help themselves anytime throughout the class.  This creates a sense of self-efficacy and reinforces that students can make choices to do something to make themselves feel better.  This theme of taking effective action entails actively doing things that make an individual feel better, safer, more comfortable, or in control.  Yoga provides many opportunities for students to take effective action.

  1. Creating Rhythms

The fourth yoga theme is about creating rhythms.  Disconnection and feeling out of synchrony is a struggle for many trauma survivors; many describe feeling out of step with others and themselves.  Synchrony means being in sync or in rhythm, moving or flowing together without effort.   Dissociation can create a sense of disconnection with one’s body and with the world, as described earlier.   It has been stated that “trauma isolates,” meaning survivors often live life cut off from other people’s rhythms, which are needed for healthy human relationships.  Yoga is one way that people can experience synchrony with others, through breath, movement and a shared experience.   The example offered earlier – about the student who could not feel his leg moving unless he was looking at it – described a type of somatic dissociation which causes a lack of synchrony with one’s own internal rhythms and experiences.  For example, many people unconsciously hold their breath and have chronic muscular tension.  At the same time, they are unaware of this tension or discomfort that creates a lack of synchrony between their body’s physical sensations and emotions and feelings.  This lack of self-awareness also gets in the way of being able to identify what response is needed in any given moment.  Many trauma survivors describe feeling out of rhythm with their basic rhythms of life such as eating, sleeping and energy.  This results in many people feeling chronically keyed up and tense, forgetting to eat/not sensing hunger, and difficulties maintaining healthy sleep patterns.  Yoga can help to calm the body’s arousal system enough to aid in sleep, relaxation, and reducing physical tension.   This can be a helpful tool to manage not only the symptoms of PTSD but to also manage life’s stressors.   

Yoga can offer many opportunities for recreating rhythms.  Students can be invited to explore the rhythm of the movement of breath, of moving the body in sync with the breath.  Movement and breath can also be used to explore a sense of flow and timing, both within ourselves and in relation to others.   There are two types of rhythm that can be explored in a yoga class – intrapersonal rhythm which involves matching one’s own breath and movement; and interpersonal rhythm, moving in synchrony with others in the group.  To create intrapersonal rhythms the teacher can ask the student to practice inhaling while lifting their arms overhead and exhaling while lowering the arms.  The practice is to synchronize one’s own breath with their movement.  Then, to practice interpersonal rhythms, students could be asked to partner up with the person next to them and shift their focus to synchronizing their breath and movement with each other.  This practice of moving in sync with the breath; then breathing and moving in sync with others, can help survivors to reconnect rhythmically with themselves and others.  They have an opportunity to begin to reconnect with the world and recreate a sense of meaning in their lives.

Another aspect of rhythm that is important in recovering from trauma, is the element of time.  Many trauma survivors have an unsettled relationship with time.  It is common for them to experience flashbacks which can bring them back to a time and place that no longer exists, back to the traumatic event that occurred in the past.  These triggered reactions can disrupt one’s sense of time and connection to the surrounding world.  Again, dissociation and the phenomenon when people lose time without their awareness is so common.  People are essentially stuck replaying their trauma over again to the point where it feels like it will never end, or that their lives will never escape this pain.  Yoga offers many opportunities to have tangible experiences that have a specific beginning and ending.  For example, postures begin, there is some time to experience the pose, experiment with making small changes within the pose, and then to come out of the pose, ending that experience and moving on to a new one.  A technique that is used in trauma-sensitive yoga to help with reestablishing a sense of time is called the “countdown.”  The teacher counts backward, out loud, while a pose is being practiced.  For example, they can invite students to explore a pose by saying “if you like, experiment with breathing in this posture for 5, 4, 3, 2, 1 and then release.  Now let’s move on.”  Counting can provide a clear sense of duration and an end point.  Trauma-sensitive yoga teachers can help their students reestablish a sense of duration and a feeling that things end, even if they are challenging yoga postures.  Students can build emotional strength by using these safe opportunities to practice tolerating some physical discomfort, knowing the pose is time-limited.  They can transfer this learning to their lives by learning to tolerate uncomfortable emotions without using maladaptive coping strategies, like self-harm or suicidal behavior, to avoid, numb or cut off the emotion.  

Conclusion

It is encouraging to see the medical community turning to aspects of yoga to assist with the treatment of trauma and other psychological issues.  The need for self-awareness in recovery from trauma is perfectly matched with the fundamental purpose of yoga, which is self-exploration.  Yoga offers a self-directed, gentle practice that individuals can use to build self-awareness, experience their emotions, build resilience, and cultivate a sense of empowerment.  The learning that comes from yoga can be used to build positive experiences, cope with stress, and ultimately take suicide ‘off the table’ as a solution to escape pain and suffering.  One can then begin to re-engage with life and create a life worth living. 

 

References:

Centre for Addiction and Mental Health. 2020.  https://www.camh.ca

 

Emerson, David. (2015). Trauma-Sensitive Yoga in Therapy. Bringing the Body into Treatment. New York: W.W. Norton & Company.

 

Emerson, D., & Hopper, E. (2011). Overcoming Trauma through Yoga. Reclaiming Your Body. California: North Atlantic Books.

 

Jobes, David A. (2006). Managing Suicidal Risk. A Collaborative Approach. New York: The Guilford Press.

 

Public Health Agency of Canada. 2019. Infographic.

 

St. Joseph’s Healthcare Hamilton. 2020. Mental Health and Addictions Program.

 

Van der Kolk, Bessel A. (2014). The Body Keeps The Score. Brain, Mind, and Body in the Healing of Trauma. New York: Viking.