Trauma Sensitive Yoga: breathing the walking wounded, part 3

breath + movement = roots

Psychologist Babette Rothschild has said:

“Breath is a reminder of trauma. Sensory messages from muscle and connective tissue that remember a specific position, action, or intention can be sources of triggers. Accelerated heart rate and increased respiration can be implicit reminders of that same reaction that accompanied the trauma.”

As we talked about the breath during the training, I thought about how fortunate I am to have studied directly in the Krishnamacharya lineage — studying with Srivatsa Ramaswami, Desikachar, Mark Whitwell, and lately with Gary Kraftsow.  They all studied with Krishnamacharya and Krishnamacharya’s yoga is all about linking breath with movement.  This aspect is crucial in teaching trauma sensitive yoga.

Donna Farhi has said that “breath is a dynamic system that most of the time runs on automatic, allowing input from internal organs to mange the rate and depth of breathing.”

Trauma is stored in the body and body memories can override thinking.  Breath is the doorway to the nervous system — trauma survivors have layers of physiological defenses in place that serve as psychological infrastructure and protection from implicit memories.  Removing these defenses too quickly can result in significant destablization.

Hearing this I thought about the yoga classes I’ve taken where pranayama is indiscriminately taught, seemingly for no purpose other than to fill space in the class (this is my experience, your mileage may vary.)  I became more aware of this after I returned from studying at the Krishnamacharya Yoga Mandiram the first time.

In that lineage yoga practice is asana-pranayama-meditation.  I remember being in a class after my return and the first thing the teacher did was kapalabhati breathing — no explanation, no instruction, just do it.  It was very jarring (I started but did not finish) and I thought…HUH?   Does this teacher know everyone’s dosha in the first place to be doing this?   If it did not feel at all right to my system, an experienced practitioner, I could only imagine what it felt like to the ones who were brand new to yoga in this class.

If you’ve read the first two parts of this series, you’ll know where I am going with this.  Breathing — just doing it or hearing the breath of another student — can be a PTSD trigger for trauma survivors.  Ujayi breath can be very scary; techniques such as kapalabhati and breath retention are out of the question in a trauma sensitive yoga class.

Trauma sensitive breathing should always be performed in the context of a muscular, physical form (asana) to facilitate grounding and present moment experience.  The movements are always initiated by the inhale or the exhale, because breath alone can trigger PTSD.

What are some breath practices for a trauma sensitive yoga class?  Simple breath awareness (constant attention to the breath); “add a little” breath; emphasizing breathing through the nose because some trauma survivors breath through their mouths; nadi shodana; and ratio breathing, i.e., different counts for the inhale/exhale.

The bottom line is helping people notice when their breath changes, helping them notice the quality of their breath so they can notice their experience in the present moment. Mindfulness. Just this, just here, just now.

As you may have determined, with so many PTSD triggers, being trauma sensitive in a “regular” group yoga class would prove difficult.  Although a trauma survivor may really want to experience yoga, the thought of walking into a public yoga class might be too challenging, too scary.  In his book Overcoming Trauma Through Yoga, our teacher Dave Emerson wrote about the experiences of trauma survivors in public yoga classes.  One woman said that just the experience of a teacher walking up to her slowly and silently as the woman was in child’s pose was enough to make her run out and never return.  She did not feel safe at all.

Creating a yoga class exclusively for PTSD or trauma survivors creates community, a sangha.  We were advised not to do this work in a vacuum, but to connect with a mental health professional, a VA center, a domestic violence shelter, among others.  We were also advised not to work privately with students because of safety issues.  I feel confident enough to work privately with domestic violence and sexual assault survivors, but I might not feel secure with others, it would depend on the situation.  I am using The Trauma Center’s protocols in working one-on-one with TS students: (1) the student must also be working with a psychologist, psychiatrist, or other mental health professional so we can work together as a team; (2) the student must continue taking their medication, if any; (3) the student must not have been hospitalized for any psychological issues within the last six months; (4) there can be no active psychosis.

At the start of our training, the question was raised: how must yoga in America change if 80% (according to a collection of research) of the population have experienced or witnessed trauma?  Trauma is defined by Dr. van der Kolk as being inescapable stress, heightened alertness (constant hyperarousal), or helplessness in response to an event.  Some responses to these states are detachment/disconnection from the body, self, or social relationships; insomnia; fight or flight responses; depression; chronic pain; constant intrusive thoughts; consistent feelings of anger and shame; substance abuse.

We were asked: do we need to return to a “simpler way” of yoga?

This training was one of the most influential trainings I’ve taken in my 10 years of teaching.  I hope I have helped both yoga teachers and trauma survivors in this three part series.

Krishnamacharya said that breath is central to yoga because it is central to life…and yoga is about life.  Trauma is a part of life, but we do not have to allow it to define us.  Yoga is about replacing old negative patterns with new positive ones, one step at a time.

Just this. Just here. Just now.

Trauma Sensitive Yoga: the walking wounded, part 2

A trauma survivor can be an adult survivor of childhood abuse, a domestic violence survivor, a survivor of sexual assault, someone who was in a horrible car wreck or natural disaster, or a returning soldier with Post-Traumatic Stress Disorder (PTSD.)

Basically, anyone who walks into your class. As teachers, we never know what a student’s story is, either physically or psychologically.

A “trauma sensitive” yoga class is taught very differently from the yoga class with which we are familiar — soft music, altars, incense, physical adjustments. A typical yoga class may not be comfortable place for a trauma survivor and in fact may feel very dangerous. Merely saying the word “relax” can be a PTSD trigger if the person was told to relax and then was abused.

For someone who has been abused, a physical assist can be a severe trigger for PTSD. Many teachers say, “but I always ask first.” Think about that statement. For someone who has a history of abuse and was not allowed to say no (so has issues with power and control), assists are problematic.

Dr. Bessel van der Kolk is the recognized authority on PTSD and heads The Trauma Center in Brookline, Massachusetts. He has said that “the goal of treatment of PTSD is to help people live in the present without feeling or behaving according to demands belonging to the past.”

The Trauma Center has begun to establish empirically that yoga is helpful for people with PTSD (van der Kolk, 2006). Along with feedback such as, “I feel like I can use my body again,” the groundbreaking study that the Trauma Center conducted in 2004 showed that yoga changes core brain physiology related to PTSD and trauma.

In a brain subjected to trauma, parts of the brain can be underdeveloped; parts of the brain can be atrophied; a compromised neocortex (the “thinking” brain) can not regulate the lower brain (the limbic brain is the emotional center of the brain); there is a lack of synaptic connections. The amygdala is the alarm clock of the brain, it is the site of stored memory and bodily sensations. It becomes engorged and overactive in PTSD. The corpus callo is the fibrous material beneath the cortex that transmits information between the two hemispheres of the brain — in PTSD this can atrophy. The right side of the prefrontal cortex can atrophy in PTSD. These are just three examples of structural changes in a traumatized brain.

This makes recent research on how the brain can change (neuroplasticity) huge. The research is out there, you can google it: via yoga and meditation, new synaptic connections are made, old pathways are reactivated and there is neurogenesis. The Trauma Center’s research has shown that a 60 minute yoga class once a week in a 10 week session begins to reduce PTSD symptoms.

So how do you make your class “trauma sensitive”? As teachers we naturally think our classes are healing in a certain way, but some aren’t. We were told how Iyengar yoga classes, for example, because of the language used and the way many are taught can be problematic for trauma survivors. Seeing yoga straps lined up on a wall is not a good environment for someone who was tied down and abused.

Since much of trauma was caused by physical manipulations, physical assists for the most part are out of the question. At the root of trauma/PTSD is an extreme lack of choice. With specific yoga shapes (don’t say “pose”), trauma sensitive yoga teachers invite people to begin to make choices again in a direct relationship to their experience. All these choices are about safety, comfort, and ease.

Environment is important: smells, mirrors, exposed windows, closets, temperature, and lighting can all be PTSD triggers to someone.

Do you see where I am going with this? ANYTHING a yoga teacher does can be a trigger for PTSD. How many teachers are equipped to handle stress responses that may come up such as hyperarousal, hypoarousal, disassociation, or flashbacks? If a stress response happens, one key is to start moving the large muscles like gluts or quads because those muscles use up the stress hormone cortisol (Warriors, forward bends.)

For a trauma survivor in a yoga class, it’s about reclaiming their body, not about a teacher manipulating a student into a shape. As teachers we need to cultivate our ability to offer verbal assists. In trauma/PTSD, survivors have “lost” their bodies. Our teacher gave an example of how one of his students said she felt like she had a hole where her stomach should be. As yoga teachers it is not our job to “fix” a student, but to help them begin to trust their bodies again. It’s about helping students use their bodies and breath as resources for self-regulation, calming themselves down if need be. Physical assists create dependency.

In a trauma sensitive yoga class, language must change: no absolutist, commanding language; use concrete and visceral language; no woo-woo “out of body” language, no metaphors. It is the invitatory language of inquiry that directs attention to the body and invites mindful movement and breathing. The teachers advised us not to say “be gentle with yourself” because that comes across as a challenge that can set people up for failure — trauma survivors don’t know how to be gentle with themselves. Even the word “play” (saying “play with the pose” is not a good idea) is a loaded word. Emphasize choice: “as you are ready”; “if you like”; “you decide”; “you choose.”

Use non-intimate language for body parts: sternum v. chest; base of spine v. tailbone; seat v. butt or pelvis. However, ANY word can be a trigger and a teacher must be able to handle triggers.

Use non-aggressive language. How many of us have been in a yoga class with a drill sergeant instead of a yoga teacher — “you SHOULD look like this.” An abuse victim interprets your words differently than a soldier would with PTSD. The body is not a combat zone…for any of us.

Some of the loaded poses (for obvious reasons) are Happy Baby, hip openers, chest openers. Powerful bodily sensations can create powerful emotions so these poses must be taken slowly, in increments. Bookend a new pose with a familiar pose.

Trauma Sensitive Yoga: the walking wounded, part 1

“The body keeps the score.” Dr. Bessel van der Kolk

According to the teachers at my recent Trauma Sensitive Yoga training, 70-80% of the population have experienced some type of trauma, whether being in a war or a catastrophic car accident. This statistic comes from a collection of the clinical literature currently out there. Keeping that statistic in mind, think of your yoga class. In many cases abuse is caused by physical manipulation of the body. Now think about what those yoga adjustments are doing to a trauma survivor with PTSD who was held down during their abuse. Even chanting and Sanskrit can be triggers for someone who suffered cult abuse.

Anything a yoga teacher does can be a trigger. Anything. Telling someone to be still and watch the breath can be a trigger, especially to a woman who was raped and the last thing she heard before she disassociated from the attack was the rapist’s breath in her ear. The word “pose” can be a trigger, especially for an adult survivor of childhood sexual abuse who was made to POSE for pornography.

How will you teach your classes? Whether as teachers or students, we know that yoga heals, that is a purpose of yoga. But for many trauma survivors, walking into a yoga class is impossible. If you were that child who had been tied up, think how seeing a yoga strap would make you feel. Trauma survivors are stuck in a body/breath/mind that is still relating to past conditions. Time is frozen in the trauma survivor’s brain, we’re stuck in a loop. I know what my triggers are.

Approximately 88% of men with Post-Traumatic Stress Disorder met lifetime criteria for one or more disorders such as depression and anxiety. Seventy-nine percent of women with PTSD met the criteria for one or more. Eighty percent of people with PTSD met criteria for another psychiatric disorder (Solomon and Davidson, 1997.)

In a word, my training at the Trauma Institute was amazing. I consider it one of the most influential trainings I’ve done in my almost 10 years of teaching. Forty yoga teachers and clinicians from all over the United States and some from Europe came for four days to learn about the ground-breaking research being done (scientists and researchers are finally catching up to what yogis intuitively knew thousands of years ago) and to learn how to create trauma sensitive classes. A “trauma sensitive” class is not your mother’s yoga class. It MUST be taught differently, even as to word choice and environment.

Many of us in the training were survivors, including me. Many felt that a true community was being created, much more so than a regular yoga teacher training. On the last day I sat in a small group and heard how just listening about trauma and PTSD was a trigger for some. Many of us had jangly nerves, as one woman described it, but all left empowered and ready to take this healing into our communities. One woman said she was proud to be a survivor and I nodded my head in agreement.

We learned much about the different parts of the brain that are literally physically damaged during trauma. Prolonged abuse damages the brain even more — parts of the brain can atrophy and shrink and the connection between our “reptilian brain” and our “thinking brain” short-circuits. There are now many studies on trauma survivors via brain scans that show the physical changes. But the fact is that it does not have to stay damaged. The fairly recent concept of neuroplasticity is huge. It was previously thought that the adult brain can not change, but brain scans show that it can change and repair itself from trauma. One of the most important things we learned was that while talk therapy is effective, it can only go so far because it is head/mind oriented and trauma/abuse is so body-based. The Trauma Institute’s soon to be published research shows that the body-centered activity of yoga combined with talk therapy is much more effective in treating PTSD and trauma survivors. Why? Because the body keeps score, the body has memory. Next year the Trauma Institute will begin a 5 year study of the effectiveness of Jon Kabat-Zinn’s Mindfulness Based Stress Reduction techniques v. yoga on trauma/PTSD. The research will utilize brain scans.

We heard about “Trauma Theory for Yoga Instructors”, “The Neurobiology of Trauma as it Relates to Yoga” (presented by Heather Mason), and also heard from Bill, a Viet Nam war vet who suffered from PTSD. He told us his story about how he was a hospital corpsman in the Marines and his PTSD did not manifest until his own children were born years later. “Life became gray,” he said. The birth of his children triggered his PTSD because when he saw his babies he remembered all the dead Vietnamese children he saw. He said he constantly feared for his children, he was stuck in the loop that something terrible would happen to them, at any time, he was sure of it.

In both 2001 and 2002 he suffered a neurological episode where his left side stopped working — PTSD and traumatic brain injuries affect the same part of the brain. He attributed his neurologic damage that showed up years later to the herbicide Agent Orange telling us that the body reacts to herbicides in a very specific way: “we were eating it and drinking it.” Bill was fortunate enough to connect with Dr. Bessel van der Kolk as his psychiatrist who told him to try yoga for his PTSD and neurologic symptoms. Bill told us that yoga managed his symptoms and have grounded and centered him. Bill is in his 60s and he told us that he has been told that he should be in a wheelchair or in a nursing home but yoga has saved his life.

Bill has been doing Bikram yoga three or four times a week and has been doing it for about five years. He says he has tried other types of yoga but Bikram is it for him. Bikram is not considered “trauma sensitive” yoga but it helps Bill because of the consistency of the routine, the same thing every day, every class. We learned that consistency is one of the top three requirements of a trauma sensitive yoga class: BE SAFE, BE PREDICTABLE, BE CONSISTENT. Bill gave us his opinion about why consistency is important:

in the last 45 years America’s warfare has been ill-defined, ambiguous, with poorly stated goals, and all have been counter-insurgency wars. In wars such as these, soldiers can never create a pattern, nothing is ever repeated, you can’t go down the same road twice because you might get killed. Bill asked us to think how it feels to have our neurological system disrupted if we don’t have patterns — it is disruptive to the emotional system that is connected to our physiological well-being. For Bill, Bikram yoga via its repeated patterns serves as his ground.

However, for someone else, Bikram yoga with its commanding teachers could be a trigger. The yoga remedies for trauma and PTSD are definitely not one size fits all. For example, Richard Miller worked with the Walter Reed Army Medical Center in a famous study of the effects of yoga nidra on soldiers with PTSD. Yoga nidra was found effective on this population. Bill told us that soldiers with PTSD like the feeling of deep relaxation that yoga nidra gives just by virtue of how “on” they had to be while in the field. Yoga nidra is a relief to them, it’s “heaven” just to be able to relax, Bill said. But for someone else, such as the survivor who was constantly told to be still and don’t move, deep stillness for so long would be a severe PTSD trigger.