Yoga for Healing from Trauma

by

Mitch Hall, PhD (h.c.), E-RYT

and Taquelia Washington, LCSW, PPSC, CYT


Abstract

The authors tell their personal and professional stories as relevant to why they chose this topic. The paper defines trauma and varieties of post-traumatic stress disorder (PTSD). The causes and types of trauma are surveyed and discussed. The incidence of trauma and PTSD in US society is indicated. The effects of trauma are described in their neurobiological, physiological, emotional, cognitive, sense-of-self, social, and behavioral dimensions, followed by reference to comorbidity with other physical and emotional disorders. Scientific research evidence supporting yoga’s benefits for healing trauma is reviewed. Areas for further research are indicated. Models of trauma-sensitive yoga for clinical, school-based, and studio practice are described.  Concluding comments are offered.



Keywords: Yoga, Trauma, Post-Traumatic Stress Disorder (PTSD), Psychology, Healing, Neurobiology, Mindfulness.



Why We Chose This Topic: Personal and Professional Relevance

Both authors of this essay are working as mental health professionals and have graduated from the yoga teachers’ training program at the Niroga Center in Berkeley, California. This paper was written as part of the requirements for yoga teacher certification. The Niroga Institute curriculum and research projects integrate the ancient, embodied wisdom of yoga with the analytical rigor of modern biological and social sciences. Niroga aspires to serve as a center for urban transformation in bringing measurable, health-enhancing benefits to such under-served populations as traumatized children, at-risk and incarcerated youth, seniors, people with disabilities, and those recovering from catastrophic illnesses.



Taquelia’s Story

As a school-based mental health therapist, I have sat with youth as they have described intimate details surrounding intense trauma that they have experienced in their lives. With each story a darker layer of the human experience is revealed. One story involved a 5-year-old young male who at the age of 13 months old was placed in boiling hot water by his biological mother. This individual, at such a young age, learned that everyone in this world is a threat to him and that his safety is not something that is guaranteed. Having 2nd and 3rd degree burns that cover 60% of his body serve as both physical and emotional scars that will always remind him of this experience. Having been in over 10 foster homes in 5 years, he was labeled as “unadoptable” by the system due to his severe acting-out behavior. At night time, he would often wake up and begin to bang his head uncontrollably against the wall as he attempted to self-soothe against the demons that haunted him. My journey in working with him was one of slowly developing a relationship and attempting to provide a consistent, loving presence in his life. Although our work together ended over 6 months ago, his story will remain with me forever.

Another story involved a 15-year-old young girl who has experienced multiple layers of trauma in the short years of her life. She was jumped by a group of girls for the first time at the age of 6 years old, was a victim of an attempted kidnapping at the age of 7, witnessed her first murder at the age of 9, and witnessed her second murder at the age of 14, at which time she sat with the victim (who was a stranger to her) as he died. Currently, amongst other symptoms, she has explosive anger, occasional flashbacks of the last murder she witnessed, and hyperarousal in her environment. She also experiences depressive symptoms that present additional challenges, including suicidal thoughts and desires to self-mutilate. Similar to the first client described, my work with this client has involved creating a strong, consistent relationship with her as we began to unpeel the layers of trauma and uncover the ways in which this trauma has influenced her functioning in the world. We have explored the relationship of generational trauma in her family and the impact that this multigenerational experience of trauma has had on her mother, and therefore her own upbringing. The stories go on and on. Anecdotally speaking, the prevalence of youth that have been traumatized in some way appears to be extremely high, as almost every youth that I encounter has their own story of to share.

As I sit with these youth, I feel there is a limit to what I can provide them as we utilize our words, art, and other mediums to explore these deep layers of their being. As my clients talk about the somatic symptoms of their trauma (and anxiety and depression, etc.) such as stomach aches, headaches, and shoulder pains, the limit of talk therapy becomes even more apparent to me.

While I have searched for additional tools to help better serve my clients, I have simultaneously searched for tools to heal my own internal layers of pain that I experience in my being. I began to practice yoga about 4 years ago and, within 6 months of developing this new practice, began to see the ways in which it began to transform both my internal and external worlds. After experiencing this impact for a few years, I began to realize that the very tool that has helped to save my life may also serve as a tool for helping those I serve in their journey as well. It is this thought process that led me to seek out a yoga training program, ultimately taking me to Niroga, and therefore leading me to writing this paper with my new colleague Mitch. I am excited to join these two worlds of mental health and yoga as I continue on this journey through this paper and afterwards.



Mitch’s Story

At the time of writing this paper, I have been working for over two years with a non-profit agency as a mental health counselor for underprivileged children and youth in Richmond, California, a city with one of the highest rates of violence in the country. Choosing to research the topic of teaching yoga to help people heal from trauma is relevant to me for personal as well as professional reasons. I’ll begin with the professional ones because it is in this clinical realm that I wish to apply my developing skills as a yoga teacher.

Most of my clients have histories of significant trauma. Here is the story of one of them, a girl who recently turned 17. A year ago she witnessed the murder by shooting of her boyfriend, a youth who had turned his life around by quitting a gang and giving up the use of drugs and alcohol. When she started seeing me, this bereaved client was suffering from traumatic flashbacks, triggered by environmental reminders; intrusive memories over which she was ruminating; disturbed sleep and appetite; emotional lability with outbursts of anger and sudden crying; difficulties with concentration in school; depression; feeling isolated and not understood by others; survivor’s guilt; and an inability to self-regulate and enjoy life’s simple pleasures. I have been providing her with empathy and acceptance, listening to whatever she wishes to share, and validating the normalcy of her painful grieving. I’ve been affirming that she is healing and can find purpose, meaning, and even joy in living, whenever she is ready, at her own pace and in her own time. I have also taught her some mindful, yogic breathing practices which have given her moments of feeling peaceful. In the five months of our work together, I have seen her smile more, and there has been a gradual abatement of the severity of her symptoms. This young woman had a relatively secure upbringing, and she said that when she had heard about other murders previously, she was not able to understand, as she can now, how this felt to those who lost loved ones. Now her empathy and compassion have been awakened through irreversible tragedy, and she recently joined a church-based youth group that seeks to reduce youth violence in this area. Her altruistic involvement in this volunteer work is itself a part of her healing.

Other clients’ varied life stories have included being abused, neglected, or abandoned, witnessing murders and other violence, being physically or sexually assaulted, being threatened and bullied, losing family members and friends due to cancer or murders, becoming assaultive themselves, and using alcohol or other drugs in vain, self-defeating attempts to numb their anxiety and forget their confusion. The traumatic experiences these clients have suffered have been compounded by their being mostly from minority groups, some from families with previously traumatized refugee parents, and mostly in households with few financial resources. Living and going to school in a high-violence zone, they cope on a daily basis with risks and exposure to other troubled people that raise their stress levels significantly.

Personally, my own life has been a healing journey. Over the past 41 years, I have learned about how helpful yoga, as well as some other healing practices, can be physically, emotionally, and spiritually. Additionally, I recognize the relevance of yoga to my concerns as a peace activist. I view wars and many other social dysfunctions as involving unconscious, collective re-enactments of individual and group traumas. It is a big topic beyond the scope of this paper. I believe that yoga may be applied socially to help with the healing of a traumatized humanity.



Defining Trauma

Trauma is a word used in both physical medicine and psychology. In each domain, it has a wide range of varied usage. This paper is focused on psychological trauma, which can, at times, result from physical trauma, among other causes. Physical trauma can refer to tissue damage and injury, from minor to life-threatening. For example, if you bruise your thumb while hammering and lose your thumb nail as a result, this loss is a result of low-level impact trauma, but it is unlikely this would be psychologically traumatic to anyone. However, losing a limb due to the explosion of a land mine would be both physically and psychologically traumatic.

Defining psychological trauma is complex and subject to varying interpretations. The definition of trauma used in the DSM-IV-TR (American Psychiatric Association, 2000), to establish a basis for diagnosing post-traumatic stress disorder (PTSD) states that trauma involves:

“direct personal experience of an event that involves actual or             threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate... The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve     disorganized or agitated behavior)”  (p. 463).

A more concise definition states that “in the ‘purest’ sense, trauma involves exposure to a life-threatening experience. This fits with its phylogenetic roots in life-or-death issues of survival, and with the involvement of older brain structures (e.g., reptilian or limbic system) in responses to stress and terror” (Baldwin, n.d.). However, this definition needs qualification because, “many individuals exposed to violations by people or institutions they must depend on or trust also show PTSD-like symptoms -- even if their abuse was not directly life-threatening...it appears that betrayal by someone on whom you depend for survival (as a child on a parent) may produce consequences similar to those from more obviously life-threatening traumas” (Baldwin). 

    In view of such considerations about interpersonally induced trauma, Gershoff (2004) wrote that, “trauma is essentially a confrontation with damage to body or mind. It may be the body which is disabled or killed, or the psychological self which is hurt or destroyed. In either case, one person’s subjectivity is denied by another person.” (p. 134). Gershoff further noted that,

“trauma is therefore also about fear in its most primal form. It             is the fear of total helplessness, knowing that no one can save you or protect you or your loved one. The bonds that tie you to others are broken. Your physical and psychological integrity is breached. The world that you took for granted, the structure that underlies reality is shattered. It doesn’t look the same any more. It is no longer safe” (Gershoff).

    As we will see in the section below about developmental trauma, some children who are severely  maltreated from the beginning of their lives may have never or only rarely known a world that was safe. In such instances, they are not able to develop normally.

Two other definitions focus on trauma's neurobiological aspects. Everett (2010) stated that, “trauma is a set of physiological, cognitive, emotional, behavioral, spiritual, and relational symptoms that result from events that overwhelm the nervous system. In her perspective, “trauma is in the nervous system, not in events.” Writing from a similar perspective, Perry (2008) provided the following definition of trauma: “Trauma, from a neurobiological perspective, is an experience or pattern of experiences which activate the stress response systems in such an extreme or prolonged fashion as to cause alterations in the regulation and functioning of these systems.” 



Defining PTSD

As with the term trauma, PTSD has many definitions. To cite one widely referenced source, PTSD

“is the most common diagnostic category used to describe symptoms arising from emotionally traumatic experience(s). This disorder presumes that the person experienced a traumatic event involving actual or threatened death or injury to themselves or others -- and where they felt fear, helplessness or horror” (Baldwin, n.d.).

    Three clusters of symptoms generally justify this diagnosis and further define the condition. They are intrusions, avoidance, and hyper-arousal (Baldwin) or, in some instances alternatively to the third cluster, hypo-arousal (Levine, 1997; Schore, 2003a). Intrusions occur through flashbacks and nightmares in which the previously traumatized person feels as if he or she is presently experiencing the trauma, with all the accompanying terror. Avoidance means that people with PTSD try to avoid anyone and anything that will remind them of the original trauma and, thereby, trigger a vivid re-experiencing of it. Hyper-arousal involves hyper-vigilance and enhanced startle response with raised heart rate and blood pressure, among other physiological indicators. Hypo-arousal involves dissociation, numbness, and lowered heart rate and blood pressure.

It was not until 1980 that the APA gave, due to persuasive research and tenacious advocacy by some scientists to overcome fierce resistance from many other psychiatrists, professional recognition to PTSD. When van der Kolk and others had tried to get funding for research on enduring, adverse effects of traumatic war experiences among tens of thousands of  Vietnam veterans who were “suffering from flashbacks, beating their wives, drinking and drugging to suppress their feelings, closing down emotionally,” the Veterans’ Administration initially denied that such symptoms, often persisting for years, could be due to traumatic combat experience (Wylie, n.d.).

In similar fashion, conservative forces in the APA are currently resisting a highly evidence-based proposal (van der Kolk & Pynoos, 2009) for inclusion in the DSM-V (now scheduled for publication in 2013) of a developmental trauma disorder diagnosis for children and adolescents (Johanson, 2010). The reasons for the old-guard resistance are manifold and, in a sense, political. They appear to include resistance to acknowledgment of pervasive child abuse and neglect in this society, acceptance of a diagnostic category that does not lend itself to orthodox pharmaceutical or cognitive-behavioral methods, and, of special significance for this paper, psychiatrists’ “having to admit that their various verbal, top-down processing methods need to be supplemented by learning more about body-centered methods” (Johanson, 2010). As will be demonstrated below, there is now clinical and research evidence that yoga is among the effective body-centered treatments for healing unresolved trauma.

From the foregoing discussion of the definitions of trauma and PTSD, it is evident that the ramifications of these terms are far-reaching, complicated, and, in some professional circles, controversial. Traumatic stress can manifest differently depending upon many variables. The following section on causes and types of trauma will survey some elements of the variance.



Causes and Types of Trauma

Trauma can result from many causes and be of many types. We shall review the causes and types under the five following headings: shock trauma, developmental trauma, perpetration-induced trauma, historical trauma, and vicarious trauma. Whereas we humans are interdependent, social beings, unfortunately “most traumas occur in the context of interpersonal relationships, which involve boundary violations, loss of autonomous action, and loss of self-regulation (van der Kolk, 2006, p. 7).



Shock Trauma

Shocking traumatic events that shatter a person’s physical and psychological security may, among other possible causes, result from any of the following:

“military combat, violent personal assault (sexual assault,                 physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness” (APA, 2000, pp. 463-464).

PTSD resulting from such shock trauma, whether experienced oneself, witnessed, or learned about as having affected loved ones, “may be especially severe or long lasting when the stressor is of human design (e.g., torture, rape)” (APA, p. 464). The description of PTSD that was developed for the DSM has been especially relevant for this type of trauma.

Three types of shock trauma, occurring early in life, that are not considered in the DSM consideration of PTSD are prenatal trauma, birth trauma, and circumcision trauma. The Association for Prenatal and Perinatal Psychology and Health (APPPAH), the Primal Health Research Centre in London, and the National Organization of Circumcision Information Resource Centers are three of several professional organizations that are conducting and publishing research in such areas.

For an example of prenatal trauma, consider the research concerning the infants of mothers in their third trimester of pregnancy who were in the vicinity of the World Trade Center destruction on September 11, 2001. The babies of those mothers who developed PTSD as a result of that tragedy showed one year after their birth lower-than-normal salivary cortisol level (Yehuda et al. 2005). This condition is recognized as a risk factor for developing PTSD, and it has also been found in the adult children of holocaust survivors.

Examples of birth trauma are found in Swedish research on “perinatal origins of adult self-destructive behavior” (Jacobson, Eklund, et al. 1987). Here is the abstract of this revealing research:

“Birth record data were gathered for 412 forensic cases comprising suicide victims, alcoholics, and drug addicts born in Stockholm after 1940 and who died there in 1978 -1984. Comparison with 2901 controls. Suicides involving asphyxiation were closely associated with asphyxiation at birth; suicides by violent mechanical means were associated with mechanical birth trauma; drug addiction was associated with opiate or barbiturate administration to mothers during labor” (p. 364).

Whereas the ancient, religiously sanctioned practice of penile circumcision has been a culturally normative operation on infant males in the US, it causes  excruciatingly painful shock, trauma, and dissociation (Fleiss, 1998; NOCIRC, 1995). From 1932 to 1971, 77 percent of males born in this country were circumcised, with the highest incidence of 85 percent occurring in 1965. The current rate is around 50 percent (Circumcision Reference Library, 2008). In the year 2000, among 133 million males living in the US, 94 million had been circumcised, whereas 39 million had been left intact (O’Donnell, 2001). The lifelong physical, psychological, and societal effects of this traumatic male genital mutilation, “where sex and violence first meet,” are being researched, amidst controversy. Advocacy groups are trying to inform the medical profession, legislators, and the general public about this widespread source of trauma.



Developmental Trauma

We human beings are born utterly unable to fend for ourselves in the natural world. We mature biologically and socially over a period of several years. We depend for our survival and thriving upon physically and emotionally attentive, responsive, attuned caregiving. According to attachment theorists and researchers, beginning with Bowlby (1969/1982), we are born with an innate, biologically determined attachment behavioral system that motivates us to seek proximity to specific people who will provide a safe haven from dangers and a safe base from which we can depart and to which we can return for our explorations of the wider world. When, instead of nurturing, sheltering, and protecting us, the people upon whom we rely for our very existence traumatize us, we suffer, depending upon the severity and chronicity of the trauma as well as on our genetic vulnerability, from developmental trauma. The traumatic maltreatment may take many forms: physical and emotional neglect; physical, sexual, and emotional abuse; witnessing domestic violence. Usually children in families that traumatize them experience not just one  form of trauma but many, sometimes simultaneously, sometimes repeatedly over extended periods of time. Such repeated traumatic exposures have led researchers to use the term complex trauma when referring to developmental trauma (NCTSN, 2003).

Another, more subtly caused form of developmental trauma has been found in the children of non-maltreating parents who themselves suffer from unresolved trauma (Hesse, et al., 2003). The children become terrified and disorganized because the parents unconsciously and nonverbally embody their trauma in their movements, gestures, sounds, and body posture. Similarly the blank, unresponsive face and lack of affectionate touching of a clinically depressed mother or other primary caregiver is traumatizing to young children who are biologically programmed to seek a responsive interplay of facial expressiveness and soothing touch (Cozolino, 2006).

Parental verbal abuse has also been found in a study of young adults to have caused enduring damage to neural pathways for emotion regulation and language processing in children’s vulnerable developing brains (Choi, et al., 2008). Similarly the culturally normative practice of physical punishment, still legal in homes in all states of this nation and in the schools in 20 states, has been found in a study of young adults exposed to harsh physical punishment as children to cause long-lasting traumatic brain damage (Tomoda, et al., 2009). Such punishment “is a chronic, developmental stressor associated with depression, aggression, and addictive behaviors” (Tomoda, et al.).

The loss of a primary care giver or other loved one when a child is young and vulnerable can also be traumatic. Loss may be due to death, abandonment, divorce, imprisonment, or other causes. The younger and more vulnerable the child, the more severe the trauma will be.

In view of its pervasive, harmful effects and widespread incidence, both of which will be addressed in subsequent sections of this paper, child maltreatment is putatively the foremost public health challenge in this country (van der Kolk, 2005). However, it has not yet been given due recognition with regard to DSM-sanctioned mental health diagnoses that form the basis of both treatment protocols and insurance billing.

Because the DSM IV has a diagnosis for adult onset trauma, PTSD, this label often is applied to traumatized children, as well. However, the majority of traumatized children do not meet diagnostic criteria for PTSD...,and PTSD cannot capture the multiplicity of exposures over critical developmental periods (van der Kolk, p. 406). It is to be hoped that the significant and growing body of persuasive research and clinical evidence will lead to the inclusion of developmental trauma in the DSM-V.



Perpetration-Induced Trauma

Some researchers have documented that soldiers who have killed develop perpetration-induced traumatic stress symptoms that are even more severe than the PTSD in soldiers who have been traumatized in combat but have not killed (MacNair, 2002). Similar findings have been made concerning post-traumatic stress in others who harm or kill, whether as part of their legally sanctioned duties, as in the case of police officers, or in criminal activities. This evidence strongly suggests that one cannot injure or destroy the lives of other humans without negative consequences to oneself.



Historical Trauma

Some traumas are historical, affecting large groups collectively, and the post-traumatic effects may be transmitted, with varying degrees of severity, over generations. Examples of such traumas are numerous and include, but are not limited to, the following: the European colonial conquest and exploitation of  the indigenous peoples and resources of much of Africa, Asia, the Pacific islands, Australia, New Zealand, and the Americas; the trans-Atlantic slave trade; the genocides perpetrated against the Armenians in Turkey, the Jews and Roma in Europe, the Tutsis, in Rwanda, and others; and the tyrannical regimes in so many countries. Furthermore, the peace researcher Galtung (1997) identified how national and regional groups maintain identity through what he called a megalo-paranoia complex involving myths of collective grandeur (being “chosen”) along with memories of trauma. For the US as a whole, the traumas involve Pearl Harbor, the defeat in Vietnam, 9/11, and the specter of further terrorism. Many of the population groups within the US have their own legacies of historical trauma.



Vicarious Trauma

Vicarious trauma, also called secondary trauma and compassion fatigue, refers to the stress often experienced by those in the helping professions who work closely with trauma victims and survivors. The effects on the helpers may be similar to those experienced by the victims themselves. This phenomenon has been found among a wide range of professionals, including psychotherapists, social workers, medical personnel, psychiatrists, caregivers, victims’ advocates, humanitarian and relief workers, responders to catastrophes, and others. Helpers, both professionals and volunteers, frequently witness a high volume, frequency, and intensity of traumatized people and their stories, and the effects on the helpers are cumulative. Helpers’ empathic responses are modulated to provide compassion and understanding, as well as appropriate practical assistance. At the same time, the helpers’ sense of self and world is affected. The stories of trauma that helpers hear and the harm they witness may trigger reactions related directly or indirectly to their own life stories, including any unresolved traumas. Symptoms of vicarious traumatization include numbing, social withdrawal, nightmares, despair and hopelessness, lack of time or energy for oneself, disconnection from loved ones, and increased sensitivity to violence (Dorado, 2008). Vicariously traumatized workers may experience a diminished ability to tolerate strong affect. In the extreme, a client’s memories may become enmeshed with the helper’s memories. Disruptions may occur in a helper’s needs for safety, trust, esteem, intimacy, and self-efficacy. A helper may find it more difficult to keep clear boundaries, take perspective, show empathy, activate a sense of humor, seek personal growth, think clearly, and be introspective (Dorado). Clearly these are serious impairments of personal well-being. Therefore, it is essential for helpers of trauma sufferers to receive care, support, and respite themselves.  



The Scope of the Problem: Incidence of Trauma and PTSD

Trauma and PTSD are prevalent in US society, as the following data (Perry & Szalavitz; 2006) indicate.

•7 % of the population suffer from PTSD.

• 40 % of children have at least one potentially traumatizing experience before age eighteen.

•3 million official reports of child abuse and neglect were filed in 2004, and 82,000 of these cases were corroborated. However, the actual numbers are much higher because most instances are never reported, and some real cases cannot be corroborated.

•1 in 8 children reported serious maltreatment by adults within the past year of a large survey.

•27 % of adult women and 16 percent of men reported having been sexually victimized when they were children.

•10 million children are exposed to domestic violence annually.

•4 % of children under 15 experience the death of a parent each year.

•8 million children “suffer from serious, diagnosable, trauma-related psychiatric problems. Millions more experience less serious but still distressing consequences” (p. 3).

•About one-third of abused children develop psychological problems as a result.



van der Kolk (2003) provided other data on the prevalence of       

trauma and PTSD in U.S. society.

•“At least 15% of the population is reported to have been molested, physically attacked,  raped, or involved in combat” (p. 169).

•11.1% of men and 10.3% of women are physically assaulted.

•7.3% of women and 1.3% of men are sexually assaulted.

•50% of victims of violence are under age 25.

•29% of victims of forcible rape are under age 11.

•Among adolescents aged 12 to 17, 8% are victims of serious sexual assault, 17% are victims of serious physical assault, and 40% have witnessed serious violence.

•Perpetrators of rapes are 22% strangers, 19% husbands and boyfriends, and 38% other relatives of the victims.

•62% of almost 3 million violent assaults on women in 1994 were perpetrated by people they knew.

•63% of almost 4 million violent assaults on males in 1994 were perpetrated by strangers.

•Parents perpetrate 80% of assaults on children.

•More than a third of victims of domestic violence suffer serious injuries.

•A quarter of victims of assault by strangers suffer serious injuries.

•Children in homes where spousal abuse occurs are 1500%  more likely to be abused than the national average.

•The most common causes of PTSD in men are mortal combat and seeing death or severe harm.

•In women, the most frequent causes of PTSD are rape and sexual molestation.

•Women are twice as likely as men to develop PTSD as a consequence of trauma.

The schools of this nation can also be sites of traumatic violence and bullying. Grossman and DeGaetano (1999) reported that, “at least 160,00 children miss school every day because they fear an attack or intimidation by other students” (p. 18). While the foregoing data are relevant to the incidence of trauma in the US, trauma and PTSD are, of course, worldwide phenomena.



Effects of Trauma

Trauma may adversely and pervasively affect all levels of human functioning. In this section, we consider the neurobiological, physiological, emotional, cognitive, sense-of-self, social, and behavioral effects of trauma. We also look at comorbidity, meaning the simultaneous presence of more than one disorder. PTSD, or other types of unresolved trauma, is often present along with other problems of mental, behavioral, and physical health. While we consider the effects of trauma under different categories, it is important to remember that they are all interdependent. Furthermore, the profile of traumatic stress may vary depending upon many factors, including type of trauma, age of traumatic exposure, frequency and intensity of trauma, quality of interpersonal support the traumatized person receives, genetic vulnerability factors, and many other variables. For the purposes of this paper, a survey of the extensive range of effects of trauma will suffice.



Neurobiological

Thanks to neuroimaging research in recent years, much has been learned about how the brains of traumatized people, due to the damaging impact of trauma, differ in structure and functioning from the brains of those who have been more fortunate because the latter have not been traumatized. This research is important with regard to the subject of this study because it shows the neurobiological basis for why mainstream, talk-based therapies, such as cognitive behavioral therapy (CBT) and psychodynamic psychotherapy, both of which seek to help through promoting insight and understanding, “are usually not enough to keep traumatized people from regularly feeling and acting as if they are traumatized all over again” (van der Kolk, 2006, p. 6). This is because when people with PTSD “are reminded of a personal trauma they activate brain regions that support intense emotions, while decreasing activity of brain structures involved in the inhibition of emotions and the translation of experience into communicable language” (van der Kolk, p. 2).

Furthermore, the dorsolateral prefrontal cortex (dlPFC), the brain area “which is involved with insight, understanding, and planning the future, has virtually no connecting pathways to the brain centers that generate and elaborate emotions” (van der Kolk, p. 6). In other words, “the imprint of trauma does not ‘sit’ in the verbal, understanding part of the brain, but in much deeper regions--amygdala, hippocampus, hypothalamus, brain stem--which are only marginally affected by thinking and cognition” (van der Kolk cited in Wylie, n.d.). Under the impact of trauma, activation is significantly decreased in Broca’s area in the left temporal lobe (van der Kolk, 2006). This is the brain region that mediates the semantic components of speech. Therefore, therapeutic interventions are needed that help people learn more directly and physically, not just verbally, to recognize and regulate their own levels of distressed emotional arousal. As will be shown below, yoga practices involving breathing, mindfulness of inner sensations, and asanas have been demonstrated through research to help people suffering from PTSD to become more self-regulating, better able to calm themselves, and better able to be mindful in the present.

Trauma has profound, frequently long-lasting effects on the structure and functioning of the human brain and the rest of the nervous system through overwhelming the stress-response systems. In fact, “the brain’s stress-mediating systems are widely distributed; they involve the brain and the autonomic nervous system as well as neuroendocrine and neuroimmune responses. Clearly stress-related neural pathways permeate the entire brain” (Perry, 2008). These stress-mediating systems, the monoamine neurons, originate in the lowest levels of the brain, the brainstem and diencephalon, which are functional at birth, and “send direct connections into all other brain areas” (Perry). These stress-mediating networks involve the activity of the monoamine neurotransmitters--epinephrine (adrenaline), norepinephrine (noradrenalin), serotonin, and dopamine. “Collectively this network has been referred to as the reticular activating system (RAS)” (Perry). When the RAS becomes overwhelmed, “traumatic stress can impact cortically mediated (e.g., cognition), limbic mediated (e.g., affect regulation), diencephalic-mediated (e.g., fine motor regulation, startle response), and brainstem-regulated (e.g., heart rate, blood pressure regulation) functioning” (Perry).

Recent neurobiological research has found that those adults who had suffered severe trauma as infants and toddlers, trauma due to emotional and physical neglect and/or abuse, and who have not benefited from healing relationships and practices during critical windows of opportunity in their subsequent development, have suffered brain damage due to the neurotoxic effects of abnormally high levels of the stress hormone cortisol, resulting in the destruction of billions of neurons in the very areas of the brain that make affect regulation, self-witnessing, mindfulness, empathy, and compassion possible (Perry, 1997; Perry & Szalavitz, 2006; Schore, 2003a&b; Teicher, 2002). Some of the adversely affected brain areas and their significance to our human experience will now be addressed.



Reticular activating system (RAS)

As discussed above, this complex, pervasive set of adrenergic, noradrenergic, serotonergic, and dopaminergic neuronal networks is responsible to “provide the flexible and diverse functions necessary to modulate stress, distress, and trauma” (Perry, 2008). When the trauma is severe and/or prolonged, and when the person affected is genetically and/or developmentally vulnerable, the RAS may become hyperaroused, dissociated, or a mix of both.



Locus coeruleus

This crucial component of the RAS, located in the brainstem, “is involved in initiating, maintaining, and mobilizing the total body response to threat” (Perry, 2008). It “sends axonal projections to virtually all major brain regions and thus functions as a general regulator of noradrenergic tone and activity” (Perry). Under conditions of traumatic stress, along with the ventral tegmental nucleus, the locus coeruleus increases its activity by releasing cascades of the adrenal cathecolamine hormones--adrenaline, noradrenaline, and dopamine--throughout the brain and body. These catecholamine systems “play a critical role in regulating arousal, vigilance, affect, behavioral irritability, locomotion, attention, and sleep, as well as the startle response and the response to stress (Perry).



       Orbitofrontal cortex

The orbitofrontal cortex, located in the limbic brain, becomes functional at the age of 10 to 12 months, matures during toddlerhood, and is critical to empathic understanding of the emotional experience of others, self-awareness, the development of moral behavior, and much else (Schore, 2000 a & b; Siegel & Hartzell, 2004). It is adversely affected by developmental and other traumas. The earlier and more chronic the traumatization, the more poorly it develops. “This part of the brain is unique because it’s the only area of the brain that is one synapse away from all three major regions of the brain. In other words, its central location anatomically enables it to integrate the cortex, limbic structures, and brain stem into a functional whole” (Siegel, 2003, p. 21). When trauma disrupts the development and functioning of the orbitofrontal cortex, neural integration is impaired. The role of a portion of the orbitofrontal cortex will be further elaborated under the next subheading.



Medial prefrontal cortex: Anterior cingulate cortex and medial orbitofrontal cortex

Other highly evolved brain areas are also adversely affected and become less active due to trauma and ensuing PTSD. These encompass “the higher brain areas involved in ‘executive functioning’: planning for the future, anticipating the consequences of one’s actions, and inhibiting inappropriate responses” (van der Kolk, 2006, p. 11). According to neuroimaging studies, people with PTSD have reduced activation of the medial prefrontal cortex (mPFC), which includes the anterior cingulate cortex (ACC) and “medial parts of the orbitofrontal prefrontal cortices” (van der Kolk, p. 11). The ACC “plays a role in the experiential aspects of emotion, as well as in the integration of emotion and cognition” (van der Kolk, p. 11). When the mPFC is dysfunctional, the individual cannot exercise voluntary control over inhibiting generalized, conditioned fear reactions, as found in PTSD. The great clinical implication is that “activation of interoceptive awareness can enhance control over emotions” (van der Kolk, p. 11). In the section below on yoga therapy for PTSD, we will see how the mindfulness, breathing, and asana practices of yoga are helpful in enhancing such interoceptive awareness.



Hippocampus

The hippocampus, a part of the limbic system, becomes functional in the second and third years of life and is “not fully myelinated until the third and fourth years of life” (van der Kolk, 1994, p. 8). It mediates explicit memory, evaluates situations, and can act as a brake on the amygdala’s threat-alarm system. When its structure and functioning are intact, it plays a role in integrating traumatic memories into verbal memory. It is involved in a sense of self through narrative awareness of one’s life story organized into categories of past, present, and future (Teicher, 2002). In people suffering from chronic PTSD, according to three different neuroimaging studies, hippocampal volume is decreased from 8% to 26% (van der Kolk, 2003, p. 184). This is significant since the intrusive, troubling memories found in PTSD patients “initially have few narrative elements,” and “what makes memories traumatic is a failure of the CNS (central nervous system) to synthesize the sensations related to the traumatic memory into an integrated semantic memory” (van der Kolk, p. 183). Some studies have found especially “diminished left hippocampal volume and development” (Cozolino, 2006, p. 233).



Amygdala

The amygdala, located in the limbic brain, is functional at birth. It is the fear and anxiety center of the brain. It appraises safety, or the lack thereof, evaluates the emotional valence of incoming stimuli, unconsciously stores memories of trauma, and sends alarm signals for fight, flight, or freeze behaviors (Siegel, 1999). Following trauma, when a person can neither flee nor fight effectively, the amygdala becomes hyper-alert, and “the lateral nucleus of the amygdala is the critical anatomical structure in the formation of conditioned fear memories” (van der Kolk, 2006, p. 7), such as are prevalent in PTSD sufferers.



Corpus striatum

The corpus striatum receives information about threat from the lateral amygdala and engages motor circuits for active coping actions. In people with PTSD, neuroimaging studies have found decreased activation of the corpus striatum (van der Kolk, 2006). This is significant because at the time of the trauma no effective coping behavior, whether fight or flight, was available to the traumatized individual, so there was a physiological freezing. In PTSD, there appears to be a persistent conditioned behavior of inhibited action that maintains the organism in a traumatized state.



Corpus collosum

The corpus collosum is made of bands of nerve fibers that connect the left and right hemispheres and make the integration of hemispheric information-processing possible. It allows for the integration of emotional functions, largely mediated by the right hemisphere, with cognitive functions, largely mediated by the left hemisphere. In PTSD, this right-left cortical integration is disrupted, and the volume and density of nerve fibers in the corpus collosum is reduced (Cozolino, 2006).



Left hemisphere

People who have suffered developmental trauma due to early, chronic, severe abuse and/or neglect have “diminished left hemisphere development” (Cozolino, 2006, p. 233). This is significant with regard to both emotional and cognitive functioning. In emotionally healthy people, the left hemisphere of the brain tends to be more active than the right hemisphere. “An active left brain is linked to positive feelings, cheerfulness and a willingness to approach others with a kind of extraverted outlook” (Gerhardt, 2004, p. 121). Furthermore, an underdeveloped left hemisphere is associated with a diminished ability to identify feelings verbally and to process cognitively the emotional interactions that are the basis of understanding self and others in relationship. When people with PTSD are experimentally “exposed to traumatic reminders,” they show “a relative deactivation in the left anterior prefrontal cortex, specifically in Broca’s area, the expressive speech center in the brain, the area necessary to communicate what one is thinking and feeling” (van der Kolk, 2006, p. 2). Furthermore, the lack of hemispheric integration is a key feature in intrusive flashbacks, one of the key symptoms of PTSD. “Flashbacks appear to involve the intense activation of the right hemisphere (visual cortex) in the setting of left hemisphere (speech area) deactivation” (Siegel, 2003, p. 49).



Right hemisphere

The right hemisphere tends to predominate when there are negative, unhappy feelings and moods. In the same experimental exposure to traumatic reminders mentioned in the preceding paragraph, PTSD “subjects had cerebral blood flow increases in the right medial orbitofrontal cortex, insula, amygdala, and anterior temporal pole” (van der Kolk, 2006, p. 2). It would be a mistake, however, to think simplistically that the right hemisphere is only about the processing of unhappy feelings. It has many other functions.

The right side of the brain processes information as nonverbal signals in a holistic, parallel, visual spatial manner. Self-soothing is also a major function of the right hemisphere. The right hemisphere is usually dominant for nonverbal aspects of language (tone of voice, gestures), facial expression of affect, the perception of emotion, the regulation of the autonomic nervous system, the registration of the state of the body, and for social cognition including the process called theory of mind (Siegel, 2003, p. 14).



Brainstem and heart rate variability (HRV)

The brainstem, which regulates such vital functions as heart rate, blood pressure, and breathing, is also adversely affected by trauma and PTSD. Evidence for this dysregulation at the primal level of the brain stem is found in the fact that traumatized people have lower resting heart rate variability (HRV) than people who have not been traumatized. HRV “provides the best available means of measuring the interaction of sympathetic and parasympathetic tone, that is, of brainstem regulatory integrity” (van der Kolk, 2006, p. 9). Low HRV is associated with negative emotions, including anxiety and depression, which understandably predominate in the subjective experience of traumatized people. Low HRV is also associated with lowered resistance to stress, cardiovascular disease, and higher risk of mortality. “PTSD involves a fundamental dysregulation of arousal modulation at the brainstem level” (van der Kolk, p. 9).



Cerebellar vermis and GABA

Developmental trauma has also been found to damage the cerebellar vermis. The cerebellum is located just above the brainstem at the back of the brain, and the vermis is its central part. The vermis controls the neurotransmitters dopamine and norepinephrine as well as the brain’s primary inhibitory neurotransmitter, gamma aminobutyric acid (GABA). Trauma adversely affects the ability of the vermis to soothe emotional arousal in the limbic brain and to support GABA input to the hypothalamus, thereby causing heightened irritability (Teicher, 2002; Siegel, 2003).



Insula

The insula is also harmed by developmental trauma (deMause, 2007). It has several functions, a few of which will be cited here. It helps “integrate limbic processing and link it to cortical

networks” (Cozolino, 2006, p. 41) “The insula allows us to be aware of what is happening inside our bodies and reflect on our emotional experience” (Cozolino, p. 56). Furthermore, “recent research suggests that the insula is involved with mediating the entire range of emotions from disgust to love” (Cozolino, p.56). Also, “it appears to play a role in the experience of self and our ability to distinguish between ourselves and others” (Cozolino, p. 206).  Along with the anterior cingulate, it also plays a role “in linking hearts and minds” (Cozolino, p 208). In fact, “the degree of activation of these two structures has been shown to correlate with measures of empathy” (Cozolino, p. 208).



Mirror neuron system

The mirror neuron system is also dysregulated by trauma (deMause, 2007). This system was first discovered in research on monkey’s brains when it was found that the same neurons were activated when the monkeys were performing a specific action as when they were observing other monkeys doing the same action (Cozolino, 2006). “Mirror neurons lie at the crossroads of the processing of inner and outer experience, where multiple networks of visual, motor, and emotional processing converge” (Cozolino, p. 187). Thus, mirror neurons are distributed in several locations of the social brain, affecting the learning of verbal and nonverbal communication, empathy, social cohesion, and manual and bodily skills. “Current research supports that the human mirror system extends to the temporal, parietal, and frontal lobes as well as to the insula, amygdala, basal ganglia, and cerebellum”(Cozolino, p. 193).



EEG

As could be inferred from the foregoing discussion in this section, EEG readings are abnormal in traumatized people (Cozolino, 2006).



This review of the neurobiological effects of unresolved trauma does not cover all currently available research findings on the subject. It is primarily intended to reveal the extent and depth of neurobiological disturbances at all levels of the brain. It also provides a scientific basis for the exposition later in this paper of how yoga can be an effective therapeutic modality for helping people heal from trauma and PTSD.



Physiological

For traumatized people, the startle response, mediated by the hypothalamus-pituitary-adrenal (HPA) axis, is exaggerated (Dorado, 2008). Their sleep-waking cycles are dysregulated, and they often experience insomnia, whether in falling or staying asleep.

According to one model, the physiological reactions to trauma occur in two stages. “In the initial stage, hyperarousal, an alarm reaction is initiated by the sympathetic nervous system” (Schore, 203a. p. 67). This involves such physiological reactions as increased heart rate and blood pressure, faster and more shallow breathing, dilation of the pupils, and increased muscular tension, all aspects of the instinctual “fight or flight” strategies orchestrated at the level of the reptilian brain (Levine, p. 95). The second stage of reaction to trauma is a “later-forming and longer-lasting reaction…a parasympathetic response” (Schore, p. 67). It involves dissociation, which is the physiological, emotional, and psychological shutting down and withdrawal from the threatening external world (Schore, p. 67).“ When fight and flight responses are thwarted, the organism instinctively constricts as it moves toward its last option, the freezing response” (Levine, pp. 16, 99). This response is seen in all animals, as for example, when they cannot evade a predator. They freeze as if already dead. If an animal has gone into the freezing phase, but for some reason senses it has a new opportunity to escape from a predator, its body begins to vibrate, twitch, and tremble, which is “…the organism’s way of regulating extremely different states of nervous system activation” (Levine, pp. 97-98). Human reactions to trauma follow similar patterns.

According to another model (Perry, 2003), “For most children and adults, however, the adaptive response to an acute trauma involves a mixture of hyperarousal and dissociation” (p.4). These heterogenous responses to traumatic threat vary from one individual to another. Perry (2003) summarized them in the following table:



Differential Response to Threat

Dissociation                         Hyperarousal

Detached                             Hypervigilance

Numb                                  Anxious

Compliant                          Reactive

Decrease HR                      Alarm response

Suspension of time              Increase HR

De-realization                      Freeze: Fear

‘Mini-psychoses‘                   Flight: Panic

Fainting                              Fight: Terror



Perry (2003) noted the variables that affect whether a person’s primary adaptive response to traumatic threat is dissociation or hyperarousal:

Dissociation is more common in younger children, females and during traumatic events that are characterized by pain or an inability to escape. A hyperarousal response is more common in older children, males and when the trauma involves “witnessing or playing an active role in the event. In most traumatic events, the individual will use a combination of these two primary adaptive response patterns” (p. 8).

The neurobiological aspects of hyperarousal and dissociation are related yet a bit different. “Both use the monoamine systems in the brainstem and diencephalon, but somewhat different elements of these complex networks” (Perry, 2008). Both reactions to traumatic stress involve “increases in circulating epinephrine and associated stress hormones” (Perry). In dissociation, however, “vagal tone increases dramatically, decreasing blood pressure and heart rate (occasionally resulting in fainting) despite increases in circulating epinephrine,” and there is “an increased relative importance of dopaminergic systems,” as well as of “endogenous opioid systems” (Perry).

Levine (1997) summarized, within the framework of his trauma model, the four key components of the traumatic reaction as “hyperarousal, constriction, dissociation, and freezing (immobility) associated with helplessness” (p. 132). He observed that, “When we are unable to flow through trauma and complete instinctive responses, these uncompleted actions often undermine our lives”  (Levine, p. 32). Traumatized people’s lives can be undermined in varied ways. Their physical health may suffer. They may reenact the helpless victim role. They may become perpetrators who inflict trauma on others. deMause sees warfare as the collective reenactment of early, widespread, developmental trauma (deMause, 2002).

To help people heal from the effects of trauma, we need to understand the physiological and energetic, as well as psychological dimensions of these effects.



Traumatic symptoms are not caused by the ‘triggering’ event itself. They stem from the frozen residue of energy that has not been resolved and discharged; this residue remains trapped in the nervous system where it can wreak havoc on our bodies and spirits. The long-term, alarming, debilitating, and often bizarre symptoms of PTSD develop when we cannot complete the process of moving in, through, and out of the ‘immobility’ or ‘freezing’ state (Levine,1997, p. 19).



The roots of trauma lie in our instinctual physiologies. As a result, it is through our bodies, as well as our minds, that we discover the key to its healing. …My observations of scores of traumatized people have led me to conclude that post-traumatic symptoms are, fundamentally, incomplete physiological responses suspended in fear. Reactions to life-threatening situations remain symptomatic until they are completed. Post-traumatic stress is one example (Levine, p. 34).



It is important to recognize that for traumatized people, “…the intense, frozen energy, instead of discharging, gets bound up with the overwhelming, highly activated, emotional states of terror, rage, and helplessness” (Levine, 1997, p. 100).  By flowing through trauma, Levine means the release, in a supportive context, of energy that has become mobilized to maintain chronic neuromuscular and emotional constriction. The role of this constriction is to defend us from being overwhelmed by feelings of helplessness, by the anger and rage that were repressed when we were not able to fight back, and by the fear and terror that could not be released by fleeing the threat. Below we will discuss how yoga, taught in supportive contexts, can facilitate the gentle, gradual release of the constrictions and frozen energetic charges that characterize post-traumatic stress.

Another negative physiological effect of trauma is reduced heart rate variability (HRV) (van der Kolk, 2006), as discussed above in the section on neurobiology. HRV is an indicator of the interaction between the sympathetic and parasympathetic branches of the autonomic nervous system and, therefore, of brainstem regulatory effectiveness. “Low HRV has been associated with anxiety and depression, with coronary vascular disease, and increased mortality while high HRV is associated with positive emotions and resistance to stress”  (van der Kolk, 2006, p. 9).

Trauma victims often have disturbances with regard to tactile sensations. They may have analgesia, hypersensitivity to physical contact, and problems localizing skin contact (NCTSN, 2003).Moreover, they experience problems with body tone, balance, coordination, and sensorimotor development and integration (NCTSN).



Emotional

The emotional manifestations of unresolved trauma are manifold. They include, to varying degrees from person to person, impairments in emotional self-regulation and self-soothing; emotional lability; explosive anger; heightened fearfulness; constriction and rigidity; inability to feel empathy for others’ emotions; lack of ability to give words to feelings; inability to distinguish sensations from emotions; and inability to differentiate among different levels and states of emotional arousal.

Many traumatized children and adults, confronted with chronically overwhelming emotions, lose their capacity to use emotions as guides for effective action. They often do not recognize what they are feeling. This phenomenon is call ‘alexithymia,’ an inability to identify the meaning of physical sensations and muscle activation” (van der Kolk, 2006, p. 5).

Similarly,

“clinical experience shows that traumatized individuals, as a rule, have great difficulty attending to their inner sensations and perceptions--when asked to focus on internal sensations they tend to feel overwhelmed, or deny having an inner sense of themselves” (van der Kolk, 2006, p. 11).

Rather than being focused on tasks, projects, processes, and understanding, traumatized people develop emotion-focused coping, “a style in which the goal is to alter one’s emotional state, rather than the circumstances that give rise to those states” (van der Kolk, 2003, p. 170). In healthier functioning, one is oriented to solving problems, building relationships, and achieving projects, rather than primarily to avoiding distressing feelings.



Cognitive

Survivors of trauma tend to confuse past, present, and future (A. St.Just, personal communication, March 29, 2003). Memory is correspondingly distorted:

PTSD, by definition, is accompanied by memory disturbances, consisting of both hypermnesias and amnesias. Research into the nature of traumatic memories indicates that trauma interferes with declarative memory, i.e. conscious recall of experience, but does not inhibit implicit, or non-declarative, memory, “the memory system that controls conditioned emotional responses, skills and habits, and sensorimotor sensations related to experience” (van der Kolk, 1994, p. 6)

Those suffering from unresolved trauma, whether PTSD or developmental trauma disorder, have difficulty with focusing and regulating their attention. Executive functioning is impaired. This involves rational decision making, planning, sequencing, anticipating, initiative, and task orientation. There is often a lack of meaningful interest and sustained curiosity. New information is difficult to process and integrate. Traumatized people often have an external locus of control, meaning there is little recognition of their own agency or contributions to what is happening to them. They experience learning impediments and impaired language development. They are disoriented in space, as well as in time.  The may easily misperceive and misinterpret incoming auditory and visual information. When they are flooded by intrusive memories, triggered by internal or external cues and sometimes accompanied by visual, auditory, tactile, gustatory, or olfactory hallucinations, their higher-level cognitive functioning shuts down, and they believe, feel, and act as if they are presently experiencing the trauma. Nightmares related to the trauma may also be vividly disturbing.

Dissociation is a distinguishing characteristic of trauma. While it is functional for buffering shock in the moment of overwhelming traumatic stress, it becomes dysfunctional when it persists. It may take different forms. These include experiencing cognition without appropriate affect; experiencing affect without cognition; unconscious somatization of emotional issues; and compulsive behavioral reenactments without awareness (Dorado, 2008). In a state of dissociation, a person may experience a loss of a sense of self (depersonalization) or a sense of reality (derealization).

The more triggered a traumatic stress response is, the more foreshortened a person’s sense of time is. Perry (2002) presented an elegant model for understanding this. The model correlates mental state, cognition, primary and secondary brain areas involved, and time awareness:



Mental State    Cognition          Primary/Secondary Brain Area     Sense of Time



Calm                 Abstract           Neocortex/Subcortex                 Extended future



Arousal               Concrete                Subcortex/Limbic                       Days/Hours



Alarm                 Emotional                  Limbic/Midbrain                             Hours/Minutes



Fear                      Reactive                     Midbrain/Brainstem                Minutes/Seconds



Terror                 Reflex                  Brainstem/Autonomic        Loss of Sense of Time



The table above helps understand why the more traumatized or reactive a person is, the less that person is capable of the self-discipline required for delayed gratification and working toward a future goal.



Self-Awareness

The sense of self of trauma victims is often fragmented, discontinuous, and unpredictable.  They cannot narrate a coherent narrative of their life story. Their boundaries are blurred, and they do not know where they end and others begin, what is theirs and what belongs to others.  “Trauma victims tend to have a negative body image--as far as they are concerned, the less attention they pay to their bodies, and thereby, their internal sensations, the better” (van der Kolk, 2006, pp.11-12). They lack a robust sense of self-worth, and they suffer from pervasive, incapacitating shame and guilt.



Social

People with unresolved trauma often feel alienated and estranged from others, as well as uncertain about human trustworthiness, reliability, and predictability. As noted above, they lack clear interpersonal boundaries. They tend to be wary and suspicious. Their interpersonal relationships are often troubled. They find it difficult to attune empathically to other people’s emotions. It is challenging to them to take the perspective of others, to enlist others as allies and advocates. Intimacy and attachment are particularly problematic and frightening for them (NCTSN, 2003), and they may be incapable of intimacy.



Behavioral

Avoidance of reminders of the trauma is a defining behavioral symptom of PTSD. The avoidance can be related to sounds, sights, smells, tastes, people, locations, times, anniversaries, words, situations, and more. Such associational triggers may elicit overwhelming, intrusive flashbacks and unpleasant feelings that the person with unresolved trauma is desperately seeking to avoid.

Those suffering from the effects of trauma have poor ability to monitor and inhibit their impulses. They often engage in self-destructive and pathological, self-soothing behaviors, such as alcoholism, drug abuse, and self-cutting in instinctive efforts to numb their torment.

Those suffering from developmental trauma have high rates of aggression, violence, and criminality.

“People with childhood histories of trauma, abuse, and neglect make up almost our entire criminal justice population; physical abuse and neglect are associated with very high rates of arrest for violent offenses. In one prospective study of victims of abuse and neglect, almost half were arrested for non-traffic related offenses by age 32” (van der Kolk, 2005, p. 402).

Among combat veterans with PTSD, there are high rates of domestic violence, child abuse, and suicide.

Eating disorders are also common among trauma survivors. Relations to authority, societal norms, and institutional rules are marked by either excessive compliance or oppositional/defiant behavior. When they are unable to communicate narratively about their traumatic past, traumatized people reenact it, perhaps aggressively or sexually, in everyday behaviors and play (NCTSN, p. 18), and in the role of either perpetrator or victim.



Comorbidity

The after-effects of trauma are physical as well as psychological. Adults who had been severely maltreated as children are, according to a study involving about 10,000 medical patients, at greater than normal risk for a range of health problems as follows:

“a 4 to 12 times greater risk of developing alcoholism, depression, and drug abuse, attempting suicide, a 2 to 4 times greater risk of smoking, having at least 50 sexual partners, acquiring sexually transmitted disease, a 1.4 to 1.6 times greater risk for physical inactivity and obesity, a 1.6 to 1.9 times greater risk for ischemic heart disease, cancer, chronic lung disease, skeletal fractures, hepatitis, stroke, diabetes, and liver disease” (van der Kolk, 2003, p. 168).

Further retrospective epidemiological evidence from the Adverse Childhood Experiences (ACE) studies of 17,000 adults have shown “increased risk of a host of emotional, social, behavioral and physical health problems following abuse and related traumatic experiences in childhood” (Perry,  2008). Additionally,

“among the ACE findings are a graded increase in risk (i.e., more abuse = more risk) for affective symptoms and panic attacks; for memory problems; for hallucinations; for poor anger control; for perpetrating partner violence; unhealthy sexual behavior (early intercourse, promiscuity, sexual dissatisfaction); suicide; substance abuse; alcohol use and abuse; smoking” (Perry).

Trauma is frequently the hidden story beneath substance abuse issues. “Between 25% and 50% of all patients who seek substance-abuse treatment also suffer from a comorbid PTSD diagnosis. The relationship between substance abuse and PTSD is reciprocal: drug abuse leads to assault, and assault leads to substance use” (van der Kolk, 2003, p. 170).

The extensive, lifelong repercussions of developmental trauma due to neglectful and/or abusive child maltreatment led Perry (2008) to call it the “Great Imposter.” He wrote that, “depending upon the age, nature and pattern of maltreatment a child may develop symptoms that mimic dozens of traditional DSM-IV diagnoses from autism or ADHD or ‘learning disorder’” (Perry). This helps explain why a national study found that “88% of people with PTSD had at least one co-occurring psychiatric illness” (Emerson, Sharma, & Chaudry, 2009, p.123).



                    Scientific Research Supporting

                Yoga’s Benefits for Healing Trauma

Having reviewed the pervasive, disruptive effects of trauma on human well-being, and prior to introducing models of trauma-sensitive yoga, we shall now discuss encouraging research findings that confirm the efficacy of yoga as a therapeutic intervention for helping trauma victims heal. One pilot study (Streeter, et al., 2007) found a robust 27% increase in GABA levels as a result of an hour’s yoga practice. As discussed in the neurobiology section of this paper, trauma disrupts the cerebellar vermis and its ability to soothe emotional arousal in the limbic brain and to support GABA input to the hypothalamus, thereby causing heightened irritability (Teicher, 2002; Siegel, 2003). GABA is the primary inhibitory neurotransmitter. Therefore, this pilot research finding is highly promising. It indicates how yoga affects changes at a deep neurobiological level and correlates with the subjectively experienced calming effects of yoga.  Because of the small sample size in this study that involved experienced yoga practitioners in the experimental group compared with a control group who read for an hour rather than engaging in an alternative physical activity to yoga, it is to be hoped that more research into the GABA-enhancing effect of yoga will be conducted.

At the Child Trauma Academy (CTA) (see http://www.childtrauma.org), the pediatric psychiatrist, neuroscientist, and trauma researcher Bruce D. Perry and his associates endorse yoga as a therapeutic modality within the context of the neurosequential model of therapeutics they have developed (NMT) for treating severely traumatized children (CTA, 2010; Perry, 2006). “The primary assumption of the NMT is that the human brain is the organ that mediates all emotional, behavioral, social, motor, and neurophysiological functioning” (Perry, p. 30). Because the brain develops in a sequential manner, from the bottom up, therapeutic treatments of brain-mediated dysfunctions, such as traumatic stress, need to begin at the lowest level of disrupted brain structure and functioning. With regard to trauma, “the key to therapeutic intervention is to remember that the stress response systems originate in the brainstem and diencephalon. As long as these systems are poorly regulated and dysfunctional, they will disrupt and dysregulate the higher parts of the brain” (Perry, 2006, pp. 38-39). This key therapeutic principle is relevant for work with traumatized adults as well as children. Because yoga involves breathing, proprioceptive awareness, movement, and balance, it affects the brainstem and diencephalon directly and profoundly. It introduces regulatory rhythms where there was chaotic irregularity and facilitates healthy integration at all levels of functioning, beginning from the bottom up, as is needed.

It is heartening that in a recent Child Trauma Academy newsletter (CTA, 2010), yoga is featured as a therapeutic modality for healing traumatized children. The report noted that, “because kids do not have the cognitive abilities to understand and control their feelings, in order to change how they feel, they may need to actually manipulate their physical state” (CTA). Because yoga combines exercise, breath awareness, relaxation, and meditation, it offers more than just physical exercise. The article highlights yoga’s ability to enhance relaxation.

A person is not capable of feeling anxious or angry when his or her body is relaxed, and children can feel their tense and confusing emotional state changing as their bodies relax. Thus, children learn to regulate their emotions through yoga even if they do not understand why they felt anger, confusion, or frustration initially (CTA).

       Furthermore, the CTA noted yoga’s beneficial effects in teaching competence and mastery, concentration, and self-efficacy by placing “the control over one’s body and emotions into the hands of the child” (CTA). A yoga center in North Carolina has become affiliated with the CTA and has incorporated Dr. Perry’s research about healing trauma into its approach for working with children, noting that those who practice yoga and meditation can “lower brainstem temperature and better self-regulate their

behavior” (CTA).

In a study that compared the therapeutic effects of Dialectical Behavior Therapy (DBT), a well-regarded psychotherapeutic modality, with those of yoga for treating trauma, van der Kolk and associates found

“at the end of the eight week-period, yoga participants scored higher than the DBT group on the body image/body awareness and mood scale, which suggested that yoga was helping traumatized individuals develop a kinder, more positive relationship to their bodies” (Emerson, 2008, p. 4).

Furthermore, “in comparison with DBT only the yoga group showed significant decreases in frequency of intrusions and severity of hyperarousal symptoms between time 1 and time 2” (van der Kolk, 2006, p. 10). Since intrusions and hyperarousal are two of the three primary indicators of PTSD, this study is very good news for the promise of yoga for treating PTSD. The third primary indicator of PTSD is avoidance, including avoidance of awareness of one’s own body, sensations, and feelings. Practicing yoga directly involves overcoming such avoidance mindfully.

In another study, van der Kolk’s team “compared yoga groups of trauma survivors with wait-listed groups of trauma survivors and yoga groups of non-trauma survivors” (Emerson, 2008, p. 4).  Both subjective reports from participants in the study and standard clinical interview procedures found “about a 50% drop in PTSD symptoms” (Emerson, p.4) for the experimental group of trauma survivors who did the yoga practice. It is noteworthy that, “without ever talking about the trauma, participants showed a decrease in symptoms that was both statistically significant and clinically substantial” (Emerson, pp. 4-5).

While the non-traumatized control group who did yoga in this study experienced a substantial and desirable increase in HRV, the traumatized participants did not. This was an important finding because HRV, as mentioned above, is the best available measure of brainstem regulatory integrity and balance between sympathetic and parasympathetic tone. The researchers concluded from this finding that “one yoga session per week over 10-weeks is not likely to be enough to alter the chronic dysregulation of the stress response in traumatized individuals, and that a longer, more intensive protocol may be appropriate and effective” (Emerson, 2008, p. 5). The researchers aspire to explore the validity of this hypothesis in further research.

Numerous scientific studies have been conducted on the benefits of mindfulness, one of the key components of yoga, and the findings are significant with regard to the potency of mindfulness for healing trauma. In one meta-analysis (Grossman, Niemann, Schmidt, & Wallach, 2004), researchers reviewed 64 studies about health benefits and stress reduction correlated with mindfulness. They found that only 20 of these studies met their research criteria for relevance and quality. Across these 20 studies, they found consistent effect sizes of about 0.5, which indicates a sturdy correlation of physical and mental well-being benefits from regular mindfulness practice. In another meta-analysis, Baer (2003) observed that “the empirical literature on the effects of mindfulness training contains many methodological weaknesses, but it suggests that mindfulness interventions may lead to reductions in a variety of problematic conditions, including pain, stress, anxiety, depressive relapse, and disordered eating” (p. 126).  These findings are relevant to treating trauma since the cited problematic conditions are highly correlated with traumatic stress.

van der Kolk (2006) cited a revelatory fMRI neuroimaging study of 20 mindfulness practitioners “engaged in meditation involving sustained mindful attention to internal and external sensory stimuli and nonjudgmental awareness of present-moment stimuli without cognitive elaboration” (van der Kolk, p. 12). The findings were that “brain regions associated with attention, interoception, and sensory processing were thicker in meditation participants than matched controls, including the prefrontal cortex and right anterior insula” (van der Kolk, p.12). The insula showed the most significant enhancement from mindfulness practice. This is relevant to healing the disempowering effects of trauma because, among its functions, “the insula serves as an interface between our sense of self and our self-control capabilities” (Cozolino, 2006, p. 207). As we have noted above, trauma victims suffer losses in both sense of self and self-control on all levels, so the mindful practice of yoga, including meditation, can yield meaningful recovery benefits. Along with the anterior cingulate, the insula is also key to experiencing empathy.

This study “lends support to the notion that treatment of traumatic stress may need to include becoming mindful: that is, learning to become a careful observer of the ebb and flow of internal experience, and noticing whatever thoughts, feelings, body sensations, and impulses emerge” (van der Kolk, 2006, p. 12). In this connection, it is important to remember that one of the three primary indicators of PTSD is avoidance, and this includes avoidance of both external reminders of the trauma and of internal awareness. Therefore, a gentle, gradual introduction of mindfulness to trauma survivors is recommended because “traumatized individuals need to learn that it is safe to have feelings and sensations” (van der Kolk, p. 12). Through mindful yoga practice, survivors of trauma can discover that their sensations and feelings continuously ebb and flow, that they are not stuck in a given state, and that they can regulate how they feel through their own chosen breathing and movement. Thereby, “they will viscerally discover that remembering the past does not inevitably result in overwhelming emotions” (van der Kolk, p. 12). It can be subtly calming for traumatized people in practicing yoga to learn “to attend to nontraumatic stimuli” (van der Kolk, p. 13), to become genuinely interested in the present, and to discover feelings of safety and capacities for self-care and self-protection. This can be a substantial gift of yoga in promoting healing from trauma.



Trauma-Sensitive Yoga

Dr. Bessel van der Kolk, one of the leading experts in the field of traumatology, has been a key collaborator in the creation of trauma-sensitive yoga. Combining his own passion for yoga and his in-depth research on how trauma impacts the brain, Dr. van der Kolk, was able to prove that yoga can “positively affect the core regulatory mechanism in the brain” (IYM, 2009, p.12), as the research findings cited above substantiate. This model of trauma-sensitive yoga is now the focus of treatment at the Trauma Center based out of Brookline, Massachusetts. This program is led by another key collaborator, David Emerson, an experienced and successful yoga instructor.

As described in previous sections, trauma impacts many aspects of one’s being, including the storage of traumatic memory in one’s body. “Yoga offers a way to reprogram automatic physical responses” (IYM, 2009, p. 13). This is done in many ways, including through asanas, pranayama, mindfulness techniques, and meditation. Through exposing yoga to individuals who have been traumatized, one aims to accomplish several goals. Helping trauma survivors reclaim their bodies is one of these overarching goals. Many people who have experienced trauma in their lives have lost a sense of control and/or awareness of their bodies. “Trauma involves the internalization of a profound lack of safety, and the key [characteristic] to severe trauma is that there is nowhere to go to be safe – NOT EVEN TO ONE’S BODY” (Emerson, 2009, p. 6). Yoga can be used as a powerful tool to help them regain this awareness and connectedness to their bodies. Another goal of trauma-sensitive yoga is to teach self-regulation. Self-regulation is a clinical term that refers to the ability to calm oneself down. The use of asanas and pranayama are key tools in teaching self-regulation.

The trauma-sensitive yoga model teaches that there are five domains present in each yoga class. These domains are (1) language, (2) assists, (3) teacher qualities, (4) environment, and (5) exercises. Each of these domains will be discussed in detail below. It is important to know that while these are an integral part of classes designed for trauma survivors, it is equally as crucial that these elements be integrated into any class that aims to create a safe and nurturing environment for all the participants, including those who have been traumatized. A yoga teacher will often not know the past history of each of the students in their class. As a result, during any point, material may come up for a student, and the teacher must be prepared to “help people to calm down their bodies, by working with the breath and quieting poses” (IYM, 2009, p. 13). While this material may come up for students at any point, utilizing the five domains outlined below helps to transform any class into a trauma-sensitive, caring, and supportive environment.



Language

There are two types of languages that are important to be aware of when creating a trauma-sensitive environment: language of inquiry and invitatory language. Using these specific types of language techniques in a yoga class helps participants to “begin to inquire about their body – to look into it, explore it, and investigate it” (Emerson, 2009, p.7). “Every time you use language of inquiry and invitatory language you are reminding students that they have a body and they are in control of what they are doing to their body” (Emerson, p.7).  Some words commonly used in language of inquiry include “notice, curiosity, interest, allow, try, and feel” (Emerson, p. 10). For example, a teacher may choose to use phrases such as “I invite you,” and  “notice any difference you experience.” Similarly, words seen in invitatory language include “as you are ready, if you like, when you are ready, and at your own pace” (Emerson, p. 7).



Assists

As it applies to teaching a yoga class, assists can be broken down into two categories: physical and verbal. Physical assists are described as using one’s body (i.e. hands) to adjust another person’s body as they are in a particular posture. Verbal assists are similar; however, instead of using one’s own body to adjust a participant, one relies solely on words to help guide the participant into a different alignment. There are both pros and cons to using each of these types of assists. However, overwhelmingly so, the literature states that physical assists should not be utilized for the first several months of a yoga class, if one chooses to use them at all. In particular, when working with an individual or groups of individuals who have experienced traumatic events in their lives, physical touch can trigger traumatic memory in the participant’s body and/or mind. As a general rule, if one chooses to incorporate physical touch at any point in their class, it is always advised that the instructor ask for permission before touching another individual. This allows for the participants to experience ownership of their bodies and to be provided with space to choose to allow or deny the experience of touch to take place during that moment.



Teacher Qualities

    According to the manual, Toward Becoming a Trauma-Sensitive Yoga Teacher (Emerson, 2009), there are several key qualities that successful yoga instructors should strive toward incorporating into their being. Some of these qualities include being present and light (i.e. smiles from time to time), engaged, welcoming, and approachable. These qualities, collectively, help to create a safe environment for participants to feel comfortable exploring the depths of themselves. Additionally, an instructor should be able to invite feedback and be willing and available not only to listen to this feedback but also to make changes when things are not working for the students.



Environment

While instructors have little control of the structural elements of the building in which they are conducting class, there are still many things that one can do to the classroom environment to make it safer for individuals who have been traumatized. Some key considerations include not having open, exposed windows, having soft light (not too dark), and making sure that you have enough props for everyone (Emerson, 2009). One should also attempt to minimize the amount of walking in and out of the class that may occur as this may be a distraction to participants. Another consideration that each teacher should think about is the role of music in their class. While there is no set recommendation about the use of music in a trauma- sensitive yoga class, one should carefully consider the pros and cons associated with its usage. For individuals who have been traumatized, music can serve as a way to dissociate from the experience of connecting with one’s body. On the other hand, music might be a way to connect with the participants and to create a more peaceful environment. If not sure what to choose in this regard, it can always be helpful to ask the class what their preference is (Emerson).



Exercises

The first phase of a trauma-sensitive yoga class is to help participants notice that they have a body. “The emphasis in teaching is not so much on precise alignment and form as it is on gently inviting the individual back into their physical experience in a non-threatening way” (Emerson, 2008, p.11).  One way that this can be done is through the use of invitatory and inquiry language. As mentioned before, using this type of language in yoga class helps participants to “begin to inquire about their body – to look into it, explore it, and investigate it” (Emerson, 2009, p.7). Once participants become aware of their body, the next step is to facilitate an opportunity for participants to start to notice some details of their experience (i.e. feeling feet on floor, allowing the lower back to be at ease (Emerson). After these details are experienced in one’s body, the goal then becomes for each participant to begin to befriend their bodies, and ultimately leading to a place of self-regulation. Asanas and pranayama can be very powerful tools to utilize at each step along the way. Meditation can be equally as powerful; however, it is a tool that should be worked up to, as meditation can be very challenging for individuals who have been traumatized because of the risk of intrusive memories and flashbacks.

When choosing what particular asanas are used for each class, an instructor should be mindful not to start off with an extreme opener (i.e. hip openers, chest openers), as these more advanced openers should be gradually worked up to (Emerson, 2009). In his article “The Core” (Emerson, 2007), David Emerson  explains that the core of the body, ranging from the knees to the solar plexus, is also very important to focus on during a trauma-sensitive yoga class. While the core of one’s body is crucial for many aspects of one’s life, having a strong core will allow one to have a stable and supportive base in which to experience life (Emerson, 2007).This can be particularly important for trauma survivors. According to Emerson, “when a traumatized individual learns to maintain a center in the midst even of intense sensation they have gained an invaluable tool to help them along the healing process” (Emerson, 2007, p.1).



Settings for Offering Yoga for Healing from Trauma

There are many setting in which yoga can be used as a modality for healing trauma. More important than the physical structure of the building in which the class takes place is the instructor’s ability to follow the basic guidelines outlined in the sections above. While these guidelines have been proven to be effective when working with traumatized individuals, they can also be equally as effective when working with those who have not experienced traumatic events. As a result, these guidelines can be incorporated into any setting offering yoga classes. Three settings have been chosen to be explored in more depth in this section--clinical practices, yoga studios, and school sites.



Clinical Practice

Psychotherapy is considered a common option to use when treating individuals who have experienced trauma. While in some ways, psychotherapy can be seen as helpful in this treatment process, traditional therapy fails to integrate somatic work. As a result, therapy can be seen as limited when attempting to help individuals heal from their traumatic stress responses. As mental health therapists, the authors of this paper have become curious about the union between psychotherapy and yoga. As yoga practitioners, we have learned firsthand about the positive impact yoga has had on our own healing. We are now excited about merging these two powerful tools together to aid in facilitating a deeper healing amongst our clients. As mental health therapists sitting with our client’s, it is vital that we become attuned to the ways in which our client’s story has been imprinted into their being. In what ways can yoga be used to complement these moments? As suggested in the trauma-sensitive yoga curriculum, one must start with helping their clients notice that they have a body, then understanding the details of their body, as they aim to befriend their body and ultimately begin to self-regulate. If properly trained, mental health therapists are able to use both words and somatic exercises (i.e. asanas, pranayama, meditation) to accomplish these steps, clients can benefit from the confluence of both top-down and bottom-up approaches. One important consideration in this section is to create an atmosphere that supports communication with your client. This is important because many individuals who sign up for therapy are not expecting somatic work (i.e. yoga) to be incorporated into their sessions. Having an open dialogue with all clients about this process will ensure that it fits the needs of the particular client that you are working with in that moment.

Kelly Inselmann and Anita Stoll of Texas have created a therapeutic model that combines traditional talk therapy with yoga. This model, called Yoga and Talk, was developed with the knowledge of how successful both therapy and yoga can be in helping with emotion regulation. At their center, Ms. Inselmann and Ms. Stoll offer a variety of specialty yoga classes each week, as well as individual sessions geared toward individuals who are interested in the experience of “yoga and talk.” During these sessions, the therapist begins with a one-on-one yoga session with the client. According to their website, this is intended to help calm the client’s central nervous system, allowing them to be more clear and present during the “talk” portion of their session.

Practicing yoga just prior to therapy interrupts cycles of stress and negative self-talk, allowing participants to create a shift in their internal state towards a feeling of well-being, relaxation, and hope. Coming from a relaxed state, they engage more readily in the “therapy process and are more open to receiving the wisdom, comfort, support (and sometimes confrontation!) they need from others” (www.yogaandtalk.com/). This model provides one example of ways in which those trained in both the mental health field and yoga can combine these two disciplines in a way that proves to be effective for their clientele.



Yoga Studios

Unlike in a clinical setting, each student that enters a yoga studio is doing so with the preconceived understanding that they will participate in yoga. However, also contrary to a clinical setting, instructors often do not know the intimate details of their student’s lives, and, therefore, are unaware of any potential trauma survivors in the class.  Having this level of awareness or not is the crucial dividing factor that separates specialized trauma classes from regular community-based classes. Regardless of the type of class it is, the benefits of using the guidelines of the trauma-sensitive yoga curriculum are tremendous. Due to the prevalence of trauma in this society, it may be safe for yoga instructors to assume that there will be at least one trauma survivor in their class.

Schools

    Research done in the area of youth violence has found that more than half of the youth living in the United States have been exposed to violence in their lives (Finkelhor, et al., 2009). In fact,

“more than 60 percent of the children surveyed [in this study] were exposed to violence within the past year, either directly or indirectly (ie: as a witness to a violent act; by learning of a violent act against a family member, neighbor, or close friend; or from harm against their home or school)” (Finkelhor, et al., p. 1).

Such exposure to violence can lead to traumatic responses that have been outlined in previous sections of this paper. The long-term impact that childhood trauma has on one’s life varies. However, for many, the long-term effects can last into adulthood.  As this paper has discussed, yoga can play an important role in helping these youth heal. Children between the ages of 5-18 often times spend approximately 50% of their waking day at school. As a result, schools are an ideal setting to hold yoga classes geared toward youth.

In order to create a safe environment for all its participants, school-based yoga programs should strongly consider implementing techniques from the trauma-sensitive yoga curriculum. This feels particularly important considering the large percentage of youth who are exposed to traumatic events every year.

One model of a school-based yoga program is currently being implemented by a nonprofit agency located in Berkeley, California. The mission of the Niroga Institute is “to foster health and well being through Transformative Life Skills (TLS) for at-risk and underserved individuals, families, and

communities” (www.niroga.org), and Niroga yoga teachers are offering TLS training to students, teachers, and administrators in the schools. Executive Director of Niroga, Bidyut Bose, emphasized the impact he envisions for TLS-training: “when you are able to systematically develop self-confidence, self-esteem, self-control... all fundamental to changing ourselves, so that we can transform the world around us” (http://www.niroga.org).

TLS is a multilayered intervention that can be catered to the particular needs of the school. The first layer can involve having 15-minute yoga sessions take place throughout the day in classrooms. These 15-minute sessions focus on yoga, breathing techniques, and meditation. Other layers of this model can include professional development for teachers and longer yoga classes through particular classes such as physical education. Research (Matthew, 2008) proved the effectiveness of the TLS model in reducing stress and increasing self-control and resilience. When combining a school-based program such as the one offered through Niroga with the elements of the trauma-sensitive yoga program, one will be able to create an environment that will help to facilitate healing in the lives of our youth.

Discussion

In concluding our journey of exploration into the study of trauma, post-traumatic stress disorders, and yoga as a healing modality for traumatized people, we'd like to review the territory we have traveled and to indicate how we envision ourselves applying what we have been learning. We began by sharing glimpses of the professional and personal backgrounds that brought each of us to this study. We considered various definitions of trauma and PTSD and noted some of the professional controversies that have taken place around diagnostic recognition of trauma-induced disorders. We discussed five types of trauma--shock trauma, developmental trauma, perpetration-induced trauma, historical trauma, and vicarious trauma. This was followed by information and statistics concerning the alarming prevalence of trauma and PTSD in US society. We then examined seven, interrelated categories of effects of trauma--neurobiological, physiological, emotional, cognitive, sense-of-self, social, and behavioral, along with comorbidity effects. We saw how trauma disrupts all levels of human functioning. Then we reviewed scientific research that has validated yoga as a compassionate, effective healing modality for traumatized people. We  presented the five key domains--language, assists, teacher qualities, environment, and exercises--of a pioneering model of trauma-sensitive yoga We considered three settings for teaching trauma-sensitive yoga--clinical practice, yoga studios, and schools--with reference to particular clinical and school-based programs.  We have been heartened by our discoveries of how relevant yoga is for restoring traumatized people to wholeness.

In light of the compelling evidence presented above, it is  clear that the prevention of trauma and the healing of unresolved traumatic stress deserve to be among the highest priorities for public health policy in this nation and the world. As we have seen, trauma is alarmingly prevalent, and its effects, if not healed, can devastate traumatized people's bodies, minds, hearts, souls, and relationships at the deepest levels. Furthermore, the prognosis for unhealed trauma victims, especially those suffering from developmental abuse and neglect, is often dismal. Without therapeutic interventions and supportive, healing relationships, the traumatized are likely either to fall into the victim role again or to become perpetrators of trauma upon others, if not both.

Most trauma, unfortunately, is enacted by humans upon one another. Children are especially vulnerable. More powerful family members and family acquaintances are by far the most likely perpetrators of traumatic violence and abuse upon children, most often, alas, in the home. While the media sensationalize the horrors of violence on the streets, "the adolescents and adults responsible for violence in the community developed these violent behaviors as a result of intrafamilial violence during childhood" (Perry, 2002, p. 2). Therefore, it is imperative that parents and future parents who may themselves have been traumatized in their families of origin benefit from therapeutic  practices, healing relationships, and education so that they become emotionally healthy and capable of providing their children with the safety, security, nurturance, attention, guidance, and care they need to thrive. In this way, the intergenerational transmission of violence and trauma can be prevented.

As this essay has shown, robust research evidence has established that yoga is a profoundly effective intervention for healing trauma and promoting wellness. It is to be hoped, therefore, that well-qualified, trauma-sensitive yoga teachers be first trained and then engaged in the schools, clinics, community centers, and yoga studios of our traumatized world for the sake of individual and societal healing. We need to build a culture of empathy compassion, nonviolence, and peace for the sake of present and future generations. Such a culture necessitates the prevention and healing of trauma, and yoga has much to offer toward this goal.

We would like to close this paper with our personal reflections and dreams for applying our knowledge for the benefit of others.



Taquelia's Reflections

As we transition into the time and space that follows this paper, I am excited about the many ways that I see myself incorporating the information that I acquired along the journey of writing this paper into my professional and personal lives. On a personal level, I am committed to continuing to use yoga as a healing modality in my own life. On a daily basis people allow me to play a partnership in their quest for healing. In doing this, I often energetically take on their experiences and begin to carry it on my shoulders, often without even realizing that it is there. Yoga allows me one way of releasing this experience.  On a professional level, I feel that there are endless possibilities of how I can incorporate this knowledge into my work with my clients. In addition, I would also like to share this information with other mental health professionals as a means of providing them with additional tools that can also be used to complement more traditional forms of therapy.   Lastly, I would also like to educate other yoga instructors about the ways in which they can create classes that are more trauma-sensitive. I appreciate the time that I have had in working with my new colleague Mitch on this project and look forward to collaborating in this further as our paths continue to meet.



Mitch's Reflections

I share with my gracious colleague Taquelia a sense of enthusiasm about the value and potential applications of what we have been learning through our collaboration on this project. Having turned intuitively to yoga for my own healing, I am thankful for the ongoing benefits I experience from the practice. The professional mental health work that Taquelia and I do puts us at risk for vicarious traumatization. Without yoga, meditation, and mutual support among colleagues, I would find it overwhelming to continue working in this challenging field. Yoga is one of my primary ways of restoring myself to balance. I envision building upon the foundation established through the research we have done for this paper and through our collaboration. Among potential projects I envision are teaching yoga to at-risk children and youth; integrating more yoga into my current clinical work; training and educating mental health professionals, educators, and other yoga instructors in trauma-sensitive yoga; bringing yoga to members of marginalized and traumatized communities; and offering trauma-sensitive yoga to advocates for peace, human rights, social justice, and humanitarian relief work who often experience vicarious traumatization.



References

American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: APA.



Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice. 10(2), 125-143.



Bowlby, J. (1969/1982). Attachment. New York: Basic Books, Inc.

Baldwin, D.V. (n.d.). About trauma. David Baldwin’s trauma information pages. Retrieved January 29, 2010 from http://www.trauma-pages.com/trauma.php



Child Trauma Academy (CTA). (2010). Yoga therapy for kids. February CTA Newsletter, February 5, 2010.

Circumcision Reference Library. (2008). United States circumcision incidence. Retrieved January 31, 2010 from http://www.cirp.org/library/statistics/USA/



Choi, J., Jeong, B., Rohan, M.L., Polcari, A.M., & Teicher, M.H. (2008). Preliminary Evidence for White Matter Tract Abnormalities in Young Adults Exposed to Parental Verbal Abuse. Biological Psychiatry, 65(3), 227-234.



Cozolino, L. (2006). The neuroscience of human relationships: Attachment and the developing social brain. New York & London: W.W. Norton & Company.



deMause, L. (2002). The emotional life of nations. New York, London: Karnac.



deMause, L. (2007). The psychology and neurobiology of violence. The Journal of Psychohistory, 35(2), 114-141.



Dorado, J. (2008). Understanding trauma and its effects on mental health workers. PowerPoint presentation and handout. San Francisco: Child and Adolescent Services, UCSF/San Francisco General Hospital.



Emerson, D. (2007). The Core. Yoga Articles. The Trauma Center at JRI. Retrieved February 7, 2010 from http://www.traumacenter.org/clients/yoga_articles.php



Emerson, D. (2008). Yoga: For peace of body and mind: A manual for clinicians from the Trauma Center at JRI. Brookline, MA: Trauma Center at Justice Resource Institute.



Emerson, D. (2009). Toward becoming a trauma-sensitive yoga teacher. Brookline, MA: The Trauma Center at Justice Resource Institute.



Emerson, D., Sharma, R., Chaudry, J.T. (2009). Trauma-sensitive yoga: Principles, practice, and research. International Journal of Yoga Therapy, 19, 123-128).



Everett, G. (2010). Trauma first aide: Introductory training. Presented February 3, 2010 at Kennedy High School, Richmond, CA.



Finkelhor, D., Turner, H., Ormrod, R., Hamby, S.,& Kracke, K. (2009). Children's exposure to violence: A comprehensive national survey. Juvenile Justice Bulletin (October 2009). Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Office of Justice Programs. US Department of Justice. Retrieved February 7, 2009 from www.ojp.usdoj.gov



Fleiss, P.M. (1998). The case against circumcision. Mothering, July 10, 1998, 36-45.



Galtung, J. (1997). Therapy for pathological cosmologies. In J.Turpin & L.R. Katz, The web of violence: From interpersonal to global. Urbana & Chicago: University of Illinois Press, 188-205.



Gerhardt, S. (2004).  Why love matters: How affection shapes a baby’s brain. Hove & New York: Brunner-Routledge.



Grossman, D. & DeGaetano, G. (1999). Stop teaching our kids to kill: A call to action against TV, movie & video game violence. New York: Crown Publishers.



Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits: A meta-analysis, Journal of Psychosomatic Research, 51(1), 35-43.



Hesse, E., Main, M. Yost Abrams, K., & Rifkin, A., (2003).

Unresolved states regarding loss or abuse can have “second

generation” effects: Disorganization, role inversion, and frightening

ideation in the offspring of traumatized, non-maltreating parents,

57-106,  in M.F. Solomon & D.J. Siegel (2003). Healing trauma:

Attachment, mind, body, and brain. New York & London, W. W.

Norton & Company.



Integral Yoga Magazine (IYM). (2009). Yoga and post-traumatic

stress: An interview with Dr. Bessell van der Kolk, MD, 12-13.

Retrieved January 14, 2010 from

http://www.traumacenter.org/products/publications.php



Jacobson, B. Eklund, G., et al. (1987). Perinatal origin of adult self-destructive behavior. Acta Psychiatrica Scandinavica 76, 364-371. Retrieved January 31, 2010 from

http://www.birthworks.org/site/primal-health-research/databank-keywords.html



Johanson, G.J. (2010). Dialogues: Comments on recent posting on DSM-V controversies.Posted Sundarajan, L (louiselu@frontiernet.net)., Dialogues list, January 17, 2010.



Levine, P.A. (1997). Waking the tiger: Healing trauma. Berkeley, CA: North Atlantic Books.



MacNair, R.M. (2002). Perpetration-induced traumatic stress: The psychological consequences of killing. Westport, CT: Praeger Publishers.



Matthew, R. (2008). Executive summary: El Cerrito High School transformative life skills program; Fall semester 2008. Berkeley, CA: School of Social Welfare, University of California, Berkeley.



NCTSN (National Child Traumatic Stress Network). (2003). Complex Trauma in Children and Adolescents. Retrieved March 1, 2009 from www.NCTSN.org



NOCIRC. (2005). Whose body, whose rights? Examining the ethics and the human rights issues of infant male circumcision. San Anselmo, CA: NOCIRC.



O’Donnell, H. (2001). The United States’ circumcision century. Retrieved January 31, 2010 from http://www.boystoo.com/history/statistics.htm



Perry, B.D. (1997). “Incubated in terror: Neurodevelopmental factors in the ‘cycle of violence.’ In J. Osofsky (Ed.). (1997) Children, youth and violence: The search for solutions. New York: The Guilford Press, 124-148.



Perry, B.D. (2002). The vortex of violence: How children adapt and survive in a violent world. Retrieved June 6, 2008 from http://www.ChildTrauma.org



Perry, B.D. (2003). Effects of traumatic events on children: An introduction. Retrieved June 22, 2008 from www.childtrauma.org



Perry, B. D. (2006). Applying principles of neurodevelopment to clinical work with maltreated and traumatized children: The neurosequential model of therapeutics, 27-52, in N.B. Webb, Working with traumatized youth in child welfare. New York: The Guilford Press.



Perry, B.D. (2008). Child maltreatment: A neurodevelopmental perspective on the role of trauma and neglect in psychophathology. In T. Beauchaine & S.P.Hinshaw, Child and adolescent psychopathology. Hoboken, NJ: John Wiley & Sons, 93-129. Child Trauma Academy, Web-version retrieved May 30, 2008 from www.ChildTrauma.org.



Perry, B.D. & Szalavitz, M. (2006). The boy who was raised as a dog: And other stories from a child psychiatrist's notebook: What traumatized children can teach us about loss, love and healing. NY: Basic Books.



Pilisuk, M. & Rountree, J. (2007). Who benefits from global violence and war: Uncovering a destructive system. Westport, CT & London: Praeger Security International.



Schore, A. N. (2003a). Affect regulation and the repair of the self. NewYork: W. W. Norton & Company.



Schore, A. N. (2003b). Early relational trauma, disorganized attachment, and the development of a predisposition to violence, pp. 107-167, in M.F. Solomon & D.J.Siegel (2003). Healing trauma: Attachment, mind, body, and brain. New York & London, W. W. Norton & Company.



Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are. New York & London: The Guilford Press.



Siegel, D. J. (2003). An interpersonal neurobiology of psychotherapy: The developing mind and the resolution of trauma, pp. 1-56,  in Solomon, M.F. & Siegel, D.J. (2003). Healing trauma: Attachment, mind, body, and brain. New York & London, W. W. Norton & Company.



Siegel, D. J. & Hartzell, M. (2004). Parenting from the inside out: How a deeper self-understanding can help you raise children who thrive. New York: Tarcher/Penguin.



Streeter, C.C., Jensen, J.E., Perlmutter, R.M., Cabral, H.J., Tian, H., Ciraulo, D.A., & Renshaw, P.F. (2007). Yoga asana sessions increase brain GABA levels: A pilot study. Journal of Alternative and Complementary Medicine, 13, 419-426.



Teicher, M. H. (2002). Scars that won’t heal: The neurobiology of child abuse. Scientific American, March, 2002, 68-75.



Tomada, A., Suzuki, H., Rabi, K., Sheu, Y.S., Polcari, A, & Teicher M.H. (2009). Reduced prefrontal cortical gray matter volume in young adults exposed to harsh corporal punishment. Neuroimage (2009) 47 Supplement 2:T66-71.



van der Kolk, B.A. (1994). The body keeps the score: Memory and the evolving psychobiology of post traumatic stress. Harvard Review of Psychiatry, 1(5), 253-265. Retrieved January 7, 2010 from www.trauma-pages.com/a/vanderk4.php



van der Kolk, B.A. (2003). Posttraumatic stress disorder and the nature of trauma,168-195, in M.F. Solomon  & D.J. Siegel, (2003). Healing trauma: Attachment, mind, body, and brain. New York & London, W. W. Norton & Company.



van der Kolk, B.A. (2005). Developmental trauma disorder: Towards a rational diagnosis for children with complex trauma histories. Psychiatric Annals (2005), 401-408.



van der Kolk, B.A. (2006). Clinical implications of neuroscience research in PTSD. Annals of the New York Academy of Sciences, 30,  1-17.



van der Kolk, B.A. & Pynoos, R.S. (2009). Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V. Final version February 2, 2009. Retrieved January 29, 2010 from www.traumacenter.org



Wylie, M.S. (n.d.). The limits of talk: Bessel van der Kolk wants to transform the treatment of trauma. Psychotherapy Networker. Retrieved January 4, 2010 from

http://www.traumacenter.org/products/pdf_files/Networker.pdf



Yehuda, R., Engel, S.M., Brand, S.R., Seckl, J., Marcus, S.M., & Berkowitz, G.S. (2005). Transgenerational Posttraumatic Stress Disorder in Babies of Mothers Exposed to the World Trade Center Attacks during Pregnancy. The Journal of Clinical Endocrinology & Metabolism, 90(7), 4115-4118.