Dagmar Härle: Trauma-sensitive Yoga

 This extract was adapted for the Virtual Yoga Summit from Trauma-Sensitive Yoga by Dagmar Härle. 

Since primeval times, people have tried to cope with the adversities of life. There have always been upsetting and traumatizing events, but the methods for confronting the consequences of these shocks have varied greatly. They range from shamanic rituals such as soul retrieval to physical forms of expression such as singing and dancing to cognitive and narrative forms. Many of our contemporary therapeutic approaches in the West are based on cognitive considerations. However, traumatization is not just shown in a change of convictions. Due to the lasting stress response, it is also displayed in the somatic effects that affect posture, physical reactions, and bodily sensations—phenomena that were the focus of treatment at other times and by other cultures. Feelings of numbness and being separated from one’s own body often alternate with strong, overwhelming reactions to triggers, and in many cases make an efficient therapeutic approach more difficult. Instead of introducing a new method, I see body-oriented work as a basis and supplement to the tried and tested techniques of trauma treatment.

 

WHY I WORK WITH YOGA IN TRAUMA THERAPY

The idea of integrating yoga asanas (postures), pranayama (breathing exercises), and mindfulness into trauma therapy arose while working with my clients. When I completed my training in Somatic Experiencing and received my Master’s degree in Psychotraumatology, I was convinced that exposure therapy combined with a body-oriented approach is expedient in treating complex post-traumatic stress disorders (PTSDs). I am still convinced of this, although it has become apparent to me that progress is not possible with every client when using this approach. For some people with complex trauma, the exposure of traumatic contents was simply not tolerable—relating to their own bodies was so disturbing to them that it triggered a response of panic and dissociation.

As a trained yoga teacher and yoga practitioner for many years, I have experienced the merits of bodywork in relation to a pronounced body awareness, increased mindfulness, and relaxation in everyday life, and presence in the here and now. My personal experience, as well as the feedback from my yoga students, encouraged me to integrate yoga into trauma therapy. I made my first attempt at this with a small group of female clients by offering them gentle yoga that allowed much space for mindful sensing. Above all, it was hardly directive.

This means that it was fine if someone didn’t want to do something or wasn’t capable of it. It was fascinating to see the kind of progress that the participants of my Mindful Yoga course made in therapy. Only now did it seem like the participants had a body that they could “expect” something of. It was finally possible to work with them. A female client confirmed my observations: “The therapy has only started through the yoga. Before this, I wasn’t even in my body and couldn’t do anything at all.” These kinds of success encouraged me to increasingly integrate yoga into trauma therapy, especially in the individual setting, and allowed me to respond more to individual needs. I began to weave the yoga asanas and pranayama into trauma therapy, to work out resources with clients, promote body perceptions, and make it possible for them to approach their own bodies in a gentle way.

My work underwent systemization, expansion, and deepening through the basic course and subsequent certification program in Trauma-Sensitive Yoga (TSY) that I completed with David Emerson and his team at The Trauma Center in the Justice Resource Institute, Brookline, MA, USA. Bessel van der Kolk and David Emerson, pioneers and masters in the field of integrating yoga into trauma work, developed this therapeutic use of yoga based on the current research results regarding trauma and PTSD, which also takes the latest brain research and attachment theory into consideration. The positive effect on PTSD symptoms, which is comparable with results from other methods of trauma therapy, has now been scientifically proven by a number of studies.

Since I primarily work in a one-to-one setting in my practice as a trauma therapist, my intention was to have my experiences and principles of TSY flow into individual therapy. This enabled me to not only instruct groups and individuals, but also to use TSY in trauma individual therapy. Through my many years of experience in incorporating asanas, pranayama, and mindfulness into body-oriented trauma therapy, and combined with the principles of TSY, I created a tool for trauma therapists. With its help, possibilities for individual affect and self-regulation can be developed. This form of body-oriented work is also suitable for building up and strengthening personal resources.

When we speak about trauma, we tend to focus not on the physical experiencing, but on the event, which means the story that is told. We use it to explain the symptoms as well as changes in the thinking, feeling, behavior, and actions of the affected person. However, a trauma consists not only of the brain’s continuing memories in the form of pictures, smells, sounds, and affects. Above all, a trauma is an experience that has happened to the body and has been stored there.

Consequently, a trauma is also the story of a body that is frozen at the point in time of an event or, in the case of severely traumatized people, in the time period of the tormenting occurrences. The body is stuck in a constantly repeating stress response.

On the physical level, this paralysis is reflected in movement, breath, and posture patterns. In danger situations, the affected person would like to take action and escape the paralysis, but their body fails them instead of getting them to safety. In everyday life and situations in which they would normally be able to relax, they feel anxious, hypervigilant, and nervous, or numb and paralyzed. These states often alternate. The person is trapped between arousal and shut-down, between too much and too little. The body is not the place where traumatized people feel good. A female client expressed it like this: “I’m here,” and pointed to her head. “What’s down there should take me from A to B. I don’t want to be concerned with it. It irritates me that it makes demands of me.”

Exposure therapies are designed for clients to remember these traumatic occurrences within a safe environment and to report on them to therapists. This approach does not work for severely traumatized people due to the fact that they are unable to tolerate the exposure. As they suffer from flashbacks and dissociation, they are in no way able to benefit from the therapy—sometimes this endeavor causes more harm than benefit. To counteract this, the therapy usually starts with a stabilization phase. For example, visualizations are practiced in which clients see something like a “safe place” or a “vault” in which they can lock away terrible memories. Efforts are also focused on building a trusting therapeutic relationship. However, safe places and feelings of trust are rare for severely traumatized people, and it is often not even possible to get beyond the stabilization phase. Although we work on a sustainable therapeutic relationship, we avoid everything related to the trauma for the sake of the relationship. When people have relationship and attachment traumas, the relationship remains a fragile structure despite the good will of both parties, since being close to another person may already trigger stress for the client.

 

INTERACTION BETWEEN BODY AND PSYCHE

When both the physical reactions and the relationship with other people become a trigger, the idea of a transitional space can be helpful. This is a space in which the focus is not on the trauma or the relationship with the therapist, but a place where something new can happen. Yoga and other movement-focused forms, as well as art and expressive therapeutic approaches, offer such spaces. Since all of the unbearable affects, impulses, and sensations are played out in the body, offering possibilities of physical expression within this space suggests itself.

In contrast to other cultures, the West does not have a tradition for modulating mental states through physical activity such as those that have been practiced from time immemorial in African cultures through dance, singing, and rhythm, or Eastern cultures through forms of movement such as tai chi or qi gong. Yet all of us have probably had the experience of being able to regulate our mental states through movement. Dancing, singing, and moving rhythmically have a direct effect on our emotional state. Sad songs and rhythms make us wistful, and cheerful tunes brighten our mood. However, we do not use this empirical knowledge in a systematic way. We are also not accustomed to getting relief in this manner, and this path is blocked more than ever in stressful situations.

In Western culture, we rely on conversation to process difficult experiences. This is also reflected in the classic therapeutic setting that does not attach much importance to the training of body experience. We normally sit more or less upright on chairs, which is a posture that demands little proprioceptive and kinesthetic information processing. In this posture, we require almost no body awareness, and miss out on the opportunity to use our body for affect regulation. This primal knowledge about the interaction between body and psyche is called “embodiment” by the cognitive sciences. It could also be understood as incarnation or corporealization. Embodiment describes the simple fact that emotions are not only expressed in the body, but that the opposite is also true: Body postures and sensations also influence the psyche. Since the outer stimuli are always accompanied by a somatic reaction, it is only logical that these frightening physical reactions become triggers on their own, because they can’t be controlled. The body ultimately becomes a dangerous place. A female client got to the heart of this in one sentence: “The enemy is not on the outside!”

We make use of these considerations when we integrate asanas and pranayama into trauma therapy. The bottom-up approach focuses on the body with its forms of expression and sensations or its insensitivity. The goal is to gently “defrost” the body that is frozen in the trauma by offering unaccustomed posture and movement patterns to clients. We also experiment by exploring and changing breath patterns and movements, and subsequently consider the effect of the respective changes. Concentration on physical aspects such as stretching or powerful activity of a muscle and the mindful observation of body reactions in the constant alternation between exertion and recuperation during the practice trains the interoceptive awareness and self-exploration. Its goal is to establish a mind that is capable of observing instead of allowing itself to be overwhelmed by feelings. This benefits traumatized clients in both everyday life and the exposure therapy, because they have learned to control their affects much better. Yoga is also a gentle exposure that is controlled by the clients themselves. The body is not ignored, but instead, becomes the center of attention. During the practice, clients can perceive all of the somatosensory sensations, such as the feeling of stretching, exertion, numbness, and signs of arousal such as an elevated pulse or change in breath frequencies. We could say that they remain “outside” and take up an observer position. So they may discover that there are body regions that are okay, and this gives them a feeling of safety. Or they may notice that not everything is numb to the same degree and that there are differences. In this way, they learn to differentiate. All of this helps them in their affect regulation and impulse control, which represents a basic precondition for successful trauma therapy.

 

YOGA IN TRAUMA THERAPY: LEARNING TO FEEL SAFE IN ONE’S OWN BODY

There are various methods that train body perception. Yoga, with its focus on structured body and breathing exercises, as well as the associated training of mindfulness, is especially well suited here. In yoga, we assume various body postures in the asana practice. We have a choice between different asanas, some simple and gentle, others complex and strenuous, depending on the client’s physical capabilities, the space available, and the objectives of the therapy. In performing the asanas, muscles are consciously used through stretching, tensing, and relaxing. This trains the proprioceptive and kinaesthetic perception, which is often inadequately developed in trauma clients. In many cases, trauma clients have been proven to have reduced activity in the insula and cingulate cortex—which is where, among other things, body sensations are registered. As a result, a differentiated body image is impeded (Levine 2010). Asanas give clients new interoceptive information, and we can assume that this counteracts the reduced activity in the insula and cingulate cortex.

In addition, yoga is very much engaged with our ability to influence the breath, and therefore the autonomic nervous system. People do not usually perceive their breath. When they freeze in fright, this can promote a breath pattern that overstimulates the sympathetic nervous system and maintains high stress levels. Learning body perception and guidance of the breath are valuable steps in the direction of empowerment and control.

Through yoga’s typical structured, foreseeable approach, we offer additional safety and control. Instead of being in a “vacuum,” we get into a defined yoga position together. We explore, change, and hold it, becoming better acquainted with the body in the process. We sense a movement, a tension, or a stretch with increasing clarity. Over time, we will also become aware of how emotions, thoughts, or memories are physically expressed. The repetition of similar positions or breathing exercises takes away the fear of what is unexpected.

Yoga is also called “meditation in motion.” However, it differs from the concepts of classic mindfulness meditation in the seated position in that assuming body postures or performing movements is easier for trauma clients than sensing the body or observing thoughts and emotions during static sitting. Due to their constant vigilance, these clients often only perceive tension or numbness in a quiet posture. This makes them feel that they are all the more at the mercy of their demons. Yoga has another major advantage: The exercises have a time limit! Being traumatized means having no control over when something begins and when it ends. In the vortex of overwhelming feelings, the sense of time is disturbed and there is no possibility of influence in escaping or ending the horror. Yoga that is customized for clients gives them control over the start and length of the exercise. This is accompanied by regaining a feeling of empowerment over themselves, their body, and their surrounding world. Trauma clients have two significant experiences in this process. First, they decide whether and when something begins, and they determine when it ends. Second, something ends, for example, the feeling of stretching in the muscle is just temporary. The progressive ability to observe teaches clients that every sensation and emotion has an end (cf. Emerson and Hopper 2011), which helps them to remain in their body. It allows them to tolerate physical reactions and sensations, feelings, and thoughts without being overwhelmed.

There are unmistakable parallels with body-oriented methods such as Somatic Experiencing (Levine 2010)—in which the application of switching back and forth between sympathetic and parasympathetic activity in the form of physical sensations, images, and/or thoughts is an example of the main approach. Once we have found resources through this trauma-oriented yoga in the form of postures, movements, breath control, or breathing exercises, clients acquire something to counter the pull of the trauma when memories and sensations threaten to overwhelm them.

Switching back and forth between the pull of the trauma and somatic resources (movements, postures, breath, awareness) slows down this process. Before we work with traumatic memories, it is good to practice slowing down with clients (cf. Rothschild 2002). We do exactly the same thing in trauma-oriented yoga: We assume a posture and sense something like activity in the muscles, acceleration of the heartbeat, or change of the breath rhythm—that is, an activation of the sympathetic nervous system in the body. Afterwards, we allow ourselves the time to feel how the tension lessens, the breath and pulse calm down, and the silence spreads. We create space for relaxation.

Through the structured instructions and exercises, we provide safety to the clients. Within this offer, it is possible for them to have new experiences. At the same time, a space for change opens up—a space of transition or possibilities—in which clients can adapt and change their posture so that it is right for them. Clients have the experience that they can do something. While I do not use TSY with all of my clients, I have noticed that people with complex trauma benefit greatly from the idea of a transitional space in which they are allowed to try things out, reject them, and attempt them anew. I do not consider yoga to be a cure-all or the sole therapy for complex PTSDs. Instead, I see the body-oriented therapy approach as the basis on which I can build exposure therapy. With TSY, a measure of affect regulation ability can be attained in advance to help clients gain a sense of control over their feelings and sensations.

In the further course of the therapy, the yoga asanas and breath control (pranayama) remain important resources, and can create a fruitful interaction of the body-oriented and cognitive focus.


Trauma-Sensitive Yoga
Dagmar Härle. Foreword by David Emerson.

Trauma-sensitive yoga is a body-based intervention for treating emotional responses to trauma and post-traumatic stress disorder. This book explains why yoga is a useful approach for trauma therapy and shows how to use this method in one-to-one and group settings. It also includes useful examples of non-triggering asanas and breathing exercises. Read more

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