How can therapists use trauma-sensitive yoga with their clients?

In the second part of our Q&A with Dagmar Härle, she discusses how therapists can use trauma-sensitive yoga with their clients, and how to adapt their style of working with someone who has experienced trauma. You can read part one of the Q&A here

 

Why is it important that yoga teachers and therapists have an awareness of what positions might be potentially triggering for someone who has experienced any form of trauma?

Using yoga in the beginning of the process, we want to offer resources and foster self-efficacy and self-esteem. Offering postures with legs wide open like in happy baby where we lay on our back, holding the toes in our hands or buttocks unprotected like in a downward facing dog, for sexual traumatized people we have to be aware that those asanas can trigger. But avoiding these poses in the long-term doesn`t solve or heal because the patient cannot make new experiences like “I now can tolerate poses I couldn`t weeks ago”.

 

Holding people in their comfort zone ultimately doesn’t help them, or let them develop. It’s a matter of timing. Offer “safe” and easy asanas (always being aware that we don`t know what triggers may be) in the beginning and start to open up while the person makes good experiences and gains resources.

 

How important is flexibility or creativity in teaching style when working with people with a history of trauma?

Offering choice needs creativity. Flexibility is needed when an asana or breathing technique triggers and you want to offer another possibility.

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What effect does practising yoga have on emotional and stress responses?

In the first part of our Q&A with Dagmar Härle, she discusses her background as a therapist, and how those who have been affected by, or experienced trauma, can improve emotional and physical well-being by participating in ‘trauma-sensitive’ yoga. Click here to read part 2 of the Q&A.

 

What led you to become a yoga teacher and a trauma therapist? What inspired you to combine the two?

I practiced yoga for many years and eventually I wanted to learn more, and get a deeper understanding of yoga and its philosophy. Therefore, I completed first a kundalini and later a Hatha yoga teachers training course and began teaching yoga classes. It was a perfect combination and helped me to stay balanced and resilient in my work as a coach and therapist, and I learnt mindful tools that I could teach to my clients.

 

I started trauma therapy training about 15 years ago in somatic experiencing, as I had so many clients who suffered from various symptoms due to trauma (especially trauma beginning in childhood), and I realised that I needed tools to work with clients who had such experiences. My studies of psychotraumatology at the University of Zurich deepened my knowledge and experience of working with those with trauma, but still there was a missing piece. So many patients couldn’t tolerate trauma exposure – they either dissociated or reacted with overwhelming sensations and emotions.

 

Yoga is a perfect training for the nervous system because there exists calming as well as activating poses and breathing techniques, and it has become obvious to me that yoga is a perfect tool to support patients in self-awareness, self-efficacy and self-control. I started with mindful yoga groups for patients and then I eventually brought yoga into therapy. Going to the Trauma Center and learning from David Emerson and Jenn Turner the TCTSY (Trauma Sensitive Trauma Center Yoga),

I was reassured in my way of using choice as an important way of supporting self-control and self-efficacy to the patients. In practice, for instance, you can execute a side bend with both arms stretched or one arm stretched while the other arm may hang loose or you sit on a chair and bend forward putting your hands on your knees or you go deeper perhaps until your hands reach the floor. It`s always the choice and under control of the patient.

 

What effect does practising yoga have on emotional and stress responses?

Yoga offers asanas-postures as well as pranayama-breathing techniques to either calm down or activate the nervous system, or in other words, activate either the parasympathetic or the sympathetic branch of our nervous system. Understanding that trauma survivors suffer from both – overwhelming sensations and emotions (sympathetic branch) as well as dissociation and shut down (parasympathetic branch, or more exact, the dorsal vagal part of it) helps to let clients know that they can benefit from yoga because we can offer them the tools for both. Learning the tools to stop dissociation and to be able to handle overwhelming emotions and sensations has an important effect on self-efficiency and self-worth.

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Memory in Trauma by Steve Haines

In this article, Steve Haines shares his thoughts on memory and trauma, and how important it is to recall past memories. Steve Haines is the author of medical graphic book Pain is Really Strange. His new book Trauma is Really Strange will be available on the 21st December.

 

The old primitive brain is shown in blue and red: the limbic system, brain stem and cerebellum.

The old primitive brain is shown in blue and red: the limbic system, brain stem and cerebellum.

Some Thoughts On Memory

Where are memories stored? In order to heal trauma, how important is it to remember what happened? These are common questions that often come up working with clients and teaching on trauma.

There are folklore phrases such as ‘muscle memory’ and ‘cellular memory’ that can be very useful but need to be applied carefully. They speak to the importance of information stored in the body. However it is essential to understand that for the information to be available to our awareness, our brain needs to be involved in processing the patterns of information flow happening in the body. Where the information is processed – in the primitive brain (unconscious) or in the cortex (conscious) – determines whether or not the memory is explicit.

I have a favourite old pair of jeans right now, some holes are on the second round of stitching. The wrinkles and folds in the material are a memory of sorts, the jeans mould to my body like no other pair of trousers. The fascia researcher Gil Hedley (2005) talks about fascia as ‘fuzz’. The fuzz accumulates and represents time. A certain stickiness and alignment of the fibres in the tissues holds the joints in more habitual ways.

Imagine a small child being shouted out by her father. Her shoulders tense, her neck tightens and there is a surge of fear related hormones and activity in the body. If this happens continuously the pattern of ‘shoulders tense and neck tight’ becomes a deep ‘action pattern’ (Kozlowska et al 2015).

Now imagine 30 years later the adult is on your treatment table. With grounded presence and soft, safe, warm, hands you are holding her head and neck. The tissues in her neck begin to express long held contractions and tightness. A shape in her body emerges, similar to the pattern generated when she got shouted at. Your client begins to feel unease and may think about her father.

The ‘muscle memory’ is the tension and tone in the tensegrity of the neck (Ingber 2008). The ‘cellular memory’ is cellular membrane receptors on local and global cells that grew to be sensitive to the all the stress hormones, immune system signaling and inflammatory chemicals that used to be secreted in the fear response (Damasio and Carvalho 2013). The ‘action patterns’ are simple, default movement schemas held in the old primitive brain.

Sensory nerves signal the changes in tension and chemical milieu to the brain. Only with the brain involved do we have emotions, feelings and thoughts generated in awareness. They may or may not be fully integrated into cognition, but something is happening. A memory is being expressed.

Instead of explicit memories we can have implicit memories (I first heard this term from Babette Rothschild, 2000), here the activation is chiefly in the primitive brain (brain stem, cerebellum and limbic system). The client on the table becomes scared when you touch her neck and too much changes too soon, but she does not really know why she is getting upset.

As a therapist working with trauma it is important to note the surges and changes in the rhythmic activity of the body as implicit memories occur. There are some great early warning signals that something is happening.

We can then help find the right pace of change for the individual so they can learn to self-regulate. The therapist’s skillful presence can lead to co-regulation such that the individual can learn to self-regulate (Ndefo 2015). The primitive brain does not do words and concepts very well, but will respond to safety, touch and presence.

Implicit memories are coded very simply in the primitive brain. Often they are without a timeline. The amygdala – an important part of our threat detection system (LeDoux 2015) – holds lots of symbolic representations of threat. The amygdala will trigger ‘fight-or-flight’ or ‘immobility’ responses (‘defense cascade’ Kozlowska et al 2015) if it senses danger in the incoming information stream.

If the cortex gets involved then we will have explicit memory – we can pull in associated events and a timeline to contextualise the activity in the body. Explicit memories usually only emerge into awareness after the body has changed. The hippocampus and prefrontal cortex should help us say ‘That happened 30 years ago’. The skill of the therapist here is to honor the memories and stories that appear but keep orienting the client to resources in the body and environment; ‘Its not happening now’, even if your body is screaming at you be scared.

Following Dr David Berceli (2008), founder of Trauma Releasing Exercises (TRE), I am fond of saying ‘You do not need to remember or do not need to understand to heal trauma’. The goal is to overwrite the symbols in the amygdala with present time information. The body is a great source of good news that can bring you into now.

Summary

Information is stored in the tissues and cells of the body.

The threat detection systems in the primitive brain can be activated as the body changes.

The primitive brain does not do words and concepts very well, but will respond to safety, touch and presence.

If we can support change in the body and down regulate arousal we can change memories with out needing to understand or remember the trauma event.

The goal is to uncouple the charge of the defense cascade from the sensations of the implicit memory.

Notes

1 Kozlowska et al (2015) list some early signs of arousal. For flight-or-fight (their preferred order of this phrase) they list; changes in breath, furrowing of the eyebrows, the tensing of the jaw, or the clenching of a fist, narrowing of the range of attention. For immobility states they list; visual blurring, sweating, nausea, warmth, light-headedness, and fatigue. 

My favourite signs to look out for are anything going too quick (thoughts, sensations or emotions that cannot be integrated into the present moment) and anything going too slow (spacey, floaty, absence, hard to make eye contact, numbness or tingling or loss of body awareness). 

Dry mouth, sense of small or far away feet, absent belly, cold hands and a sense of someone withdrawing are all good signs to put the brakes on, whatever process is being expressed. David Berceli teaches ‘Freezing, Flooding or Dissociation’ as signs that too much arousal is occurring.

Download as pdf: memory v3 2015-10-29

References

Berceli D (2008) The Revolutionary Trauma Release Process. Transcend Your Toughest Times. Vancouver: Namaste Publishing.

Damasio A and Carvalho GB (2013) The nature of feelings: evolutionary and neurobiological origins. Nature Reviews Neuroscience, Vol 14, February 2013, 143.

Hedley G (2005) The Integral Anatomy Series. 4 Vol DVD set. Integral Anatomy Productions, LLC, 430 Westwood Avenue, Westwood, NJ 07675, USA (or check ‘The Fuzz Speech’ on YouTube).

Ingber DE (2008) Tensegrity and mechanotransduction. Journal of Bodywork and Movement Therapies 12, 198–200.

Kozlowska K, Walker P, McLean L, and Carrive P (2015) Fear and the Defense Cascade: Clinical Implications and Management. Harv Rev Psychiatry. 2015 Jul; 23(4): 263–287.

LeDoux JE (2015) The Amygdala Is NOT the Brain’s Fear Center. psychologytoday.com http://bit.ly/ledoux-no-fear-center  Accessed 2015-09-01

Ndefo N (2015) Personal communication. www.trelosangeles.com ‘Sometimes we have to co-regulate before we can self-regulate’.

Rothschild B (2000) The Body Remembers – The Psychophysiology of Trauma and Trauma Treatment. London: W.W. Norton.

Medical graphic books by Steve Haines, published by Singing Dragon

Haines-Standing_Pain-is-Really_978-1-84819-264-5_colourjpg-web

Pain is Really Strange is a scientifically-based, detailed, and gently humorous graphic book on pain and pain management. Answering questions such as ‘how can I change my pain experience?’, ‘what is pain?’, and ‘how do nerves work?’, this short research-based graphic book reveals just how strange pain is and explains how understanding it is often the key to relieving its effects.

 

Haines-Standing_Trauma-is-Reall_978-1-84819-293-5_colourjpg-web

Trauma is Really Strange is a science-based medical graphic book explaining trauma, its effects on our psychology and physiology, and what to do about it. When something traumatic happens to us, we dissociate and our bodies shut down their normal processes. This unique comic explains the strange nature of trauma and how it confuses the brain and affects the body. With wonderful artwork, cat and mouse metaphors, essential scientific facts, and a healthy dose of wit, the narrator reveals how trauma resolution involves changing the body’s physiology and describes techniques that can achieve this, including Trauma Releasing Exercises that allow the body to shake away tension, safely releasing deep muscular patterns of stress and trauma.

Trauma is Really Strange will publish on December 21st 2015.

Call for Comic and Graphic novel submissions

Singing Dragon and Jessica Kingsley Publishers have recently started developing an exciting new line of comics and graphics novels and we are now open for submissions.

Singing Dragon publishes authoritative books on all aspects of Chinese medicine, yoga therapy, aromatherapy, massage, Qigong and complementary and alternative health more generally, as well as Oriental martial arts. Find out more on www.singingdragon.com

JKP are committed to publishing books that make a difference. The range of subjects includes autism, dementia, social work, art therapies, mental health, counselling, palliative care and practical theology. Have a look on www.jkp.com for the full range of titles.

If you have an idea that you think would work well as a graphic book, or are an artist interested in working with us, here is what we are looking for:

Graphic novel or comic – Long form

We are looking for book proposals that are between 100 and 200 pages, black and white or colour, and explore the topics listed above or another subject that would fit into the JKP/Singing Dragon list. Specifically we are hoping to develop more personal autobiographical stories.

Here are the guidelines for submission:

  1. A one-page written synopsis detailing the plot/outline of the book, as well as short bios of all the creators involved.
  2. Character sketches of the main characters with descriptions.
  3. Solo artist/writers or writer and artist teams should submit 5 to 10 completed pages to allow us to get a sense of the pace, art style and writing.
  4. Solo writers will need to submit 10 to 20 pages of script as well as the one-page synopsis from point 1.

Comic – Short form

We have some shorter comic projects underway and are looking to expand the range of topics covered. These books can run from 20 to 40 pages, black and white or colour, with dimensions of 170x230mm. We are mainly looking for comics that provide ideas and information for both professionals and general readers.

For example, the first in this series, published by Singing Dragon, is a book exploring the latest developments in chronic pain research.

Here are the guidelines for submission:

  1. A one-page written synopsis detailing the narrative style and subject matter to be explored in the book. Also include short bios of all the creators involved.
  2. Solo artist/writers or writer and artist teams should submit 3 to 5 completed pages to allow us to get a sense of the pace, art style and writing.
  3. Solo writers will need to submit 5 to 10 pages of script as well as the one-page synopsis from point 1.

When submitting please provide low-res images and send them, along with everything else, to Mike Medaglia at mike.medaglia@jkp.com

If you have any other ideas that don’t directly relate to the subjects described above but you feel might still fit into the Singing Dragon or JKP list, please feel free to get in touch with ideas and enquiries on the email above.

Raise awareness of Ehlers-Danlos Syndrome this May

 

EDS awarenessMay is Ehlers-Danlos Syndrome (EDS) Awareness Month, raising awareness of this multi-systemic and complex connective tissue disorder, and supporting those who live with this invisible condition.

As awareness and understanding of EDS are central to early diagnosis and management of symptoms, take the time to learn about the condition, and simple steps that can help the many people who live with it.

Learn more about EDS (especially type III – Hypermobility Syndrome) with these interviews and resources, and more:

Books:

Interviews:

Organisations:

See also:

© 2013 Singing Dragon blog. All Rights Reserved

Understanding and treating the complex chronic patient – an interview with Isobel Knight

Isobel KnightWhat makes treating the chronic complex  patient so difficult? Do you think there is still a lack of understanding about how best to approach this?

I think that practitioners are very scared by complex chronic conditions and can become very overwhelmed. I’ve had so many medical professionals dismiss me because they really didn’t understand what the problem was. Treatment of chronic complex conditions really does require a multi-disciplinary team of people and medical experts, as well as an overarching approach to treatment plans. This can all be overwhelming for one person.

Conditions become chronic and complex over the years. There’s often a long delay in diagnosis (research by the Hypermobility Syndrome Association in the UK suggests that diagnoses can take about 10 years). As an individual gets older, he or she will gather more problems, which makes treatment even more difficult, relating to more bodily systems. If the condition is intercepted younger, these can all be addressed and hopefully better controlled.

How has being an individual with EDSIII (Ehlers-Danlos Syndrome – Type 3, Hypermobility) influenced the way you treat people in your clinic?

Based on what I’ve experienced, I can certainly spot the condition very quickly in people who haven’t had a diagnosis. Although I can’t officially diagnose, if the symptoms are there, I can get them sent to their GP for a referral to an expert rheumatologist. So in this way it’s really helped some people. I also know what ongoing management they are often going to require, so I can both refer them on to practitioners that I know, and support them with Bowen Therapy in the areas that I know they will need help with.

I’m never overwhelmed by what patients say, and I always believe them. And that helps a lot.

Why did you choose the autoethnographic approach in writing your new book?

That was inspired by an author I quote in the book, who wrote about life with a kidney condition and eventually turned it into a PhD thesis. I thought it was a really good way of framing the book. It uses my story as a basis, but also weaves in the stories of others, to ensure that it’s socially representative of that culture group. But also, this is a personal story. I include some quite personal details, and I hope that this makes it much more accessible to read, not a dry textbook. It really says how the patient feels, from my point of view and from the points of view of others.

Book cover: A Multi-Disciplinary Approach to Managing Ehlers-Danlos (Type III) - Hypermobility SyndromeIn the book, you go into quite a lot of depth on the psychology involved both in having a chronic complex condition and in treatment. Do you think that the importance of this area is underestimated?

Yes. I was actually really surprised how large the psychological section of the book ended up being. There are so many layers to it, trust being a very important one. The issue of trust is so important for any medical professional dealing with a chronic complex patient. Personally, I had been consistently told by a range of professionals that the pain I was experiencing was psychosomatic, and that there was nothing wrong with me. I think that most patients have years of that to contend with. In so many cases these conditions involve a legacies of problems that haven’t been fully handled since a young age. Behaviours change because of pain. That really has an impact on people. They get angry, they get depressed, they get anxious.

I’ve also included a section for the patient on managing chronic pain, cognitive behavioural therapy, and other psychological aids such as goal-setting, pacing, ways of communicating and dealing with doctors.

Medical professionals also need support psychologically in dealing with the complex chronic patient because, as mentioned, treatment can be very overwhelming for them, and quite emotionally draining. If one of your patients comes back every week with little improvement to their pain, it can be emotionally difficult as a therapist to make a positive spin on it and focus on treatment.

Social media seems to be a really supportive, positive force for the treatment and understanding of these conditions. How do you see this developing in future?

I think that because some patients with this condition can become quite disabled, and socially isolated, Facebook, for example, can be a real lifeline for them. It’s a way for them to get mutual support, to learn more about the condition, to realise they’re not alone in their experience. I’ve been staggered by the response to my Facebook page, and how it’s being used internationally to provide support and share information on this subject (but never any medical advice).

How do you hope this book will help professionals working with, and patients with the syndrome?

I hope that the patients will be able to see that there has been, in my story, quite a positive improvement due to the level of care I’ve had, and the experts I’ve managed to have access to. Physiotherapy has been essential in this. I’d like to offer patients hope but also the reality that this is a genetically inherited condition, which is about management, not cure. I hope that the book provides not only treatment information, but validation – they can take the book to their doctors to show them what’s going on. It’s as up to the minute as up to the minute can be in terms of medical research and practice.

In terms of the medical professionals, I hope that they can understand the full impact of a multi-systemic chronic complex condition, what it means to have bodily systems not working very well, and the impact that this has psychologically, physically and socially. I hope this helps them to develop a bit of a more empathetic approach.

I’m incredibly lucky to have been able to have 6 real experts in each field contributing to the book. This means that they’ve been really able to bring the book up to date with the latest research on treatment and medical management of the condition. That’s a real privilege.

© 2013 Singing Dragon blog. All Rights Reserved