Concepts in Yoga-Based InterventionsAn Application of

Trauma-Sensitive Yoga Instruction

toOccupational Therapy

A Presentation for OT24VX2012

Allison Sullivan, MS, OTR/L, CAGS, RYTOctober 30, 2012

Learning is movement from Moment to Moment” -Krishnamurti

Learning is movement from Moment to Moment -Krishnamurti

About Me: Allison Sullivan

Assistant Professor of Occupational Therapy, American International College, Springfield, MA

Teaching responsibilities include courses in mental health, management, and research

Research interests in transformative and experiential learning, social media in educational practice, trauma-informed care, sensory modulation, movement-based therapy

Director of Occupational Therapy Services, Sunshine Village, Chicopee, MA

Occupational Therapist for 20 years AFAA certified Group Exercise Instructor for 29

years RYT 200, Sacred Rivers, Glastonbury, CT, 2011

Studying yoga for past 15 years, teaching yoga for 7 years

Lecture Objectives

Identify beneficial practices and outcomes of yoga

practice in addressing effects of trauma and PTSD Review the 5 Domains of Trauma-Sensitive Yoga

Instruction, as identified by David Emerson, E-RYT, from the Trauma Center at the Justice Resource Institute (JRI): Language; Assists; Teacher Qualities; Environment, Exercises

Review the Principles of Practice developed by Duke University Health System’s Therapeutic Yoga for Seniors program and their relationship to the 5 Domains of Trauma-Sensitive Yoga Instruction

Identify Clinical Applications of these techniques to Occupational Therapy practice

What is Trauma?

The DSM-IV defines a “traumatic event” as one in which “the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the integrity of self or others.”

The second critical component of a traumatic

event is that “the person’s response involved intense fear, helplessness, or horror.”

Within the DSM IV, trauma is tied to two specific trauma-related diagnoses (Acute Stress Disorder, ASD, and Posttraumatic Stress Disorder, PTSD), but the definition of trauma is also free standing.

What makes an event traumatic?

Lack of predictability Lack of Control Lack of Safety

What is PTSD?

PTSD is defined as a prolonged, maladaptive response to a traumatic event

Symptoms of PTSD include: Recurrent and intrusive distressing recollections of the

event including images, thoughts, or perceptions Nightmares Flashbacks: Acting and feeling as if the event is being

relived Intense psychological distress at exposure to internal or

external cues that symbolize or resemble as aspect of the traumatic event

Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Who experiences PTSD?

PTSD occurs relatively commonly in the population, with some research showing that as many as 1 in 10 people have experienced PTSD at some point in their lives.  Prevalence is higher in:

Holocaust survivors Patients with cancer Patients following heart surgery Veterans Survivors of child abuse, rape, and sexual assault

http://www.hopkinsmedicine.org/gec/studies/ptsd.html

Associated features of PTSD Depression

40-45% comorbidity Anger Moral Injury

(i.e. SurvivorGuilt) Somatization, Chronic Pain

25-80% comorbidity Substance Abuse

58-80% in Vietnam Veteran Population TBI, Executive Dysfunction

The Brain and PTSD

The brain consists of 2 hemispheres:

Left Brain Right BrainVerbal NonverbalLabeling of Associated with theEmotional States Amygdala and

Limbic System (“Primitive

Brain”)

How we think about a situation often influences our experience of it:

Being worried or anxious can cause increased muscle tension and inefficient breathing patterns

Sympathetic nervous system becomes more engaged; triggers “fight or flight” response

The Good News!

Neural Plasticity! The brain can change

Where attention goes, neural firing goes. And where neurons fire, new connections can be made.

Siegel, 2007

Evidence that yoga works: Mindfulness meditation research has been

associated with increases in Left Hippocampal volume

Evidence of significant decreases in both state and trait anxiety in experimental group participants in a veterans’ run and organized yoga program in Central Massachusetts In this same study, treatment subjects also

showed greater improvement on 16 out of 18 Quality of Life survey variables, as compared to the control group

Yoga Practices Can Create Positive Changes:

Mind-Body-Breath Pattern of Disorder =

Sensory Dysregulation (“Fight or Flight”)

vs

Mind-Body-Breath Pattern of Order =

Sensory Regulation (“Rest and Digest”)

Clinical benefits of yoga related to Trauma/PTSD:

Living: Being in the here and now Provides a structure around the practices of mindfulness

and self-regulation Mindfulness, introceptive awareness Building curiosity Learning to drop the content of one’s thoughts Connectedness to body and somatic states Changing relationship to body-befriending it Affect regulation Grounding Connection to others Centering Becoming stronger and more flexible, physically and

emotionally

E. Hopper, Ph.D. Trauma Center at JRI

Ok, I’m interested, so where can I go for advice?

In 2003, the Trauma Center at JRI launched a pioneering yoga program to address the needs of its clients and developed a teaching approach tailored to those with trauma histories

In 2007, the Duke University Health System opened its integrative medicine facility and started The Therapeutic Yoga for Seniors program

To provide a skillful framework for teaching yoga to seniors, specific Principles of Practice were developed, which integrate knowledge gained from Western medicine with yogic teachings

5 Domains of a Yoga Class*as described in the Trauma Center’s Guide, “Toward Becoming A Trauma-Sensitive Yoga Teacher”

LANGUAGE

ASSISTS

TEACHERQUALITIESENVIRONMENT

EXERCISESPacingChoicesTiming

Language

“Trauma sensitive language tends to be concrete and visceral. We are not asking trauma survivors to imagine some out of body state (story) but rather to experience what’s happening in their body right now.”

There are two basic styles of language that are used at the Trauma Center Yoga Program: Language of Inquiry and Invitatory Language

A Challenge With Invitational Language

Some clinicians have expressed concern that for some trauma survivors hearing the words “try” and “like” may be triggers that result in giving up entirely.Best advice: It is most important for the teacher to give clear, simple, postural cues with very little use of metaphor.• Keep it clear• Keep it simple• Keep it grounded in the here and

now.

Teacher Qualities

Be SafeBe PredictableBe Consistent

This allows students to challenge themselves as they are ready and in their own way.

This domain also addresses how the teacher presents her/himself in the room: how we dress; how we “use” our bodies in the physical space of the room; how we act in relation to self and other.

Assists

• The staff at the Trauma Center’s Yoga Program

considers physical assists to be a clinicalissue and don’t recommend them. Instead, they suggest that instructors cultivate their ability to offer verbal assists. **OTs, however, often work with people whose needs and diagnostic symptoms do not match those of the population typically treated at JRI. We may need to physically assist our clients so that they can experience movement.

Environment

Consider the space in which you are teaching.

Some things to think about: Lighting Mirrors Props Exposed windows Privacy Temperature

* Listen to feedback from students and be willing to respond to reasonable requests to modify the environment.

Exercises

Posture choiceClass progression/what postures whenOngoing/open class or limited/closed coursePace of delivery - how much time to give each posture and how much silence vs. instruction around each posture.

Carson–Krucoff Principles of Practice

1. First, Ahimsa-Do No Harm. 2. Create a Safe Environment. Cultivate

ahimsa (nonharming) by encouraging students to honor their own personal journey and explore their full potential, with compassion and integrity.

3. Encourage Yogic Balance. Sthira sukham asanam—A yoga pose is, by Patanjali’s definition, stable and comfortable. Invite students to challenge themselves, but never strain.

4. Meet People Where They Are. Honor individual abilities and limitations by offering accessible and appropriate modifications that reflect the intention and function of traditional postures.

4. Meet People Where They Are

Carson–Krucoff Principles of Practice Con’d

5. Emphasize Feeling Over Form. Let go of ideas of how a pose should look. Focus instead on how a pose feels. Teach students to discriminate between discomfort, which may be welcomed as an inherent part of the growth process, and pain, which is to be avoided.

6. Honor the Inner Teacher. Don’t assume you know what’s going on with someone, even if you’ve asked. Consider yourself a guide, helping students explore what works best for them

5. Emphasize Feeling Over Form

Carson–Krucoff Principles of Practice Con’d

7. Encourage Gratitude and Joy. Create an environment that celebrates what students can do.

8. Emphasize Fluidity. The Tao’s teaching that ‘‘those who are soft and supple are disciples of life’’ is particularly important as the body becomes rigid with age. Minimize static ‘‘holdings.’’

9. Use Skillful Language. Encourage and invite rather than direct and demand.

Carson–Krucoff Principles of Practice Con’d

10.Respect Our Scope of Practice. Recognize that what we do as therapists is only part of the integrated healthcare landscape. Do only what we are trained to do and refer to other practitioners when necessary.

11. Be a Guardian of Safety. Get CPR/AED training and keep your certification current.

12. Teach People, Not Poses or Conditions. While acknowledging the inevitable changes inherent in life, it is essential to recognize the unchanging spirit at the heart of all beings.

At the heart of these Principles of Practice is the recognition that how yoga is taught

to seniors is as important as what is taught

Examples:

“The principle of honoring Feeling Over Form suggests a teaching style that focuses on inviting students to

move with a specific intention of a posture, exploring their own

sensations and letting how the pose feels guide their movements.

This is in contrast to telling students specifically what their

body should look like in a pose.”

“Another principle, Emphasize Fluidity, is particularly important as the body tends to become more rigid with age and the circulation is more sensitive to fluctuations during the respiratory inhale/exhale cycle.”

http://dukespace.lib.duke.edu/dspace/bitstream/handle/10161/3303/280739600012.pdf?sequence=1

Applications to OT Practice:Habit Shaping

The spirit-mind-body-world is an integrated, intelligent, sensing and active system (Capra, 1996)

Human dynamic systems are embedded in the physical world and are interdependent and interconnected within it (Champagne, 2007)

Other Applications to OT Practice:Therapeutic Benefits

Interest in yoga presents a tremendous opportunity to help people with complex trauma histories:

Contribute to vitality, mood and alertness

Add comfort and control to breathing Improve strength and flexibility Enhance balance and coordination to

reduce risk of falls Pain management Outlet for Spirituality Addresses Aging and End-of-Life issues

Applications to OT Practice con’d:General Safety Guidelines

Have participants complete a medical history before joining classes

Ask permission to partner with their physician so you can seek guidance in creating a safe and effective yoga-based interventions.

If you are ever uncertain as to whether or not a specific posture or practice is safe, avoid it.

Observe the safety-first principle—when in doubt, do not do it.

Applications to OT Practice:Trauma-Sensitive Guidelines

Use trauma-sensitive language Avoid physical assists as much as

possible Be authentic and open to feedback Consider the environment and

consciously work to create “a safe space”

Consider the pace of instruction, choices available, and timing when creating a movement sequence

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References

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Survivors. Workshop Presentation, Boston, MA: The Trauma Center at JRI, 2010.

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