Download Concepts in Yoga-Based Interventions

An Application of
Trauma-Sensitive Yoga Instruction
to
Occupational Therapy
A Presentation for OT24VX2012
Allison Sullivan, MS, OTR/L, CAGS, RYT
October 30, 2012
Learning is movement from Moment to Moment
-Krishnamurti
Learning is movement from Moment to Moment”
-Krishnamurti
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, traumainformed 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
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Studying yoga for past 15 years, teaching yoga for 7 years
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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
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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.”
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The second critical component of a traumatic
event is that “the person’s response involved
intense fear, helplessness, or horror.”
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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.
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Lack of predictability
Lack of Control
Lack of Safety
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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
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
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Depression
 40-45% comorbidity
Anger
Moral Injury
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Somatization, Chronic Pain
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25-80% comorbidity
Substance Abuse
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(i.e. SurvivorGuilt)
58-80% in Vietnam Veteran Population
TBI, Executive Dysfunction
The brain consists of 2 hemispheres:
Left Brain
Right Brain
Verbal
Labeling of
Emotional States
Nonverbal
Associated with the
Amygdala and
Limbic System
(“Primitive Brain”)
 Being worried or anxious can cause increased muscle
tension and inefficient breathing patterns
 Sympathetic nervous system becomes more engaged;
triggers “fight or flight” response
Neural Plasticity!
The brain can change
Where attention goes, neural firing
goes. And where neurons fire, new
connections can be made.
Siegel, 2007
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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
Mind-Body-Breath Pattern of Disorder =
Sensory Dysregulation (“Fight or Flight”)
vs
Mind-Body-Breath Pattern of Order =
Sensory Regulation (“Rest and Digest”)
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
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E. Hopper, Ph.D. Trauma Center at JRI
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
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LANGUAGE
EXERCISES
Pacing
Choices
Timing
ENVIRONMENT
ASSISTS
TEACHER
QUALITIES
“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
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.
Be Safe
Be Predictable
Be 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.
• The staff at the Trauma Center’s Yoga Program
considers physical assists to be a clinical
issue 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.
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.
Posture choice
Class progression/what postures when
Ongoing/open class or limited/closed
course
Pace of delivery - how much time to
give each posture and how much silence
vs. instruction around each posture.
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
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
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.
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.
Examples:
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“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
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The spirit-mind-body-world is an
integrated, intelligent, sensing and active
system (Capra, 1996)
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Human dynamic systems are embedded in
the physical world and are interdependent
and interconnected within it (Champagne, 2007)
Interest in yoga presents a tremendous opportunity to help
people with complex trauma histories:
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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
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.
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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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