Mindfulness and yoga as treatment for PTSD a contribution from Josephine Norrbo of Sweden, who qualified for our 500 hour Certification in July 2017

This essay will present a brief overview on some experiences on treating PTSD (post- traumatic stress disorder) with mindfulness based stress reduction (MBSR) and Trauma Sensitive Yoga (TSY). To start with I will give a summary on what trauma and PTSD is, then explore MBSR and TSY as treatment for PTSD and then finally compare MBSR with TSY.

What is Trauma?

Trauma is a natural response to a terrible event. What characterizes trauma unlike the suffering of everyday life is that it generally involves threats to life or bodily integrity or brings one into close encounter with death and violence1. Trauma is a natural part of our lives as human beings and we have been living with it as long as humans have existed. Traumatic experiences leave traces, both on those who are directly exposed to it, but also to those around them. Trauma is by definition bearable and intolerable, and most victims of rape, violence and abuse try to the best of their abilities to push the trauma away and live on as nothing happened. Our survival brain on the other hand, is not very good at denial and is trying to warn us of future danger based on past events. This makes the traumatized individual reactive to slightest hint of perceived danger and mobilizes disturbed brain circuits to release massive amounts of stress hormones2. Unresolved trauma can cause many different psychological symptoms such as hyperarousal, dissociative states, flashbacks, insomnia, anxiety, depression, aggression and many more.

What is PTSD?

Post Traumatic Stress Disorder is a psychiatric diagnose that was introduced after the Vietnam war when combatants came home from war unable to continue their lives, plagued by after maths of the war. PTSD was first called ’shell chock’ but then became a diagnosis in 1980 with a list one criteria one have to meet in order to be diagnosed with PTSD. Criteria are intrusive memories or flashbacks, avoidance, negative thoughts and emotions and arousal, which can include anxiety, insomnia, anger out bursts or a self-destructive behavior. One can develop PTSD after one traumatic experience, such as a robbery, an accident, domestic violence or a loved ones death but it can also be an effect of prolonged trauma, such as war experience, torture, captivity or child abuse.

There are ongoing discussions on how to and if one should separate singular traumatic events, such as a car crash, and long term traumatic experiences, as sustained long term torture or childhood abuse. The psychological consequences are naturally and normally more severe and more treatment resilient if the trauma has been going on under a longer period, therefore a new diagnosis has been suggested by Bessel van der Kolk and many other trauma therapists,since the PTSD diagnose and treatment seems not to be applicable to this group. 

Treatment of PTSD may be cognitive Behavioral therapy, cognitive processing therapy, prolonged exposure and EMDR, Eye Movement Desensitization and Reprocessing. Other forms of therapy that are used is psycho dynamic therapy and group therapy. In addition to this anti-depressant medication can be used.

Mindfulness based stress reduction and PTSD

Mindfulness in modern psychology stems from the work of Jon Kabat Zinn who introduced and developed MBSR in the seventies at the University of Massachusetts. As we know, mindfulness is an older concept then that and has been central in Buddhist practice for over 2500 years and perhaps ever present since the birth of conciousness. Jon Kabat-Zinn defines mindfulness as ”the awareness that unfolds as we pay attention, on purpose, in the present moment”. MBSR uses a combination of mindfulness meditation, body awareness, and yoga to help people become more mindful, reduce stress, increase relaxation and improve quality of life.

There are several studies where different kinds of mindfulness based initiative have been used as part of treatment for PTSD with positive results. A literature review from Pennsylvania State university concludes that mindfulness is now a widely accepted treatment method for all sorts of psychological conditions and among benefits are objectivity, affect tolerance, enhanced flexibility, equanimity, improved concentration and mental clarity, emotional intelligence , and the ability to relate to others and one’s self with kindness, acceptance and compassion3.

In a pilot study from 2010, 27 survivors of childhood abuse with PTSD participated in a 24 week MBSR program. At 8 weeks, depressive symptoms were reduced by 65%. Statistically significant improvements were observed in all outcomes post-MBSR. Of three PTSD symptom criteria, symptoms of avoidance/numbing were most greatly reduced. The program was perceived as safe by the participants. 4

In one other study from 2012, performed in Seattle, the researchers looked at the effects of MBSR in a group of war veterans suffering from PTSD. The group was taken through an eight week program of MBSR. The results of the study was very positive, concluding that the veterans that took part of the MBSR program experienced significant improvements in measures of mental health, including measures of PTSD, depression, experiential avoidance,and behavioral activation as well as mental and physical health-related quality of life over a 6-month period. The study could also show that the participants increased their mindfulness skills over the program and that mindfulness seemed to be safe for people with PTSD. The benefits of mindfulness might be the decrease of rumination about terrible events in the past, which is a major part of trauma, swell as starting to stop avoiding painful situations, emotions or thoughts 5.

As we can see in these brief examples above of working with PTSD and Mindfulness is that it is a valid method of treatment with beneficial outcomes. There are also critics of mindfulness as treatment, saying that there is not enough studies done on MBSR and PTSD to say that mindfulness is more effective than other therapy forms.

Trauma Sensitive Yoga and PTSD

Trauma sensitive yoga was developed at Boston trauma center by yoga teacher David Emerson and psychiatrist Bessel Van der Kolk. Van der Kolk had a long experience of treating sufferers of PTSD with psychodynamic therapy, but felt there was something lacking and that trauma was somehow stored in the body. When he met David Emerson they started to explore if and how yoga could be the missing link and help patients get in contact with their bodies again. Common in trauma is to loose contact with the body, which holds painful memories and emotions, and instead one disassociates from the present moment and it is common among trauma survivors to not be able to feel their bodies. TSY have then been developed over the years and shown positive results decreasing symptoms of PTSD and complex trauma. Trauma Sensitive Yoga compromises three steps, Having a body, Befriending the body and Body as resource. TSY uses the word interoception as a way to describe the process of TSY and Emerson defines interoception as ”...our awareness on what is going on within the boundary of our own skin: it is intra-organismic awareness.6Emerson distinguishes interception from mindfulness and argues that mindfulness meditation is a cognitive practice while TSY is a process of interoception. In meditation we keep the body still and the mind is doing most of the work, while in TSY the body is doing most of the work. Emerson also points out the challenges for severely traumatized patients without a stable enough frontal lobe to be able to be aware of feelings and thoughts at all.

Characteristics of TSY is that the yoga teacher is not physically assisting the participants, the language should always be invitational, always giving choices, working with rhythms, avoiding walking around in the room, avoiding music and avoid looking straight at people. Pranayama is not used as such but participants are encouraged to feel their breath in the body without manipulating it.

TSY as treatment for PTSD show very promising results. One study published 2017 showed that participants suffering from chronic PTSD who took part in a 20-week TSY program experienced significant reductions in PTSD and dissociative symptoms7. Another study the year before, also performed in Boston, showed that the benefits of yoga was constant in long-term. 1,5 years after completion of the yoga program, the participants still had benefits from it, if the yoga practice was kept up. In this way the researchers could show a correlation between practicing yoga and the level of PTSD symptoms 8.

Mindfulness based stress reduction VS Trauma Sensitive Yoga

MBSR and TSY are both valid methods in treatment of PTSD. Both of the approaches have taken an ancient concept and stripped away the religious and mystical aspects of it and kept what have seemed useful for the modern day human. In MBSR the mindfulness of feelings, thoughts and body are taught and in TSY only asana and breath remains.

As far as I can see the word interoception, which is used in TSY, means the same as mindfulness of body. Emerson argues that mindfulness meditation is a mind-related activity while TSY is a bad based practice and this might be true to some extent, but depend a lot on how you teach meditation. In my view the body is very much a part of meditating and it can be very helpful to teach mindfulness from the body, rather then from the mind. But I can see the challenge of teaching still sitting meditation to people who don’t even know they have a body, that might be very unhelpful and at its worst even re-traumatizing. If you look at the anapanasatti sutta mindfulness of body is the first step and it might be that people suffering from PTSD need to stay in that area for a really long time. Moving meditation, as yoga, is always easier for most people than sitting still and having nowhere to escape.

Where MBSR has an aim to educate the participants on how the brain works, what emotions are, what thoughts are and so on, TSY has no such approach. The core of TSY is to just allow the participants to be and experience. The self-education is then happening in talk therapy, which is always supporting the yoga. In this way the TSY practice is less demanding than MBSR and that is also a central concept of TSY, to make everything up to the participants. While MBSR also encourage an invitation language and an open and kind approach, I think TSY takes it one step further. There are almost no demands on the participants. This might be helpful for some but no so helpful in some cases. In my point of view we need to have a balance of form and freedom, who ever we are working with.

Summary and conclusion

MBSR and TSY are to interesting and intriguing approaches to address the suffering of PTSD. They both have promising results and in many ways are trying to do the same thing, increase mindfulness. While TSY is demanding less of its participants and meeting the patients at their level, MBSR might have a more holistic approach. Depending on the people you are working with they might both be useful. If people have more resources, MBSR might be the way forward and if people have less, TSY.

1 Trauma and recovery, Herman 1992

2 The body keeps the score, van der Kolk 2015 

What Are the Benefits of Mindfulness? A Practice Review of Psychotherapy-Related Research? Davis & Hayes 2009 

Mindfulness Intervention for Child Abuse Survivors, Kimbrough et al., 2010

Association of Participation in a Mindfulness Program With Measures of PTSD, Depression and Quality of Life in a Veteran Sample, Kearny et al. 2012 

Trauma Sensitive Yoga in Therapy - Bringing the body into treatment, Emerson, 2015 

Effectiveness of an Extended Yoga Treatment for Women with Chronic Post traumatic Stress Disorder, Price et al 2017

8 Yoga for Adult Women with Chronic PTSD: A Long-Term Follow-Up Study, Rhodes, van der Kolk 2016