28 June 2011

Trauma Sensitive Yoga: the walking wounded, part 2

A trauma survivor can be an adult survivor of childhood abuse, a domestic violence survivor, a survivor of sexual assault, someone who was in a horrible car wreck or natural disaster, or a returning soldier with Post-Traumatic Stress Disorder (PTSD.)

Basically, anyone who walks into your class. As teachers, we never know what a student's story is, either physically or psychologically.

A “trauma sensitive” yoga class is taught very differently from the yoga class with which we are familiar -- soft music, altars, incense, physical adjustments. A typical yoga class may not be comfortable place for a trauma survivor and in fact may feel very dangerous. Merely saying the word "relax" can be a PTSD trigger if the person was told to relax and then was abused.

For someone who has been abused, a physical assist can be a severe trigger for PTSD. Many teachers say, "but I always ask first." Think about that statement. For someone who has a history of abuse and was not allowed to say no (so has issues with power and control), assists are problematic.

Dr. Bessel van der Kolk is the recognized authority on PTSD and heads The Trauma Center in Brookline, Massachusetts. He has said that “the goal of treatment of PTSD is to help people live in the present without feeling or behaving according to demands belonging to the past.”

The Trauma Center has begun to establish empirically that yoga is helpful for people with PTSD (van der Kolk, 2006). Along with feedback such as, “I feel like I can use my body again,” the groundbreaking study that the Trauma Center conducted in 2004 showed that yoga changes core brain physiology related to PTSD and trauma.

In a brain subjected to trauma, parts of the brain can be underdeveloped; parts of the brain can be atrophied; a compromised neocortex (the "thinking" brain) can not regulate the lower brain (the limbic brain is the emotional center of the brain); there is a lack of synaptic connections. The amygdala is the alarm clock of the brain, it is the site of stored memory and bodily sensations. It becomes engorged and overactive in PTSD. The corpus callo is the fibrous material beneath the cortex that transmits information between the two hemispheres of the brain -- in PTSD this can atrophy. The right side of the prefrontal cortex can atrophy in PTSD. These are just three examples of structural changes in a traumatized brain.

This makes recent research on how the brain can change (neuroplasticity) huge. The research is out there, you can google it: via yoga and meditation, new synaptic connections are made, old pathways are reactivated and there is neurogenesis. The Trauma Center's research has shown that a 60 minute yoga class once a week in a 10 week session begins to reduce PTSD symptoms.

So how do you make your class "trauma sensitive"? As teachers we naturally think our classes are healing in a certain way, but some aren't. We were told how Iyengar yoga classes, for example, because of the language used and the way many are taught can be problematic for trauma survivors. Seeing yoga straps lined up on a wall is not a good environment for someone who was tied down and abused.

Since much of trauma was caused by physical manipulations, physical assists for the most part are out of the question. At the root of trauma/PTSD is an extreme lack of choice. With specific yoga shapes (don't say "pose"), trauma sensitive yoga teachers invite people to begin to make choices again in a direct relationship to their experience. All these choices are about safety, comfort, and ease.

Environment is important: smells, mirrors, exposed windows, closets, temperature, and lighting can all be PTSD triggers to someone.

Do you see where I am going with this? ANYTHING a yoga teacher does can be a trigger for PTSD. How many teachers are equipped to handle stress responses that may come up such as hyperarousal, hypoarousal, disassociation, or flashbacks? If a stress response happens, one key is to start moving the large muscles like gluts or quads because those muscles use up the stress hormone cortisol (Warriors, forward bends.)

For a trauma survivor in a yoga class, it's about reclaiming their body, not about a teacher manipulating a student into a shape. As teachers we need to cultivate our ability to offer verbal assists. In trauma/PTSD, survivors have "lost" their bodies. Our teacher gave an example of how one of his students said she felt like she had a hole where her stomach should be. As yoga teachers it is not our job to "fix" a student, but to help them begin to trust their bodies again. It's about helping students use their bodies and breath as resources for self-regulation, calming themselves down if need be. Physical assists create dependency.

In a trauma sensitive yoga class, language must change: no absolutist, commanding language; use concrete and visceral language; no woo-woo "out of body" language, no metaphors. It is the invitatory language of inquiry that directs attention to the body and invites mindful movement and breathing. The teachers advised us not to say "be gentle with yourself" because that comes across as a challenge that can set people up for failure -- trauma survivors don't know how to be gentle with themselves. Even the word "play" (saying "play with the pose" is not a good idea) is a loaded word. Emphasize choice: "as you are ready"; "if you like"; "you decide"; "you choose."

Use non-intimate language for body parts: sternum v. chest; base of spine v. tailbone; seat v. butt or pelvis. However, ANY word can be a trigger and a teacher must be able to handle triggers.

Use non-aggressive language. How many of us have been in a yoga class with a drill sergeant instead of a yoga teacher -- "you SHOULD look like this." An abuse victim interprets your words differently than a soldier would with PTSD. The body is not a combat zone...for any of us.

Some of the loaded poses (for obvious reasons) are Happy Baby, hip openers, chest openers. Powerful bodily sensations can create powerful emotions so these poses must be taken slowly, in increments. Bookend a new pose with a familiar pose.

Trauma Sensitive Yoga: the walking wounded, part 1

"The body keeps the score." - Dr. Bessel van der Kolk

According to the teachers at my recent Trauma Sensitive Yoga training, 70-80% of the population have experienced some type of trauma, whether being in a war or a catastrophic car accident. This statistic comes from a collection of the clinical literature currently out there. Keeping that statistic in mind, think of your yoga class. In many cases abuse is caused by physical manipulation of the body. Now think about what those yoga adjustments are doing to a trauma survivor with PTSD who was held down during their abuse. Even chanting and Sanskrit can be triggers for someone who suffered cult abuse.

Anything a yoga teacher does can be a trigger. Anything. Telling someone to be still and watch the breath can be a trigger, especially to a woman who was raped and the last thing she heard before she disassociated from the attack was the rapist's breath in her ear. The word "pose" can be a trigger, especially for an adult survivor of childhood sexual abuse who was made to POSE for pornography.

How will you teach your classes? Whether as teachers or students, we know that yoga heals, that is a purpose of yoga. But for many trauma survivors, walking into a yoga class is impossible. If you were that child who had been tied up, think how seeing a yoga strap would make you feel. Trauma survivors are stuck in a body/breath/mind that is still relating to past conditions. Time is frozen in the trauma survivor's brain, we're stuck in a loop. I know what my triggers are.

Approximately 88% of men with Post-Traumatic Stress Disorder met lifetime criteria for one or more disorders such as depression and anxiety. Seventy-nine percent of women with PTSD met the criteria for one or more. Eighty percent of people with PTSD met criteria for another psychiatric disorder (Solomon and Davidson, 1997.)

In a word, my training at the Trauma Institute was amazing. I consider it one of the most influential trainings I've done in my almost 10 years of teaching. Forty yoga teachers and clinicians from all over the United States and some from Europe came for four days to learn about the ground-breaking research being done (scientists and researchers are finally catching up to what yogis intuitively knew thousands of years ago) and to learn how to create trauma sensitive classes. A "trauma sensitive" class is not your mother's yoga class. It MUST be taught differently, even as to word choice and environment.

Many of us in the training were survivors, including me. Many felt that a true community was being created, much more so than a regular yoga teacher training. On the last day I sat in a small group and heard how just listening about trauma and PTSD was a trigger for some. Many of us had jangly nerves, as one woman described it, but all left empowered and ready to take this healing into our communities. One woman said she was proud to be a survivor and I nodded my head in agreement.

We learned much about the different parts of the brain that are literally physically damaged during trauma. Prolonged abuse damages the brain even more -- parts of the brain can atrophy and shrink and the connection between our "reptilian brain" and our "thinking brain" short-circuits. There are now many studies on trauma survivors via brain scans that show the physical changes. But the fact is that it does not have to stay damaged. The fairly recent concept of neuroplasticity is huge. It was previously thought that the adult brain can not change, but brain scans show that it can change and repair itself from trauma. One of the most important things we learned was that while talk therapy is effective, it can only go so far because it is head/mind oriented and trauma/abuse is so body-based. The Trauma Institute's soon to be published research shows that the body-centered activity of yoga combined with talk therapy is much more effective in treating PTSD and trauma survivors. Why? Because the body keeps score, the body has memory. Next year the Trauma Institute will begin a 5 year study of the effectiveness of Jon Kabat-Zinn's Mindfulness Based Stress Reduction techniques v. yoga on trauma/PTSD. The research will utilize brain scans.

We heard about "Trauma Theory for Yoga Instructors", "The Neurobiology of Trauma as it Relates to Yoga" (presented by Heather Mason), and also heard from Bill, a Viet Nam war vet who suffered from PTSD. He told us his story about how he was a hospital corpsman in the Marines and his PTSD did not manifest until his own children were born years later. "Life became gray," he said. The birth of his children triggered his PTSD because when he saw his babies he remembered all the dead Vietnamese children he saw. He said he constantly feared for his children, he was stuck in the loop that something terrible would happen to them, at any time, he was sure of it.

In both 2001 and 2002 he suffered a neurological episode where his left side stopped working -- PTSD and traumatic brain injuries affect the same part of the brain. He attributed his neurologic damage that showed up years later to the herbicide Agent Orange telling us that the body reacts to herbicides in a very specific way: "we were eating it and drinking it." Bill was fortunate enough to connect with Dr. Bessel van der Kolk as his psychiatrist who told him to try yoga for his PTSD and neurologic symptoms. Bill told us that yoga managed his symptoms and have grounded and centered him. Bill is in his 60s and he told us that he has been told that he should be in a wheelchair or in a nursing home but yoga has saved his life.

Bill has been doing Bikram yoga three or four times a week and has been doing it for about five years. He says he has tried other types of yoga but Bikram is it for him. Bikram is not considered "trauma sensitive" yoga but it helps Bill because of the consistency of the routine, the same thing every day, every class. We learned that consistency is one of the top three requirements of a trauma sensitive yoga class: BE SAFE, BE PREDICTABLE, BE CONSISTENT. Bill gave us his opinion about why consistency is important:

in the last 45 years America's warfare has been ill-defined, ambiguous, with poorly stated goals, and all have been counter-insurgency wars. In wars such as these, soldiers can never create a pattern, nothing is ever repeated, you can't go down the same road twice because you might get killed. Bill asked us to think how it feels to have our neurological system disrupted if we don't have patterns -- it is disruptive to the emotional system that is connected to our physiological well-being. For Bill, Bikram yoga via its repeated patterns serves as his ground.

However, for someone else, Bikram yoga with its commanding teachers could be a trigger. The yoga remedies for trauma and PTSD are definitely not one size fits all. For example, Richard Miller worked with the Walter Reed Army Medical Center in a famous study of the effects of yoga nidra on soldiers with PTSD. Yoga nidra was found effective on this population. Bill told us that soldiers with PTSD like the feeling of deep relaxation that yoga nidra gives just by virtue of how "on" they had to be while in the field. Yoga nidra is a relief to them, it's "heaven" just to be able to relax, Bill said. But for someone else, such as the survivor who was constantly told to be still and don't move, deep stillness for so long would be a severe PTSD trigger.

03 June 2011

wisdom from my teacher: "Statics and Dynamics of Asana"

Another newsletter from Srivatsa Ramaswami....enjoy

 When I was a student I had to study a course in Mathematics (or was it Physics or Engineering?) titled, “Statics and Dynamics.”  That was the time Mathematics left me but I liked the name of the course which I am using as the title of the article.

When I was young I used to be called “Soni Ramaswami” by many relatives, friends and many who were not very friendly.  "Soni" means puny.  I used to be very thin, even so I used to be very interested in outdoor sports activities. I managed to get onto the college/school teams in Tennis and Cricket.  In fact, I was coached for several years by the father of the National Tennis Champion in India at the time and the father had coached the champion.  I thought I did well in spite of a lack of the required physique and stamina.  I was the college champion in Tennis for three years and also won the district championship for college students.  My best moment was the match I played against the All India number 3 ranked player at that time.

Barely 18, I came close to beating him.  In the close match, in the final set I could not cope with the physical demands.  My coach told me later that I had a good ball sense and talent (please bear with me on this, old men like me need some bragging for sustenance), but with my kind of physique and lack of stamina I had little chance of making the grade.

Much earlier I had started learning Yoga from my guru, Sri Krishnamacharya.  Prior to that I had learned some Yoga asanas from my father, several people in my school and a few other teachers.  In my school the physical education teacher usually doubled as a yoga master as well and several students were familiar with yogasanas and many were able to do several poses like sarvangsana, padmasana, etc.  I used to do asanas randomly, no coordinated breathing, no pranayama, more interested in the form alone.

But when I started the studies with my guru the whole picture was different.  Slow synchronous breathing, the counter-poses, the sequencing, the adaptations, pranayama, chanting, text studies were all new and it was astounding studying with him.  Initially I was continuing to engage in outdoor sports which he was aware of, but did not ask me to choose between the two.  One day he said that the philosophy of Yoga and outdoor sports were very different.  He would say that while Yoga is considered as a sarvanga sadhana or practice for all parts of the body (and mind) modern sporting activities were anga bhanga sadhana as they affect different parts of the body differently producing disequilibrium and asymmetry.  I remembered at that time I came across a story in a sports magazine about the left wrist of Rod Laver an outstanding Australian Tennis player. It was said that the wrist size of his playing left hand was twice as large as the right one.

Sri Krishnamacharya also used to say very interesting things during the rest pauses between different asanas and sequences. Once he said that the Yogi should be thin or krisa. One should not be overweight....  Carelessly developed fat bellies and cultivated oversized biceps one should guard against.  It suited me as I refused to put on weight when I was a young adult.  After I became a senior citizen, of course I started putting on weight growing sidewards.

He also emphasized individual home practice. Merely studying with the teacher may not be sufficient. Regular comprehensive practice was emphasized. He would quote the following sloka:

anabhyase visa ham vidya
ajirne bhojanam visham
Visham sabha daridrasya
Vridhddhasys taruni visham

"Knowledge without practice (application) is toxic.  Food during indigestion is poison.  Partying is poison (ruinous) to the poor, while to the old a young spouse is disaster indeed."

By then I had a copy of his Yoga Makaranda, the Tamil version.  Fortunately this book, a treasure of information and instructions for everyone who wants to know the Krishnamacharya system is now at everybody’s fingertips, literally.....

Modern day yoga asana practice follows two different streams.  There are old schools which teach different asanas and require the participants to stay in the pose for a long time, no appreciable movements or breathing but just stay in the pose for a long time.  They emphasis the steadiness definition of yoga even though many find long stay in the poses painful and boring.  There is no 'sukha' in it.  Then there is another stream, more modern, in which the asana practice is a continuous flow of movements like a train going at breakneck speed not stopping and looking at at any of the beautiful stations and places called asanas in between.  A set of regimented routines on a graded scale of difficulty is done at a hurried pace without coordination with slow breathing day in and day out.

In the Yoga Makaranda of Krishnamacharya and the way I learnt Yoga from my Guru, the asanas are described in two perspectives.  The book contains pictures of a number of asanas. Krishnamacharya also in most cases mentions that one should stay in these poses for a long time:

Chaturanga dandasana (10mts),
Adhomukhasvanasana (15mts),
Urdhwamukhaswanasana(15 mts)
Mahamudra/Janusirsasana (15 mts),
sarvangasana (niralamba)10mts, etc.

It is clear that many of the static poses require time to confer the intended benefits to the abhyasi.  He also details the benefits that accrue from the long stay in these classic poses.

One also finds that Krishnamacharya has described in the Makranda a number of Vinyasas leading to an asana and then the return sequence.  These are not illustrated though.  It it is gratifying to know that Yoga Makaranda’s English version published by Krishnamacharya Yoga Mandiram has sketches to illustrate most of the Vinyasas which along with the beautiful asana pictures of Krishnamacharya makes it a very useful companion to understand the Krishnamacharya system of asana practice.  Further the required breathing also is described in the Makaranda, whether a particular movement is to be done on inhalation or exhalation or occasionally holding the breath.  However, the book does not contain the several vinyasas done in the asanas or ‘in situ’ vinyasas mainly because the book is a small one.  He has though mentioned that several of the asanas like sarvangasana, sirsasana, padmasana, etc. have a number of vinyasas emanating from the basic
poses.  These vinyasas, as many and as varied as possible, should be done.  These vinyasas make the system of yoga a sarvanga sadhana as my Guru mentions in the Makaranda. In my book. Complete Book of Vinyasa Yoga, I have attempted to include almost the complete range of vinyasas in all the major asanas as I had learnt frm my guru.  When one exercises the body with deep vinyasas one is able to squeeze as much of the venous blood as possible from the various tissues and thus enhance the muscle pump effect.  Then the deep associated breathing used in Krishnamacharya’s system helps to enhance the respiratory suction pump effect on the heart thereby increasing the rakta sanchara or blood circulation especially the venous blood return to the heart. More and more vinyasas help to stretch the blood vessels as well keeping them more elastic.

The practice of vinyasas itself is made very interesting by my Guru.  Each expansive vinyasa would be done on slow ujjayi inhalation and every contraction movement would be done on slow smooth exhalation.  What should be the length of the inhalation and exhalation as compared to our normal breathing of about 2 seconds of inhalation and 2 seconds of exhalation?  He would ask us to take a slow inhalation, say about 5 seconds and another 5 seconds for exhalation.  It is the minimum.  One could slowly increase the time for inhalation from 5 to 6 and even up to 10 or twelve seconds.  The vinyasas were never done at the breakneck speed with which they are done these days. The slower the movements the better and more beneficial it is. A rate of five to six breaths per minute in vinyasakrama is in order.  At this rate the suryanamaskara routine of 12 Vinyasas would take about 2 to 3 minutes.  By studying Yoga with him one could realize how different Yoga is from workouts, aerobics, outdoor sport activities and even fast paced Yoga where the slow, mindful breathing is compromised.

So Sri Krishnamacharya’s system of asana practice, as evident from the Makaranda and also from how I have studied with him, is a judicious combination of dynamic Vinyasas and classic asanas. Vinyasas also help to achieve perfection in poses.  A few years ago when I was conducting the teacher training program, we went through the entire gamut of vinyasas centered around Padmasana.  We continued the practice for several days gradually adding more and more vinyasas.  Then we did a number of movements staying in Padmasana. At the end of it all, a participant came to me and said that it was the first time he could do padmasana even though he was a yoga practitioner for morethan ten years. The quality of his padmasana improved day by day as he started practicing more and more vinyasas in padmasana which all helped to make the final posture more secure. And he could stay in the posture for a longer period of time, say 10 or 15 mts, as Sri Krishnamacharya would want the abhyasis to be able to do.

How can one stay in postures like paschimatanasana, sarvangasana, sirsasana, etc. for 10 to 15 mts or even 30 mts as some yogabhyasis do? Will it not be painful, won’t the limbs go to sleep and what about the mind, does it not get bored? It will be interesting to know the way Sri Krishnamacharya taught Sarvangasana to me.

First do the preliminary poses like desk pose, apanasana and urdwa prasarita pada hastasana, slowly with the appropriate breathing.  Then get into the more relaxed viparitakarani position.  Keep the legs relaxed -even limp- for a while watching the unhurried breathing.  Then come down.

Do it for a few days and then after getting into the viparitakarani position straighten the body, support the back behind the ribcage with the palms placed close to each other. Stay for a few minutes, come down, do an appropriate counterpose and do the routine a few more times for a total of about 10 minutes. From then on try to increase the duration of stay in the pose until you are able to stay for 10 mts in one try. After a few days of comfortable steady stay in sarvangasana, increase the stay to about 15 minutes the ideal duration in sarvangasana. Now start concentrating on the breath. Your inhalation can be short say 3 seconds or so in this pose as the inhalation is a bit more difficult because of the cramped nature of the chest. But one can have a very long exhalation. After a few days practice try to introduce the bandhas as you start your slow exhalation. Start drawing in the rectum and the abdomen in tandem as you exhale finishing the exhalation with mulabandha and uddiyana bandha in place. Hold the breath out and maintain the bandhas for about 5 seconds. Then release the bandhas and start the next slow inhalation.

After a few days practice count the number of breaths that you take for the entire duration of your stay in the posture. Then try to reduce the number of breaths you take for the same 15 minutes stay. The aim is to reduce this number until you reach a steady state that you can maintain consistently. There are people who are able to maintain a breath rate of about 4, 3, 2, or even one breath per minute staying in a static yoga posture as sarvangasana. It is better to learn these procedures from a teacher.

Many years back I used to teach in Houston for several weeks at a time. It was a time when asanas like sarvangasana and pranayama were taboo and padmasana was a dreaded asana. I tried to encourage the class to practice sarvangasana, learning it an orderly fashion through preparatory Vinyasas and finally the posture. It took a while and then the participants were encouraged to try to stay in the asana for a while doing slow smooth breathing. They were able to stay for longer and longer duration and towards the end of the program more than half of the class could stay for the full fifteen minutes maintaining at best a breath rate of 3 or 4 per minute. In my teacher training programs the participants are encouraged to develop endurance to stay in some of the important poses like the inversions, paschimatanasana, mahamudra, etc. even as they learn several hundred Vinyasas in the course.

Further, while asanas are a necessary routine for a yogabhyasi it is not sufficient. A well rounded yoga practice should contain other angas of yoga like pranayama because they between them help to reduce the systemic excess of rajas and tamas.  Day’s yoga practice should consist of a proper combination of dynamic vinyasas and static asanas. Add a stint of pranayama practice and some meditation or chanting, and you have a wholesome daily yoga practice.