1. An Application of Trauma-Sensitive Yoga Instruction to Occupational Therapy A Presentation for OT24VX2012 Allison Sullivan, MS, OTR/L, CAGS, RYT October 30, 2012

2. Learning is movement from Moment to Moment” -Krishnamurti Learning is movement from Moment to Moment -Krishnamurti

3.  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

4.  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

5.  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.

6.  Lack of predictability  Lack of Control  Lack of Safety

7.  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

8. 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

9.  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

10. The brain consists of 2 hemispheres: Left BrainRight Brain VerbalNonverbal Labeling ofAssociated with the Emotional StatesAmygdala and Limbic System (“Primitive Brain”)

11.  Being worried or anxious can cause increased muscle tension and inefficient breathing patterns  Sympathetic nervous system becomes more engaged; triggers “fight or flight” response

12. Neural Plasticity! The brain can change Where attention goes, neural firing goes. And where neurons fire, new connections can be made. Siegel, 2007

13.  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

14. 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”)

15.  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

16.  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

17. LANGUAGE ASSISTS TEACHER QUALITIES ENVIRONMENT EXERCISES Pacing Choices Timing

18. “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

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. 4. Meet People Where They Are

26. 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

27. 5. Emphasize Feeling Over Form

28. 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.

29. 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.

30. 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

31.  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)

32. 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

33.  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.

34.  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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36. 1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author. 2. Brault MW. Current Population Reports: Americans with Disabilities. 2005, Washington, DC: U.S. Department of Commerce, Economics and Statistics Administration, U.S.Census Bureau, 2008. 3. Capra, F. The Web of Life: A New Scientific Understanding of Living Systems, Anchor Books, 1997. 4. Champagne, T and Lazzarini, I. Neuro-Occupation: Non-linear Dynamic Approach to Rehabilitation. Workshop Presentation, Westford, MA, MAOT Conference, 2007. 5.Champagne, T. Sensory Modulation and Trauma-Informed Care. Classroom lecture, Springfield, MA: American International College, 2010. 6. Day, JC. National Population Projections. 2001. U.S. Census Bureau. Online document at: http://census.gov/population/www/pop-profile/natproj.html Accessed June 24, 2010. 7. Emerson D. Toward Becoming a Trauma-Sensitive Yoga Teacher: A Best Practices Guide from the Trauma Center. The Trauma Center at JRI, 2009. 8.Federal Interagency Forum on Aging-Related Statistics. Older Americans 2008: Key Indicators of Well- Being. Federal Interagency Forum on Aging-Related Statistics. Washington, DC: U.S. Government Printing Office, 2008. 9. Greuel, J, Stoller, C, et al. The Effect of Sensory Enhanced Yoga on Symptoms of Combat Stress in Deployed Military Personnel. Unpublished research study powerpoint presentation, 2011.

37. References continued 10.Hopper E. Trauma Theory and Yoga-Based Interventions for Trauma Survivors. Workshop Presentation, Boston, MA: The Trauma Center at JRI, 2010. 11. Krukoff C, Carson K, Peterson M, Shipp K, Krukoff, M. Paradigms: Teaching Yoga to Seniors: Essential Considerations to Enhance Safety and Reduce Risk in a Uniquely Vulnerable Age Group, The Journal of Alternative and Complementary Medicine.2010; 16: 8, 1–7. 12. Libby, D, and Manafort, S. Mindful Yoga Therapy for Veterans Coping with Trauma. Workshop Presentation, Amherst, MA, 2011. 13. National Center for Health Statistics. Health, United States,2008: A Report of the Department of Health and Human Services. Hyattsville, MD: National Center for Health Statistics, 2009. 14. National Institute on Aging, Sleep and Aging. NIH Seniors Health. Online document at: http://nihseniorhealth.gov/ sleepandaging/aboutsleep/01.html Accessed June 24, 2010. http://nihseniorhealth.gov/ 15. Schore, Allan. Affect Dysregulation and Disorders of the Self. W. W. Norton and Company, 2003. 16. Seigel, D. Mindful Brain. WW Norton, 2007. 17. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General, Atlanta, GA: U.S. Department of Health and Human Services, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention,1996. 18. Van der Kolk,B, McFarlane, Weisaeth. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. The Guilford Press, 2006.