Introduction

The bleak reality all over the world is that the likelihood of suffering substantial trauma via war, sexual assault, violence, accident, childhood abuse, or various other possibilities is quite high.  Finding a solid statistic is difficult, given that many people never report traumas.  Even so, according to the results of the first National Comorbidity Survey (NCS), Kessler et al. (1995), found that over half the general population of the U.S. reported having had a traumatic event at least once during their lifetime.  PTSD United (2013) placed that number at 70 percent and estimated the lifetime prevalence rate of posttraumatic stress disorder in the population of the United States to be 8 percent or roughly 24.4 million people.  The prevalence of trauma depends greatly on gender, environment, socioeconomic status, and culture, with women suffering trauma at a rate nearly twice that of men (Pietzak et al., 2011).

The effects of trauma vary as much as the experiences that cause it, and whether a person develops posttraumatic stress disorder may rest on several factors including social support, the resiliency and worldview of the individual, the type of event or events that caused the trauma, coping abilities, and whether the trauma was continuous or complex (Rhodes, 2014).  It is not uncommon to develop acute circumstantial stress, depression, or anxiety after a serious trauma.  More chronic disabilities such as PTSD may develop if these symptoms remain present over a long period.

Tragedy and trauma are often unexpected, overwhelming, and sometimes utterly destructive to belief and meaning-making systems, yet it is possible to overcome, move forward, or even grow psychologically and spiritually after a trauma (Tedeschi & Calhoun, 1995).  Therefore, it is of great importance to find long-term effective methods of treatment that address not only the symptom manifestations of acute stress, PTSD, and the associated comorbid disorders that may arise after a traumatizing event but also rebuild belief and meaning-making systems and offer a structure by which a person might regain trust in life again and heal themselves moving forward.

There are many partially effective treatments for PTSD to be found within Western medicine and psychology (Adshead, 2000; Friedman & Schnurr, 2008).  Current treatments typically combine some form of pharmacotherapy with psychotherapy (Ravindran & Stein, 2009) but do not typically address somatization, which is the process of expressing psychological distress in physical terms as a defense for keeping psychological distress and conflicts out of awareness (Lipowski, 1988).  Generally, somatization refers to physiological distress in the absence of any physical indicators of disease” (D’Andrea et al., 2011, p.379), which is a serious problem for individuals with PTSD.

Due to the nature of post-traumatic stress manifestations and the resulting mind-body disconnection, it can become quite difficult and frustrating to engage in talk therapy, making some patients non-responsive to this type of treatment (Emerson, 2015).  “When our self-protective capacities are consistently overwhelmed by repeated exposure to trauma it can be toxic to our bodies, and survivors often find themselves in a cycle of hyperarousal and dissociative numbing” (Emerson, 2015, p. xiii).  This up-and-down pattern often leaves an individual feeling detached from his or her own body, thoughts, and feelings (van der Kolk, 1994).  Bringing in methods that help to develop interoceptive abilities, somatic awareness, and behavioral management, like Pātañjalayoga, may be a positive addition to current treatments (Rothschild, 2000).

“Experts now recommend phase-based treatment where individuals are taught to modulate their arousal before engaging in memory processing…and highlight the importance of an initial phase focused on somatic experience, affect regulation, and distress tolerance” (West, Liang, & Spinazzola, 2016, p.2).  This is the space where research exploring the benefits of some parts of Yoga practice in the treatment of PTSD has found promising results.

Although the postures, breath controls, and meditation that constitute a Haṭhayoga practice have been studied separately, and in conjunction, and have seen positive results (Li, PharmD & Goldsmith, 2012), Pātañjalayoga — a lifestyle framework that also includes ethics, diet, study, spirituality, hygiene, and philosophy, as well as the physical and meditative practices of Haṭhayoga (Iyengar, 1993) — has not been explored in its entirety for some time long enough or with enough test subjects to gauge its value. Due to this fact, the research that has been conducted thus far could be considered incomplete, warranting further questioning and exploration of the application of the aṣṭāṅga, the eightfold system detailed in Pātañjalayoga, as a holistic lifestyle framework, spiritual system, and resiliency treatment approach for PTSD that may provide long-term symptom relief, new direction, meaning, and physical/mental/emotional wellbeing, as well as reconnection with those fragmented aspects of the self that were so abruptly or systematically broken through traumatic experience(s).

Post-Traumatic Stress Disorder: Definitions and Statistics

Jeter et al. (2015) define stress as the disruption of biological, psychological, and social dimensions in an individual, which is secondary to environmental challenges or perceived threats.  Posttraumatic stress disorder (PTSD) is a more complex, often debilitating, and long-term reaction to trauma that must last at least one month to warrant a diagnosis, and is defined by the APA (2013) as occurring when there has been exposure to a traumatic event that is abnormal to usual human experience where death was a salient possibility; the individual is reliving the experience through nightmares, flashbacks, or rumination; and is exhibiting symptoms such as hyper- or hypoarousal that make it difficult to function. Roughly 4% of men and 10% of women in the United States will develop PTSD at some point during their lives (U.S. Department of Veterans Affairs 2016).

In addition to the initial shock of the traumatic event, a person who develops PTSD will likely also suffer several symptoms — ranging from momentary and manageable to overwhelming and debilitating — such as flashbacks, nightmares, and night terrors; uncontrolled fight or flight reactions; memory loss or lack of concentration; negative and violent thought patterns such as anger, rage, suicidal ideation, guilt and shame, fear and terror; undefined triggering; and negative behaviors such as avoidance, hypervigilance, self-harm, and addiction disorders (Mayo Clinic, 2014).  According to West, Liang, & Spinazzola (2016), other core symptoms of PTSD include the following: “disturbances in self-regulatory capacities, such as affect dysregulation, troubles in relational capacities and self-perception, alterations in attention and dissociation, somatic distress, and poor body awareness” (p.1-2).  Rates of comorbidity between 62 percent and 92 percent have been reported in population-based surveys of PTSD (Kessler et al., 1995).

Re-experiencing, avoidance, negative cognitions and mood, and arousal are the four classic symptom markers of PTSD (APA, 2013).  Re-experiencing of the event may include flashbacks that feel as if one is reliving the trauma in the mind and body in the present time, nightmares/recurring dreams, and incessant rumination that keeps the traumatic event fresh and continuously psychologically intrusive.  Avoidance behaviors are defensive psychological or physical reactions to the external reminders or triggers of the traumatic event, which may prolong the symptom manifestations of PTSD due to the prevention of habituation or processing of the traumatic memories themselves (Wahbeh et al., 2014) or which may develop into phobias (Rothschild, 2000).  Negative cognitions and moods include guilt, shame, blaming, estrangement, loss of interest in activities, depression, anxiety, anger, sadness, memory loss or cloudiness, and other intense emotions (APA, 2013).

The final symptom marker, arousal, is often the most blatantly recognizable symptom of PTSD (Rothschild, 2000).  It may manifest as either a heightened fight or flight reaction that is constantly active, hyperarousal, or a deadening of the senses with emotional and physical numbness, hypoarousal.  Hyperarousal is marked by negative outbursts of violence or anger, hypervigilance, over-sensitivity to sounds and crowds, and poor sociability.  Hypoarousal is when the mind chooses neither fight or flight and instead dissociates from the body. The low-level continuance of this dissociative freezing mechanism can cause hypoarousal and eventually depression.

According to Creamer, Burgess, & McFarlane (2001), another point that makes PTSD difficult to treat is that it is often diagnosed alongside other comorbid disorders.  Their research found that men with PTSD are 27 times more likely to develop major depressive disorder, 28 times likelier to develop a panic disorder, and 38 times likelier to develop general anxiety disorder.  Women with PTSD were found to be 10 times likelier to develop general anxiety disorder or a panic disorder and were 23 times more likely to develop depression.

In any moment of acute trauma, reactions such as the constriction of muscles, racing heartbeat, hyperarousal, and augmented or heightened senses are normal and may even serve to enhance performance under stress, making self-defense or escape possible.  However, these reactions become maladaptive when they overwhelm or continue for a prolonged period (Van der Kolk, McFarlane, & Weisaeth, 1996).

Current Treatment Approaches

The most common form of treatment for PTSD is a combination of psychotherapy and psychotropic medications (Van Etten & Taylor, 1998).  More recently, somatic-based therapy (Emerson, 2015; Ogden, Minton, & Pain, 2006; Rothschild, 2000) and complementary alternative applications (Libby, Pilver, & Desai, 2012) have begun to develop more interest.  Current treatments for PTSD can be broken up into five sections: mind-body techniques and complementary alternative methods (CAM), psychodynamic methods, cognitive-behavioral therapy, existential-humanistic methods, and psychopharmacological treatment with SSRIs, MAOIs, SNRIs, and TCAs (Krippner et al., 2012).

Psychoanalysis is a lengthy treatment process, centering on the relationship between the therapist and the patient, which is meant to re-establish trust, integrate trauma, and restore meaning-making systems.  Luborski et al. (1988) found that the various methods of psychoanalytical approaches to treatment all produce similarly effective results.  However, in an extensive meta-analysis of PTSD treatment research, Bradley et al. (2005) state that residual and substantial PTSD symptoms often continue post-treatment with traditional psychotherapeutic methods and that follow-up data beyond very brief intervals is largely absent in the available research.  One problem with psychoanalysis is that long-term trauma is often associated with an inability to properly voice or understand traumatic experiences, sometimes making insight-based therapies difficult or ineffective (West, Liang, & Spinazzola, 2016).

It’s not uncommon for a client to withhold pertinent information in a clinical setting, which may frustrate the therapist when no improvement or understanding is made.  This, in turn, frustrates the patient and disrupts therapy by undermining the therapist/patient bond (Adshead, 2000).  “Unendurable emotions then become dissociated when they cannot be processed with others.  Without a way to bear these emotions, the traumatized individual senses deadness, dullness, and a loss of vitality (Carr, 2013, p.199).

Cognitive-behavioral approaches have all seen positive results in affect management and stress reduction in PTSD (Foa, Rothbaum, & Molnar, 1995; Krippner et al., 2012).  Treatment methods include Rational Emotive Behavior Therapy (Ellis, 1957; Ellis & Ellis, 2011), Cognitive Behavioral Therapy (Kabat-Zinn & Chapman-Waldrop, 1988), Acceptance and Commitment Therapy (Hayes et al., 2006), Exposure Therapy (Rauch, Eftekhari, & Ruzek, 2012; Taylor et al, 2003), Cognitive Processing Therapy (Kern, 2010), and Dialectical Behavioral Therapy (Steil et al., 2011).  Cognitive-behavioral methods are less focused on the unconscious mind and integration, and more on changing negative thought and behavior patterns that are inhibiting change and growth through psychoeducation and stress management training (Bradley et al. 2005; Krippner et al., 2012), although some methods do feature a component of mindfulness-based practices, including meditation (Baer, 2015; Lau & McMain, 2005).

Psychoeducation consists of the therapist and client working together to discuss and understand the nature of the trauma and how it is affecting the client and pinpointing methods by which these difficulties can be overcome.  Stress management skills training uses breathing exercises and relaxation techniques that are meant to help calm the client when he or she is feeling stress arousal.  Once the client can control their stress levels adequately, a technique of behavioral rehearsal is employed where the client imagines a stressful situation and practices the learned relaxation techniques.  Once this technique is mastered, clients imagine the traumatic event itself, employ relaxation techniques, and intentionally think counteractive positive thoughts when negative feelings and emotions arise in response to the re-imagined trauma.  The idea behind this method is that the conditioned negative responses found in PTSD — such as avoidance, overreaction, and rumination — are learned behaviors that can be unlearned with effort and consistency.

Although exposure treatments — prolonged exposure, EMDR, and reprocessing — can be effective in training an individual to control and regulate stress reactions, several meta-analysis studies questioning the effectiveness of exposure methods found them to have a risk for patient retraumatization (Schnyder, 2005), incomplete response, and residual symptoms in cases of complex trauma (Bradley et al., 2005; Seidler & Wagner, 2006; West et al., 2016).

According to Vasterling & Verfaellie (2009), another possible setback to cognitive-behavioral approaches is that “neurocognitive deficits may affect exposure-based interventions that rely on the ability to reliably access the trauma memory, as well as cognitive behavioral interventions that require mental flexibility in shifting appraisals of the trauma event and related affective responses” (p.827).

Humanistic and Existential methods include Humanistic-Existential Psychotherapy (Schneider & Krug, 2010), Positive Psychology (Resnick, Warmoth, & Serlin, 2001), Positivism (Pradhan, 2013), Transpersonal Psychology (Lukoff, Turner, & Lu, 1992), and Relational Dharma (Davies, 2011).  These methods serve to establish new meaning when belief systems and worldviews have been destroyed by trauma, new self-esteem, and worth when an individual’s place in the world has been compromised, and a new understanding of how to live and possibly even grow post-trauma – all important perspectives that Pātañjalayoga also provides.  Positive psychology focuses on the strengths of the client and works towards developing positive meaning within experiences.  Transpersonal psychology seeks to find methods by which an individual can transcend normal limitations of consciousness and healing through incorporating religion, spirituality, philosophy, or shamanism.

Relational Dharma (Davies, 2011; Davies, 2014) is a rather new method of therapy that presents “a progressive realization of human nature as an interdependent and inseparable unity, which is discovered through insight into the bond of human interconnectedness” (Krippner et al., 2012, p.120).  Developed from the foundation of the Buddhist doctrine of dependent origination and co-arising, Relational Dharma seeks to cultivate higher human relatedness, which includes intersubjectivity; interdependence of human relationships, the ability to feel another’s suffering as inseparable to one’s own; compassion; forgiveness; and an objective awareness of the conditions that caused the traumatizing event or the causal relationships that compelled a person to act in an abusive way, which de-personalizes the traumatic event allowing for liberation from the effects of the trauma.  This process is related to the Dharma, which includes the “principals governing liberation from fear, aggression, and ignorance, as well as…[those] elevating courage, kindness, and the wisdom that recognizes life’s inherent unity” (Krippner et al., 2012, p. 120).

The results of the efficacy of further studies using Relational Dharma as a treatment method would be of interest concerning the development of a Pātañjalayoga-based program considering the alignment of Buddhist dependent origination and the causal interdependence of sāṅkhya and the relative similarity between the Buddhist eightfold path, the āryāṣṭāṅgamārga, and that of Pātañjalayoga.

Mind-body and CAM approaches are gaining in popularity, partly due to their low cost and effective adjunctive use with other methods of therapy (Libby et al., 2012).  These approaches include methods such as Biofeedback and Neurofeedback (Peniston, 1986; Silver, Brooks, & Obenchain, 1995), Meditation (Kabat-Zinn, 1982), Haṭhayoga (Jindani & Khalsa, 2015), Hypnosis (Moore, 2001), Relaxation Techniques (Schneider et al., 1995), Energy Healing (Lanoy, 2015), Eye Movement Desensitization and Reprocessing (Taylor et al., 2003), Guided Imagery (Jain et al., 2012), and Group Therapy (Schnurr et al., 2003).

Although all the above-mentioned treatment approaches have shown to be somewhat effective methods for the treatment of PTSD, in their meta-analysis of the effectiveness of various traditional PTSD treatments, Van Etten & Taylor (1998) reported a 25-30 percent dropout rate with 45 percent of participants still presenting with symptoms.  Bradley et al. (2005) reported a 60 percent relapse rate at the six-month mark for patients who originally showed improvement post-treatment.  Additionally, very few traditional methods of treatment directly address the way that trauma is held within the body and expressed through somatization and heightened affect states outside of new mind/body-based methods, which has prompted the initial exploration of somatic and yoga-based therapies (van der Kolk, 2006).

None of the traditional treatment approaches are completely holistic — attempting to address the whole human being: mind, body, and spirit — including current Haṭhayoga-based treatments, which may affect efficacy long-term.  The aṣṭāṅga practice of Pātañjalayoga is meant to be a lifetime practice: continuous, holistic, and disciplined.  Therefore, the short-term studies that are available concerning the efficacy of current treatments utilizing elements of Haṭhayoga are insufficient to develop conclusions about a Pātañjalayoga application.  In the following section, current Yoga Therapy methods and research into their application for the treatment of PTSD will be reviewed.  Following that will be an exploration of the aṣṭāṅga as a lifestyle framework and the possibilities therein for its further research as a PTSD treatment application.

Yoga and PTSD: Current Research and Treatment Plans

Current research into Yoga as a therapeutic method has commonly focused on the practice of modern Haṭhayoga, which consists of three points: āsana (poses), prāṇāyāma (breathing exercises and control), and meditation (mostly mindfulness methods) (Fife, 2015; van der Kolk et al., 2014).  An extensive literature search, using roughly a dozen scholarly search engines provided only one example of a Yoga-based therapy, focusing on a deconditioning treatment for rumination (Vahia et al., 1972), that followed six of the eight practices of Pātañjalayoga.  The authors entirely dismissed the ethical practices.  Other research exploring Yoga as a lifestyle intervention and treatment program for anxiety (Gupta et al., 2006) provided a more holistic approach by including “āsana, prāṇāyāma, relaxation techniques, group support, individualized advice, lectures and films on the philosophy of yoga, the place of yoga in daily life, meditation, stress management, nutrition, and knowledge about the illness” (p.41).  However, this still was a form of supplemented Haṭhayoga and not Pātañjalayoga (Iyengar, 1993).  A summarization of Haṭhayoga, as the most currently applied therapeutic method, is at this point necessary.  Pātañjalayoga will then be explained in detail in the section following directly thereafter.

Haṭhayoga is one of the six major branches of Yoga, also including Rājayoga (the royal path), Karmayoga (the path of selfless service), Bhaktiyoga (the path of devotion), Jñānayoga (the wisdom path), and Tantrayoga (the path of ritual) (Carrico, 2007).  Modern Haṭhayoga, the most recognized form of Yoga in the West, is the most physical method whereby through the combination of poses and movements, breathing exercises/controls, and meditative techniques, a practitioner cultivates mindfulness of inner and outer states of his or her being (West et al., 2016).  Modern Haṭhayoga, as it is being discussed here, is a generalized term referring to any type of practice comprising mainly of physical postures often in combination with some prāṇāyāma and meditation typically developed during and after the early 1900s.  There are many forms of modern Haṭhayoga, including Ananda, Anusara, Ashtanga Vinyasa, Integral, Iyengar, Bikram, Kripalu, Kundalini, Viniyoga, Jivamukti, Sivananda, Vinyasa, Yin, and Restorative, among others (Twardowsky, 2002; Ward, 2013).

One of the major aspects of modern Haṭhayoga practice centers on bringing mindful awareness to the body through focusing on the alignment of the postures, proprioception, and the physical sensations and emotions, interoception, that arise during āsana practice.  Mindfulness-based treatment studies have shown a reduction of the symptoms of PTSD, including affect states and comorbidities; an increased ability to recognize, tolerate, and work with internal states in test subjects; and increases in brain matter density in areas affected by chronic stress (Boden et al. 2012; Greeson et al., 2015; Hölzel et al., 2011; Kabat-Zinn et al. 1992).  Other beneficial elements of mindfulness as practiced in Haṭhayoga include “(A) present moment, process-oriented focus; (B) awareness of inner states (i.e. proprioceptive and interoceptive cues); (C) using the breath as an anchor point; (D) specific patterns of postural alignment; and (E) sensitivity to the flow of movement-based energy (prana)” (Salmon et al., 2008, p.11).

The mindfulness-based treatment program developed by Kabat-Zinn (1996, 2003) includes three key components, including meditation, Haṭhayoga, and a visualization technique called a body scan (also used in Yoga Nidra meditation).  Although the mindfulness meditation technique used in MBSR is based on Theravada Buddhism, the practice of detached self-observation is also used in Yogic practice.  This technique is practiced via the following method:

“…by concentrating on one primary object (commonly the successive flow of in breaths and out breaths), until attention is relatively stable, and then allowing the field of objects of attention to expand (usually in stages) to include, ultimately, all physical and mental events -body sensations, thoughts, memories, emotions, perceptions, intuitions, fantasies-exactly as they occur in time.  Expansion of the field of attention is taught gradually over a number of sessions.”  (Kabat-Zinn, 1982, pp.34)

In one eight-week study testing the efficacy of the Mindfulness-Based Stress Reduction program for anxiety disorders, which included modern Haṭhayoga techniques, test subjects attended a weekly two-hour class where mindfulness meditation techniques were taught in addition to a limited Haṭhayoga program followed by a silent meditation retreat (Kabat-Zinn et al. 1992).  Results showed a significant decrease in anxiety, panic, and depression symptoms in all the test subjects that finished the course with maintained positive results at the three-month follow-up.

West et al., (2016) suggest that due to the mindfulness focus in Haṭhayoga, which emphasizes awareness of the present moment, working with the body to understand somatics, and improving interoceptive ability, incorporating a trauma-sensitive Haṭhayoga program for the treatment of PTSD is advisable, also stating that “heightened awareness may facilitate recognition and tolerance of physical and physiological states, rather than avoidance, and enhance the ability to act on internal cues” (p.3).

In just slightly over 100 years since it was popularized in the West, Haṭhayoga has become one of the most widely used forms of complementary health care in the United States (Barnes et al., 2004).  Most modern Haṭhayoga-based therapy treatments do not include the metaphysical or philosophical concepts of traditional Haṭhayoga practice and prefer to maintain focus on the purely physical results of body-awareness practice and affect resolution (Emerson, 2015, van der Kolk, 2014). Āsana, the postures and poses most easily recognizable in modern Haṭhayoga, strengthen the body, improve balance, improve overall fitness, and raise the vital energy of the body (McCall, 2007). McCall (2016), in a bibliographic compilation of the currently available studies, found that research results have shown 101 health conditions that are improved by the practice of modern Haṭhayoga.

Feelings, traumas, and repressed emotions are held in the physical body and expressed somatically (Rothschild, 2000; van der Kolk, 2014).  As mentioned before, hyperarousal states often cause muscular constriction, abdominal pains, racing heart rate, and shallow breathing. Āsanas release physical tension and regulate breathing while activating the nervous system in a controlled and manageable way.  Āsana alone should not be considered a prescription for diseases (Mohan, 2010).  In the case of PTSD, and depending on the type of trauma, certain āsanas seem to work better than others (McCall, 2007).  Āsana performed with attention to prāṇāyāma seems to be far more effective across a variety of somatic states but seems especially effective in calming arousal states (Harrigan, 1981).

For example, backbends and chest openers are thought to facilitate the processing of grief due to the idea that grief not only causes such sensations as tightness in the chest and throat, feelings of emptiness or weakness, digestive upset, and emotional upheaval but also may develop somatically as a concave posture in the upper and mid-spine (Philbin, 2009).  Causing the body to expand where there was once contraction positively corrects the posture, affecting the mind by returning the individual to an upright position that conveys confidence and health.  Strength-building positively affects low self-esteem and lack of focus by concentrating the mind during a physically strenuous position while providing a controllable challenge that stimulates the nervous system in a way that is tolerable and develops muscle tone.  Fear, insecurity, and anxiety respond positively to grounding poses, seated poses, and meditative poses (Nayak & Shankar, 2004).

Not all āsanas are advisable in the case of PTSD.  For instance, hip openers are very deep stretches that can provoke intense emotions due to the opening of the legs and the stretching of tissue surrounding the pelvis and groin and are therefore not always advisable in the case of sexual abuse trauma (Rothschild, 2000).

Traumatizing events often cause disconnection and conflict with the physical body, especially in the case of sexual abuse (Ogden et al., 2006).  Dissociation, a natural defense mechanism in acute stress reactions, often continues as a state of hypoarousal where an individual disconnects from the body and enters a state of continued numbness where the body feels as if it doesn’t belong to him or her anymore (Bryant, 2007).  This may happen as a mental defense against continued abuse where the body is no longer a safe place of feeling (van der Kolk, 2006).  As a result, there is little relation to physical sensations or somatic manifestations, a lack of physical integration, and a sense of disembodiment.  When placed in certain positions or asked to focus on the sensations of the body, an individual with PTSD may become triggered and overwhelmed without a clear understanding as to why (Rothschild, 2000).  Therefore, the International Society for Traumatic Stress Studies (ISTSS) has proposed guidelines for PTSD treatment that incorporate an initial phase focused on somatic experience, affect regulation, and distress tolerance before beginning other methods of treatment (West et al. 2016).  This is the space where Yoga therapy has begun to flourish as a method of exploring somatic body awareness.

Several effective Yoga Therapy programs have been created and tested for use as adjunct treatments for PTSD and other disorders (Payne, Gold, & Goldman, 2015).  There are currently 24 International Association of Yoga Therapy certified schools teaching Yoga Therapy in the US, Canada, and India (IYAT, 2016) with many more universities and institutions in India providing degree programs on the subject (Adair, Puhan & Vohra, 1993; Virudhagirinathan & Karunanidhi, 2014).  The following programs are some of the most recognized:

• Integrative Restoration iRest Yoga Nidra
• Integrative Yoga Therapy
• Iyengar Yoga Therapy
• Kundalini Yoga Therapy as taught by Yogi Bhajan
• Phoenix Rising Yoga Therapy
• Purna Yoga Therapy
• Structural Yoga Therapy and Ayurvedic Yoga Therapy
• Svastha Yoga Therapy and Ayurveda
• The American Viniyoga Institute
• The Breathing Project
• Urban Zen Integrative Therapy
• The Yoga Therapy Rx Program
• International Association of Yoga Therapy Programs
• Trauma Sensitive Yoga

Choosing one as an example, Trauma Sensitive Yoga (Emerson, 2015) — a method combining psychotherapy, gentle āsana, and simple breathing exercises that can be applied in an office setting by mental healthcare professionals — was first developed at The Trauma Center in 2003.  “TSY’s emphasis on mindful movement and interoceptive awareness helps to regulate affective arousal, increases the ability to experience emotions safely in the present moment, and promotes a sense of safety and comfort within one’s body” (West et al., 2016, p.18).

The first research study exploring the effects of TSY showed promise (van der Kolk, 2006), but it wasn’t until a more recent study (van der Kolk et al. 2014) that TSY was proven to be a successful yoga intervention for the treatment of PTSD.  In the 10-week study, a set of 64 women with chronic treatment-resistant PTSD was divided and assigned to either a weekly one-hour Trauma Sensitive Yoga class, a weekly supportive women’s health education class, or a non-treatment control group.  The TSY classes combined the central elements of Haṭhayoga practice — including āsana, prāṇāyāma, and meditation — as outlined in the protocolized trauma-informed yoga program (Emerson & Hopper, 2011), which emphasizes personal choice in either holding or releasing a pose, simple invitational language in the instructions (for example, using words such as “notice” and “allow”), and awareness of bodily sensations.  The women’s health education classes consisted of interactive teaching methods on subjects such as health, women’s self-efficacy, medical services, communication about sensitive health topics, medical terminology, and self-care.  Test subjects in the TSY application group not only showed marked improvement in affect symptoms and reduced anxiety and depression, but also reported improvement in other areas of their life, such as how they experienced themselves in relation to others and the world in general.  “Increased self-acceptance is one of the primary benefits of yoga and…physical forms (āsana) aim to increase comfort with movement, awareness, and acceptance of the body’s capabilities, functions, and reactions” (West et al., 2016, p. 14).

Other research studies exploring TSY and PTSD have reported an improved ability for clients to engage in therapeutic relationships due to a greater awareness of emotional states and tolerance of physical sensations (West et al., 2016).  Therapists using TSY have also reported a greater ability to build rapport and enhance communication with clients through the shared experience of using āsana and prāṇāyāma in the therapeutic setting (Salmon et al., 2008).

Although TSY has seen very positive results, it can be argued that it isn’t a Yoga-based treatment as it specifically states that one doesn’t have to be familiar with Yoga, a practitioner of Yoga, or a Yoga teacher in order to use TSY in treatment and also states that the philosophical and spiritual aspects of Yoga practice – including using the Sanskrit terms for the āsana or even calling them āsana, mantra practice, or any historical or cultural information about Yoga – should not be brought into the therapy room due to possible triggering or discomfort to the client (Emerson, 2015; West et al., 2016).  For the most part, all the current Yoga-based trauma applications do not incorporate traditional Yoga philosophy or spirituality into the practice and focus solely on the physical practice.  Therefore, questioning whether these new methods of “Yoga Therapy” can be considered actually “Yoga-based” is warranted.

Prāṇāyāma is the second practice of modern Haṭhayoga. Although prāṇāyāma is regularly practiced in conjunction with the āsana, there are also stand-alone breathing exercises and controls that have been studied as a treatment for PTSD (Brown & Gerbarg, 2005; Kozasa et al., 2008).  Prāṇāyāma methods consist of controlling the breath through awareness of the inhalations, exhalations, and the space between the two (Sudhiranand, n.d.). When using prāṇāyāma, the therapist should choose breathing exercises that affect either the sympathetic nervous system or the parasympathetic nervous system based on the needs of the client. For example, a depressed patient may respond well to bhastrika (bellows breath), which raises energy and oxygen levels in the body by performing forceful inhalations and exhalations for several rounds.  A person with anxiety may find this too stimulating, so anulom vilom is preferable in that case (Visceglia, 2015).  Anulom vilom (alternate nostril breathing) is the practice of slowly breathing through one nostril, holding, then exhaling through the other to a fixed count, and then repeating the process on the other side (Nayak & Shankar, 2004).

Upadhyay Dhungel et al. (2008) found that after a four-week study consisting of only 15 minutes of anulom vilom practice every morning on an empty stomach, in nearly all the 36 volunteer test subjects (all free from disease, not taking any medicines, and living a sedentary lifestyle) there was found to be an increase in parasympathetic nervous system activity, lower blood pressure, pulse rate, and respiratory rate.  Pramanik et al. (2009) found that after only five minutes of bhastrika prāṇāyāma both blood pressure and heart rate were decreased, showing a decrease in sympathetic nervous system activity, in nearly all the test volunteers who performed prāṇāyāma alone as opposed to no change in test subjects who were given an oral dose of a parasympathetic blocker drug.  Other studies have shown that prāṇāyāma also improves emotion regulation (Arch & Craske, 2006).

The third aspect of modern Haṭhayoga practice is meditation.  Dhar (2002) found that meditation practice positively affects memory, productivity, quality of life, general health, and mood.  Most interestingly, study subjects found that meditation helped them to convert feelings of loneliness into feelings of solitude, a very different emotion, which can be appreciated as a space where personal growth, exploration, and healing can occur.  Meditation practice alone has shown positive results in the treatment of PTSD and comorbid disorders such as anxiety, depression, suicidal behavior, flashbacks, and nightmares (Schreiner & Malcolm, 2008; Wahbeh et al., 2014).  As part of a combined practice of āsana and prāṇāyāma, it is more effective still.

Meditation in modern Haṭhayoga is practiced in two ways: either seated or lying comfortably and focusing on meditation solely, or during the āsana practice as a form of moving mindfulness meditation that promotes bodily awareness.  There are several types of meditation in modern Haṭhayoga practice, though most are a contemplative or mindfulness practice that highlight objective self-observation, focused attention, and present moment awareness, such as the body-scan from Yoga Nidra, mindful awareness of alignment during āsana (a moving meditation) or observing the inner dialogue in seated meditation at the beginning or end of practice.  All of these facilitate a greater understanding of when PTSD reactions are connected to present or past experiences (Follette et al., 2006) by bringing in the understanding of somatics and the physical reactions to trauma via interoceptive and proprioceptive exposure to promote self-regulation.

Developing the ability to stay in the body when emotions or sensations arise and engage in cognitive processing is important for continued treatment of PTSD, as many clients drop out of exposure-based or insight-based applications due to an inability to cope with intrusive material (Scott & Stradling, 1997).  “A greater capacity for emotion regulation, self-acceptance, and interoceptive awareness may lead to benefits in expressing the narrative of one’s trauma and trauma-related experiences without becoming overwhelmed” (West et al., 2016, p.13-14).

Studies have shown that modern Haṭhayoga practice also helps to develop a sense of centeredness in the body in test subjects who previously experienced dissociation and disconnection with the body (Raub, 2002; Streeter et al., 2010; West et al., 2016).  Centeredness facilitates the ability to control emotional reactivity and remain calm in stressful situations — such as triggering circumstances, emotionally charged situations, or flashbacks — by providing the space to consciously act and apply appropriate behavioral responses instead of reacting uncontrollably, employing avoidance behaviors, or dissociating completely.

During āsana practice, one focuses the awareness on the alignment of the body within the pose and the sensations of the body while maintaining even and relaxed respirations or applying a prāṇāyāma method such as Ujjayi breathing (Brown & Gerbarg, 2009), while also paying close attention to what type of emotions arise in relation to the movements.  Increasing connectivity to the body and awareness of somatic states not only helps to alleviate the symptoms of chronic stress, but also has been shown to increase a sense of personal responsibility and compassion towards the self that inspires individuals to take care of the body and appreciate themselves (Iyengar, Evans, & Abrams, 2005).  The combination of sustained poses, breathing control, and mindfulness meditation seems to be what makes modern Haṭhayoga an especially effective application for relieving the symptoms of an overactive sympathetic nervous system, a major problem in PTSD, as all three applications are effective separately (Raub, 2002; Streeter et al., 2010).  In conjunction, even more so.

Pātañjalayoga incorporates these methods of Haṭhayoga, but also presents a lifestyle framework for developing ethics and positive behaviors that are important for development in the meditative and physical practices discussed already as well as sensory withdrawal methods that may be especially applicable in the control of the arousal states so prevalent in chronic stress disorders.  In the following section, the practice included in the aṣṭāṅga of Pātañjalayoga will be explored as a holistic lifestyle framework for post-trauma resiliency and its application in PTSD treatment.

The aṣṭāṅga of Pātañjalayoga

Pātañjalayoga, the path of Yoga compiled by the sage Patañjali circa 200 BCE – 200 CE, is a holistic wellness framework and a psychospiritual philosophical system with the aim of focusing the mind and realizing the Self. The base text for this practice is the pātañjalayogaśāstra, a combination of 196 concise Sanskrit statements, called sutras, and their commentary, the bhasya. The first three sutras written by Patañjali are as follows: 1.1 atha yogānuśāsanam.  Now the discipline of Yoga is explained.  1.2 yogaścittavṛttinirodhaḥ. Yoga is the cessation of movements in the consciousness.  1.3 tadā draṣṭuḥ svarūpe’vasthānam.  Then, the seer dwells in his own true splendor.  When the waves of distortion in the consciousness still, the true Self shines through (Iyengar, 1993).  Yoga and psychology both strive to provide “intellectual or experiential understanding of the difficulties from which one suffers” (Visceglia, 2015, p. 144), which means to help elucidate the experience of an individual who is in some sort of disorder or imbalance, to bring awareness to behavior, stability to thoughts and emotions, and awareness of somatization and affect states.

Pātañjalayoga guides an individual to be able to still his or her mind in such a way as to see things clearly without the indoctrination of family, society, culture, past experiences, belief systems, traumas, or the influence of emotion or attachments with a specific type of discerning knowledge called vivekakhyāteḥ. Patañjali described the reason for all the suffering of humanity as a misunderstanding of the Self.  The Self, according to Yogic philosophy, is disguised behind the various layers of consciousness and clouded by the fluctuations of the mind caused by afflictions such as attachment, aversion, ego, fear of death, and ignorance.  According to Patañjali, these fluctuations of consciousness, called vrittis, cause human beings to be slaves of their emotions and desires.  Behavioral patterns, called vasana, emerge from these fluctuations and cause one to display unconscious patterns and preferences, to be reactive, and without Self-awareness (Rama, Ballentine, & Ajaya, 1976).  To develop Self-awareness as a practice, Patañjali outlined the eight limbs, or aṣṭāṅga, of Pātañjalayoga as the following: yama and niyama (ethical practices and observances), āsana (poses and postures), prāṇāyāma (breathing exercises and controls), pratyāhāra (sensory withdrawal), dhāraṇā (mental concentration), dhyāna (meditation), and samādhi (absorption) (Iyengar, 1993).

Ignorance and delusion are the normal state of the human mind without discipline and Self-awareness (Iyengar, 1993).  If the fluctuations in the consciousness become extreme and uncontrolled, then mental and physical illness may develop.  Although the neurological and physical consequences of post-traumatic stress aren’t necessarily rooted in the afflictions before mentioned, the fluctuations in consciousness that present long-term as negative rumination, somatic manifestations, and continued emotional reactions are, and could positively be affected by the disciplinary and exploratory practices of Pātañjalayoga.

One must begin the process of stilling the mind and developing Self-awareness through the ethical principles, the first two auxiliaries in the eightfold path of Pātañjalayoga, meant to limit both interpersonal and personal conflict.  These are called the yamas and niyamas (Iyengar, 1993).  The ethical principles of Pātañjalayoga form a behavioral framework that helps to avoid creating situations and circumstances that might cause triggering in PTSD, such as emotionally charged altercations or personal conflict.  Although practicing the yamas and niyamas cannot remove triggers completely, as life is often full of unpleasantness and reminders of previous traumas, their application — including mindfulness practices; behavioral modifications; contentment; conscious intention towards taking a more objective awareness of and attitude towards circumstances, the Self, and others — may reduce both the appearance of trigger induced affect states and their consequences.  The concept is like that of CBT (Foa et al, 1995), in that the method brings awareness to difficulties in thought and behavior by changing the perspective of the client to something more self-aware, healthy, and stable.

Pātañjalayoga is a disciplinary practice.  However, one should not expect to be proficient at its methods immediately.  Pātañjalayoga should be practiced diligently, as one is able, in the long term.  Therefore it should be recognized as a lifestyle framework and not as a quick fix treatment.  Initially, the more advanced practices may not be possible, which must be considered in acute trauma circumstances.  Beginning with the ethical practices is a good starting point.  One may take the eightfold path in stages and climb it like a ladder or practice all points at once.  Pātañjalayoga is a path of Self-realization, and therefore the individual must choose what feels right at what time to employ for him or herself.

According to the Yogasūtra of Patañjali (Baba, 1976), the five yamas are ahiṃsā, nonviolence; satya, truthfulness; asteya, not stealing; brahmacharya, celibacy; and aparigraha, non-attachment.  The Upaniṣads, a group of Sanskrit texts that inspired Pātañjalayoga, add five more yamas: kṣamā, forgiveness; dhṛti, fortitude; dayā, compassion; arjava, sincerity; and mitahara, sattvic (vegetarian) diet (Aiyar, K., 1914).  The niyamas according to Patañjali include the following five observances: śauca, purity of mind/body/speech/environment; santoṣa, contentment; tapas, austerity/discipline; svādhyāya, self-study; and īśvarapraṇidhāna, devotion to one’s personal God or highest Self.  In the Haṭhapradīpikā, a traditional Sanskrit Haṭhayoga text, there are ten niyamas, including tapas and santoṣa, and adding the following: Āstikya, faith; dāna, generosity; īśvarapūjana, worship/devotion; siddhānta vakya śrāvaṇa, listening to and studying scriptures; hrī, humility and acceptance of the past; mati, reflection and reconciliation of conflicting thoughts; japa, mantra recitation; and huta, ritual practice (Sahay, 2013).

The yamas and niyamas both are neglected aspects of Yoga practice in current research concerning the effectiveness of Yoga as a treatment for mental illness and psychological disorders.  Their lack of inclusion may be because several of the practices, īśvarapraṇidhāna for example, are religious in nature.  It is also possible that they’ve been neglected because it is too difficult to measure their application in quantifiable results (Nayak & Shankar, 2004).  However, most of the ethical practices in Pātañjalayoga are like methods already utilized in Positive Psychology or Positivism (Froh, 2004; Pradhan, 2013), in that they are intended to bring awareness to and cultivate positive character qualities instead of focusing on limitations or negative qualities.  These types of positive “strengths-based” approaches have seen beneficial results for resiliency and transformation post-trauma (Tedeschi & Calhoun, 1995).

The techniques of Psychological Positivism (Pradhan, 2013), a humanistic-existential therapeutic method, are aligned with Pātañjalayoga in that its basic tenants are: (A) true identity brings positivity in life (self-realization), (B) equanimity of mind (the purpose of Pātañjalayoga practice) is essential for positivity, (C) the raising of consciousness is integral to positivity, (D) only a pure mind can achieve positivity (śauca), (E) strength of intellect and wisdom are essential for positivity (developed through mental concentration), (F) and Yoga is an effective technique for achieving all of these states.

In Pātañjalayoga, one is meant to bring awareness to everyday activities and apply the yamas and niyamas in every possible moment to develop a balanced state of mind, body, and spirit (Abhedananda, 1967; Ajaya, 1983; Rama, et al., 1976).  Further detail of the yamas and niyamas is in order, as these are the differentiating features of Pātañjalayoga, and these observances are the lifestyle framework through which an individual can prepare him or herself for the physical and meditative practices that form the other six auxiliaries of Pātañjalayoga.

Ahiṃsā, non-violence, is a loving-kindness practice that extends to all sentient beings, including self, others, and animals.  For example, veterans with PTSD may suffer severe guilt concerning actions performed in combat (Henning & Frueh, 1997), and self-criticism is frequently associated with PTSD (Kearney et al., 2014).  Applying non-violence and loving-kindness practices in the present as well as in future behavior may help to relieve guilt, shame, and self-criticism if it appears.  Studies have shown that greater levels of self-compassion help to alleviate PTSD symptoms such as avoidance behaviors (Thompson & Waltz, 2008).  Practicing heart-centered or “loving-kindness” meditation has been shown to lessen pain levels, anger, and psychological distress (Carson et al., 2005), and increase self-esteem and social connectedness (Hutcherson, Seppala, & Gross, 2008).

Satya, truthfulness, is essential to eliminating interpersonal and personal conflict.  Many people with PTSD develop negative relationship patterns and difficulties in truthfully communicating, which often ruins relationships and trust (Foran, Wright, & Wood, 2013).  Always telling the truth with good intention in any given situation, no matter the consequences, allows for authenticity and a greater level of communication.  For example, combat veterans often experience fear or shame and find it difficult to be truthful with their families and therapists about emotions or past actions (Bowling & Sherman, 2008).  Understanding the purpose of pure authenticity in Pātañjalayoga practice provides the space for an individual to take responsibility for present and past actions and emotions.  Authenticity and truthfulness in communication also provide space for others to make real decisions based on honest information, thereby making relationships stronger (Abhedananda, 1967).

Being truthful about emotionally painful circumstances, past actions, or circumstances does pose a risk for triggering.  Therefore, the concept of Ahiṃsā, non-violence, is also applicable here.  The truth can be approached gently.  After establishing rapport between client and therapist, exploring the truth is essentially the goal of most psychotherapeutic methods.  In terms of Yoga, this can also be done with body and somatic awareness.  Approaching the truth, sharing it in gentle and small doses, and then bringing awareness to affect states and somatic manifestations is a method used in Trauma Sensitive Yoga therapy (Emerson, 2015).  Sometimes telling the whole truth is inappropriate but employing the intention of getting there without causing hurt to self or others can be a practice of satya as well.  When in doubt, the therapist and client should revert to the first ethical principle and do no harm.

Asteya, not taking that which does not belong to you or is not given freely, applies to material possessions as well as time and energy.  Asteya also sets the tone for reciprocity in relationships (Iyengar, 1993).  Asteya practice also means not taking another’s time, energy, or emotions for granted and respecting boundaries.  Asteya and Ahiṃsā are linked in that to steal is to commit violence against another’s being and property (Abhedananda, 1967).  Asteya and satya are linked in that to lie to another is to steal the other’s ability to make informed decisions.  Considering that social and behavioral issues, including disrespecting boundaries, theft, and domestic abuse are not abnormal manifestations in PTSD (Cloitre et al., 2005), employing the ethical observance of asteya is especially pertinent. To counter the desire to steal, one should put into place a method of goal setting and disciplined practice to manifest abundance through focus and hard work.

Brahmacharya, sexual continence, includes celibacy and sublimation practices as well as monogamy and non-promiscuity in its non-ascetic form (Iyengar, 1993).  Promiscuity is a negative behavioral manifestation often seen in cases of child sexual abuse and PTSD (Paolucci, Genuis, & Violato, 2001) that can have the added consequences of misunderstandings, unwanted pregnancy, and sexually transmitted diseases.  In brahmacharya practice, limiting oneself to one partner with undivided focus or choosing to become celibate is also considered an act of devotional love that raises self-esteem and vital energy (Vivekananda, 1956).  These practices may be helpful in the case of sexual abuse/trauma or sexual dysfunction in PTSD by providing a safe space and methods by which individuals may explore the body in an intimate fashion again, as well as changing the perception of sexual intercourse from a physical act that may be triggering or disagreeable to that of a sacred union (Finkelhor et al., 2003; Kaufman, Silverberg, & Odette, 2006; Kleinplatz, 1996).

Aparigraha, non-attachment, dictates that one should live within his or her means, not try to amass material possessions, be generous with what one has, as well as not clinging to anything with the consequential result of developing ties through possession (Abhedananda, 1967).  Patañjalayoga advises that one should not define Self or self-worth by the accumulation of material possessions or via relationships with others or due to circumstances and experience; to do so causes delusion and obscuration of the Self.  Attachment to material things, relationships, or circumstances causes suffering when those possessions are lost and those relationships and circumstances end.  Instead, Patañjalayoga suggests generosity of material and immaterial possessions, by giving freely and without expectation of anything in return and engaging in relationships and circumstances with an attitude of compassionate but objective non-attachment (Iyengar, 1993).  This practice may be applicable in cases of trauma, like a home fire where an individual has lost a significant portion of his or her material possessions, by providing the philosophical viewpoint of non-attachment and the reminder that one’s possessions do not define the Self.

Aparigraha also applies to emotions, relationships, situations, and feelings in the sense that the opposite of grasping or attachment is letting go.  Working towards letting go of unhealthy thought patterns and old behaviors that are no longer positive or helpful is also a practice of aparigraha.  One might consider that limiting definitions of the self, dysfunctional belief systems, and the unhealthy relationships that might surface because of PTSD symptoms might also be areas for letting go and changing to more fulfilling and freeing options through non-attachment.

Śauca, purity of mind, body, and environment, is practiced through mindfulness of thought processes, speech, and behavior, and through efforts to eliminate everything that may be negative therein (Abhedananda, 1967).  Pātañjalayoga considers thoughts to be as powerful as actions and requires total awareness and discipline of both in advanced stages.  Considering PTSD, this practice is applicable in the case of negative rumination and intrusive thoughts through the process of objective self-awareness and mindfulness of what is happening in the inner dialog (Michael et al., 2007).  It is understandable that the disciplinary aspects of śauca practice may not be initially possible in the case of rampant and negative inner dialogue, but little by little through mindfulness practices and meditation, it may be possible to achieve greater awareness of thoughts and actions.  Once objective awareness of the content of rumination is achieved, then it may be possible to work towards changing that content to more healthy subjects, as is done in cognitive-behavioral therapies.

Purity of body and environment in Śauca practice means having impeccable personal hygiene and living space to avoid anything that contaminates the body.  Poor hygiene and self-neglect are often a sign of mental illness (Brewer et al., 1996).  Developing self-care and cleanliness habits encourage self-esteem, healthiness, and pride in one’s environment (Visceglia, 2015).

Santoṣa, contentment, is the practice of equanimity under any circumstances.  Swami Niranjan states, “If our mind becomes disturbed by failure and success, then we swing like a pendulum, from one side to the other, from a positive and optimistic approach during success, to a negative and pessimistic approach during failure” (As cited in Vivekananda, 2005, p.197).  Being joyful and grateful for every circumstance is a lofty ideal but developing meaning and acceptance on the path to resiliency is an aspect of both Pātañjalayoga and Positive Psychology (Fredrickson, 2001).  Being content with one’s circumstances also opens space to be in the present moment and not push therapy faster than it needs to be or feel disappointed if change isn’t coming as expected.

In more advanced stages of Pātañjalayoga practice, if compelled to do so, one may choose to develop a sense of contentment regarding the initial traumatic event itself and try to consider a greater meaning within by incorporating the trauma psychologically, physically, and emotionally, and gaining strength from having survived.  It is not always possible, but through contentment practice and via the cessation of the emotional fluctuations it is meant to provoke, one might even begin to develop objectivity and compassion towards the Self that may have been involved somehow, or perhaps even towards the perpetrator of the traumatic event if that is applicable.  Understanding motivations, seeing the suffering or circumstances that caused the event, and applying the viewpoint of interpersonal relatedness may be a healing position to explore in practice and therapy when an individual feels ready to do so.

Tapas, discipline and austerity, is essential training in the ability to withstand hardship without suffering.  Tapas teaches perseverance and willpower in the face of difficulties.  For example, during āsana practice many poses may be strenuous or uncomfortable.  Sensations and emotions that arise when holding the pose may be unpleasant, but it is important to continued improvement in therapy to be able to stay present in the moment and not avoid or avert attention from what is being felt or experienced.  This is an important practice for self-regulation in PTSD treatment, and one of the foundational points of the Trauma Sensitive Yoga program mentioned previously (Emerson, 2015).  By staying in the āsana and facing the difficulties head-on with courage and determination, one learns that it is possible to apply the same measures in everyday life with a sense of openness and contentment with the outcome, whatever it may be (Israel, 2015).

Svādhyāya, self-study, is practiced by reading and studying the teachings of all traditions — science, religion, culture, spirituality, philosophy, et cetera —with a sense of curiosity and inclusiveness.  The point here is to develop insight into the nature of the Self in relation to others and to the universe (or God if one has that type of faith) through introspection and by applying learned information to one’s life experiences and deciding for oneself what resonates as truth (Abhedananada, 1967).  Patañjalayoga explains that a yogi should not simply believe anything he or she has been told or shown (Vivekananda, 2005).  All information must be applied within personal experience to gain insight into the truth.  Studies of introspective therapy have shown that focusing on and questioning attitudes and beliefs has a positive effect on behavior consistency (Silvia & Gendolla, 2001; Wilson & Dunn, 1986).  Introspection has also been found to have a positive effect in the integration and resolution of traumatizing experiences in therapy (Van der Kolk, & Ducey, 1989).

Īśvarapraṇidhāna, devotional practice, is the fixation of the mind on the īśvara, one’s personal God or Higher Self (Abhedananada, 1967).  The yearning to uncover the truth of the Self and to understand the īśvara compels the yogi to continue the often-confrontational spiritual path of Pātañjalayoga (Iyengar, 1993). One method of doing this is by using a mantra meditation where one repeatedly chants the symbol-sound for the īśvara, OM, while contemplating its meaning.

Although studies have found that turning to religion is one of the most common forms of stress management (Falsetti, Resick, & Davis, 2003), research concerning spirituality-based methods of treatment for PTSD is lacking (Bormann et al., 2008, Bormann et al. 2012). Considering that belief systems including religious and spiritual faith may be shattered during a traumatic event, causing a decrease in religiosity (Falsetti et al., 2003), this may be a fresh area for application of Pātañjalayoga as a spirituality-based method for individuals who feel they have nothing left to believe in, spirituality being defined as “a transcendent dimension within human experience…discovered in moments in which the individual questions the meaning of personal existence and attempts to place the self within a broader ontological context” (Shafranske & Gorsuch, 1984, p.231), and religiousness being defined as “adherence to the beliefs and practices of an organized church or religious institution” (Hinterkopf, 1998).

Positive results with the use of mantra recitation have been reported in volunteer test populations comprised of believers, non-believers, and agnostics (Bormann et al., 2005; Bormann et al., 2008; Fabbro et al., 1999).  Bernardi et al. (2001) found that consistent repetition of sacred words, names, and phrases has been associated with reduced arousal, respirations, and enhanced cardiovascular rhythms.  Similarly, Wolf & Abell (2003), in their research on meditative techniques including the chanting of mantras during a four-week intervention, found that their test subjects presented with decreased stress and depression levels.

The positive effect of mantra recitation could possibly have to do with the way that the practice slows down and regulates breathing, such as in prāṇāyāma breath control practice; or by redirecting the ruminating mind towards a comforting word or phrase (Bormann et al., 2005); or by increasing existential spiritual wellbeing, feelings of meaning and purpose, faith, and centeredness (Bormann et al., 2012).

Religious and spiritual beliefs are very important to many people, the practices are often comforting, and “people who regularly meditate and/or pray have been found to have fewer intrusive thoughts (Fabbro et al., 1999), so developing ways to incorporate spirituality into stress management programs may enhance their effectiveness” for those that feel inspired to turn towards faith for answers (Bormann et al., 2005, p.396).

Devotional practices have been found to positively affect disorders such as anxiety, depression, and PTSD (Garzon, 2013).  Especially in the case of trauma where belief systems may have been shattered, re-exploring faith and devotion has been found to be beneficial in developing new meaning-making structures (Bonner et al., 2013).  Simply devoting oneself to becoming well again as a personal ritualistic practice or, if they are still intact, by bringing in religious or personal beliefs to therapy and healing may provide continued focus and motivation for long-term adherence to self-care and Self-realization, and thereby Pātañjalayoga as a lifestyle framework.

The intention behind the yamas and niyamas is that via the elimination of internal and external conflict, the fluctuations of consciousness caused by the consequences of unethical behavior will cease, emotions will balance, rumination and cognitive dissonance will dissipate, and the mind will be easier to control (Ranganathananda, 1995).  This is imperative to successful meditative practice in Pātañjalayoga, but also beneficial within therapy because balance in thought and behavior provides the necessary space to reflect with objectivity upon circumstances.  Without the ethical practices, controlling the mind at the level necessary for true meditative practice according to Pātañjalayoga is difficult (Iyengar, 1993).  Once a stable ethical practice is developed, one may move forward more deeply into the physical practices of āsana and prāṇāyāma, already discussed in the previous section, which serve to prepare the body for the next auxiliaries of Pātañjalayoga: sensory withdrawal, concentration, meditation, and absorption.

Pratyāhāra is the boundary between the physical practices of yoga and the subtle/spiritual practices of concentration, meditation, and absorption.  Pratyāhāra is the practice of sensory withdrawal, i.e. drawing the consciousness away from the sensory input of the physical body and back in through the layers of consciousness.

Yoga nidra, a guided relaxation and interoception technique, has proven to be an effective sensory withdrawal practice for PTSD (Engel et al., 2007).  In an eight-week study of the effectiveness of weekly two-hour Yoga nidra (iRest) classes, the eleven male combat veterans with PTSD who completed the course reported reduced rage, anxiety, and emotional reactivity, as well as increased feelings of relaxation, peace, self-awareness, and self-efficacy (Stankovic, 2011).

In a study performed by Stankovic (2011), iRest was presented to individuals with PTSD with the intention of teaching body and somatic awareness through body scan visualizations, breath awareness, focusing on physical sensations, exploring how emotions and memories feel in the body, and objectively witnessing personal experience.  Participants were physically supported by pillows, blankets, mats, or chairs so that they could completely relax the body, and then were gently guided through the deep relaxation techniques of the body scan.  The study showed greater ability to differentiate sensations, memories, and feelings in test subjects as well as stronger feelings of self-efficacy and peace.

Pratyāhāra practice might also include temporarily limiting exposure to external stimulation such as social interaction, social media, television, or telephone to lessen intrusions and distractions to better focus on feeling safe and secure in the here and now.  When an individual can clear the mind of external stimuli, it becomes possible to look inward and reconnect with sensations and emotions that may be disconnected in PTSD (Emerson, 2015).

In regular pratyāhāra practice, one must sit or lay in a comfortable position that can be maintained for extended periods of time.  Āsana practice and somatic awareness prepare the body for this.  In Pātañjalayoga, the āsanas are essentially performed as a prerequisite to mental focus practice by aiding the body to release tension and to develop comfortable awareness of physical sensations and stillness.  They are not the focus as in Haṭhayoga.  In fact, in the Yogasūtra, Patañjali only mentions āsana practice three times out of nearly two hundred sutras, and typically in reference to a seated posture for meditation.

To practice pratyāhāra, once comfortably seated, one should close the eyes, bring the attention to the breath, and then systematically visualize and relax the body part-by-part until the skin and muscles relax completely around the skeleton, which is fixed in an upright position, spine naturally erect.  This is known as the body scan, also similarly used in MBSR, EMDR, and iRest.  After continuing to focus on the breath, completely relaxing the body, and allowing the thoughts to pass by with gentle objectivity and mindfulness to their content, the senses will draw inwards and interoceptive abilities will increase while outward sensory information will decrease and become distant.

Pratyāhāra practice is often misunderstood to be meditation, but it is only the gateway.  During the practice of pratyāhāra, one becomes acquainted with the internal dialogue, discursive thought patterns, and unconscious material of the mind as is done in mindfulness meditation.  Suppressed emotions and thoughts arise.  Allowing space for them to do so with an attitude of non-attachment “cleans out” the deeper levels of the consciousness (Rama et al., 1976).  In pratyāhāra, the goal is to transcend the feeling body, the thinking mind, and the observing intelligence, to sink deeper into the unconsciousness.

As the senses move in past the physical body into the deeper layers of consciousness, an individual might choose to draw away from emotions and thoughts as well, by shifting attention away from the subjective experience of the emotion or thought to simply observing them as they are without participating any further.  Sinking more deeply in, an individual might begin to ponder the nature of the part of the mind that is doing the observing of the thoughts and emotions, by observing the observer (Singh, 1979).  After pulling the senses and consciousness inward to objective awareness of the inner states, the individual then must apply samyama practice, which is the subtle/spiritual triad of Pātañjalayoga: dhāraṇā, dhyana, and samādhi.

Dhāraṇā, concentration, is the practice of fixing the mind on one solitary point while maintaining physical relaxation and mental alertness (Rama et al., 1976). Once the mind can focus on a state of one-pointedness without inner dialogue or fluctuations of consciousness, meditation, or dhyana, will finally begin.  Then the concentration of the mind can be directed like a laser beam towards the focal point to induce the state of samādhi, total absorption.  In this state, the individual ceases to have objective awareness of the focal point used in dhāraṇā as the consciousness merges completely, removing any sense of duality or physicality (Rao, 2002).

The benefits of meditation practice in the treatment of PTSD have already been discussed, but here in Pātañjalayoga, this type of meditation is different from the methods practiced in most of the available research.  For the most part, mindfulness meditation (Kearney et al., 2012), Vipassana meditation (Simpson et al., 2007), or Transcendental Meditation (Rosenthal et al., 2011) have been the focus of current research concerning meditation techniques and PTSD.  Concentration and absorption practices as prescribed in Pātañjalayoga have not been explored with sufficiency.  Considering that samyama practice is the apex of the pyramid of Pātañjalayoga — the method by which the individual comes into “yuj” or union with source consciousness, which is the literal meaning of Yoga practice — not practicing it in the way outlined by Patañjali in the sutras is essentially limiting the effectiveness of the entire practice.

The implications of being able to discipline the mind to the point of stilling the inner dialogue, concentrating the attention, and becoming completely absorbed in the focal point is interesting in terms of PTSD.  If it is possible to achieve this stage of discipline and focus, by this time many of the typical issues that arise as PTSD symptoms would be alleviated (Waelde, 2004), such as rumination, mood fluctuations, and intrusive affect states.

By being absorbed in samādhi, one no longer has a dualistic perception of “I” or “thou.”  There is only pure consciousness. It is difficult to continuously stay in an absorption state, but once it has been attained, the memory of it inspires deeper and more focused Yogic practice (Rama et al., 1976).  Achieving the state of samādhi through consistent meditative practice develops a more inclusive level of awareness, a higher state of consciousness, in what Yoga philosophy explains is Self-realization.  Pātañjalayoga teaches that we are all essentially the same source consciousness, eternal and unaffected by manifested reality, and this is the Self.  This core of a human being, which Pātañjalayoga states is knowable and reachable through consistent, diligent, and patient practice, still exists in its pure form, untouched by the traumatic event and eternally available through Self-realization.  Imagine the possibilities a conscious state like that could have in the treatment of PTSD and other disorders of suffering: to rest within the experiential knowledge that one is not defined by experience, by suffering, by relationship, or by trauma, that what exists at the core of human existence is still perfect and waiting to be rediscovered.

Conclusion

Considering that Pātañjalayoga is a nearly untapped resource in terms of therapeutic research, which incorporates many different methods that have already been shown to positively affect human behavior, it should be apparent the deep well of possibility within the practice.  If the claims of Patañjali are indeed correct, as whole lineages of Yogis will attest, this system has already addressed the ways in which a human being might reduce or alleviate completely the suffering of existence, including the issues incorporated in PTSD.

In the available research literature, nearly every report calls for continued research into Yoga as a therapeutic treatment (Büssing et al., 2012) as there typically aren’t enough test subjects, there isn’t enough time, there isn’t enough follow-up, and funding is always an issue.  Ideally, studies would follow test subjects over years, but typically studies last only weeks.  Considering that even short-term studies of disparate parts of the practice have shown positive results, the possibilities for the efficacy of the entire holistic practice of Pātañjalayoga continuously and diligently applied are myriad.

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