Introduction
The unfortunate reality of our current circumstances as human beings is that the likelihood of suffering a severe accidental trauma, war, violence, childhood abuse, sexual abuse, psychological abuse, assault, or various other terrible and negative experiences is quite high. Depending on location, socioeconomic status, gender, and culture the likelihood of traumatic experience can be much greater. The aftermath of traumatic experience varies as much as the experiences themselves, but resiliency hinges on many factors including social support, the initial strength and perspective of the individual, the type of event trauma, learned coping mechanisms, and whether or not the trauma was sustained or continues (Rhodes, 2014). No human being is completely safe at any time, and tragedy often strikes when least expected. One may overcome, move forward, or even grow psychologically and spiritually after a trauma. Quite understandably, one might develop circumstantial and temporary stress, depression, and anxiety after a serious trauma. However sometimes, one may develop a life altering and quite serious reaction recognized as posttraumatic stress disorder or PTSD (Rhodes, 2014).
Aside from the initial trauma and shock of the triggering event, a person suffering with PTSD may manifest debilitating symptoms such as flashbacks, nightmares, freezing, violent thoughts, anger/rage, rumination, suicidal thoughts, severe distress when presented with situations that resemble the previous trauma, avoidance, hypervigilance, guilt/shame, insomnia, fear, irritability, self-harm, lack of concentration, and addiction disorders (Mayo Clinic, 2014). These symptoms range in intensity from momentary and manageable to completely overwhelming. “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 disassociative numbing” (Emerson, 2015, p. xiii). This cycle often leaves the person totally detached from his or her own body, thoughts, and feelings. Life becomes a perpetual dance with the devil of traumatic experience. The comorbidity rate for other diseases and complexes paired with PTSD and complex posttraumatic stress disorder is high (Ducrocq, F., Vaiva, G., Cottencin, O., Molenda, S. & Bailly D, 2001).
There are many relatively effective treatments for PTSD to be found within Western medicine and psychology (Adshead, 2000; Rothbaum, 2013; Friedman, M. & Schnurr, P. 2008). The majority of these combine some form of pharmacotherapy with psychotherapy (Stein, 2013). But one of the interesting things about PTSD is that this previously mentioned dance between hyperarousal and disassociative numbing can disconnect a person so deeply from his or her own body, thoughts and emotions that it can become quite difficult to engage reasonably in talk therapy, making some patients non-responsive to this type of treatment (Emerson, 2015). How can one communicate feelings if one is totally disconnected from their feelings? Aside from that problem, I suggest that medications may serve well enough to calm the symptoms of depression and anxiety, and talk therapy may help to form coping mechanisms and awareness of behavior and thought processes, but it doesn’t completely get to the root issue and is therefore only part of the puzzle. A person is only partially intellect, behavior, and chemical balance.
Real healing begins elsewhere, deep within the body that is holding the trauma, deep in the mind that has suppressed the trauma, surrounding the spirit that lived the trauma, and held within the community that witnessed the trauma. Without approaching the body/mind/spirit trinity, the healing doesn’t properly unfold. Here is where I suggest the practice of the Ashtanga – the eightfold path – according the the Yoga Sutras of Patanjali as a framework within which the patient may find direction and meaning as well as reconnect with those lost aspects of him or herself that were so abruptly or systematically denied through the traumatic experience.
PTSD as defined by Western medicine
Posttraumatic stress disorder is defined so incredibly differently in Western medicine when compared to Yoga psychology. Western psychology relates the phenomenon greatly to neuropsychological damage and chemical imbalance (Rhodes, 2014). Yoga psychology focuses more on the subtle body and the energetic and spiritual consequences of traumatic experience. The Department of Veterans Affairs gives the following definition of PTSD in their Clinical Practice Guideline for Management of Post-traumatic Stress (2010):
Post-traumatic stress disorder (PTSD) is a clinically significant condition with symptoms continuing more than one month after exposure to a trauma that has caused significant distress or impairment in social, occupational, or other important areas of functioning. Patients with PTSD may exhibit persistent reexperiencing of the traumatic event(s), persistent avoidance of stimuli associated with the trauma, numbing of general responsiveness (not present before the trauma), and persistent symptoms of increased arousal (not present before the trauma). PTSD can also have a delayed onset, which is described as a clinically significant presentation of symptoms (causing significant distress or impairment in social, occupational, or other important areas of functioning) at least 6 months after exposure to trauma (p. 4)
The APA defines PTSD like so:
PTSD, or post-traumatic stress disorder, is an anxiety problem that develops in some people after extremely traumatic events, such as combat, crime, an accident or natural disaster. People with PTSD may relive the event via intrusive memories, flashbacks and nightmares; avoid anything that reminds them of the trauma; and have anxious feelings they didn’t have before that are so intense their lives are disrupted (American psychological Association, 2015).
One can see the relatively straightforward definition here of a disorder that is referenced in terms of symptom manifestation after an event. There is no mention of the more holistic elements of PTSD. It is no wonder from this perspective that the treatment methods are also directed towards the symptoms that are manifesting and not necessarily the human being that is suffering behind those symptoms. That leads to methods such as cognitive behavior modification, pharmacotherapy, exposure therapies, and such. The treatment mentality is somewhat like fixing a broken machine, yet is not always as effective.
PTSD in Yoga Psychology
Yoga psychology views the trauma from the perspective of the subtle body. Most often, people suffering from PTSD have fracturing within the first three koshas, damage to the function of the chakras, blockages within the energy channels of the body, and a loss of vital energy. There isn’t enough space in this short paper to go into the chakra system or the subtle body system in depth, but we can assume for our purposes here that the subtle body is defined as layers of consciousness emanating outward from the core of the physical body, or the energetic levels of the manifestation of the being itself that envelop the physical body, called the koshas. The chakras are recognized as vortices of energy situated in the area of the physical body, yet on the precipice between the physical and subtle body, that act as outlets between the two. So the chakras move energy from the physical to the subtle and vice versa. Each chakra is associated with certain elements, energies, thought processes, emotions, and aspects of the physical being. When there is a trauma to the physical body, it also manifests in the subtle body. The chakra that is associated with that particular frequency of consciousness is affected, the koshas are likewise negatively affected, and there is a rupture between body, mind, and spirit. If one only heals the trauma on the physical level, it remains in the subtle and mental and causes energetic imbalance that often manifests as disease (see Dale, 1996, and Judith, 1996, for more information regarding the chakras and subtle bodies).
From this perspective, yes, it is important to deal with the psychological and physical consequences of a trauma, but without coming back into the body and really working through the energetic consequences of the trauma, the scar remains in a deep part of the human being where it will consistently reappear when triggered and also affect all the other aspects of the being as well.
When the first chakra is damaged, we are plagued with issues of survival…. We may find that a basic feeling of safety and security seems to elude us no matter what we do even when there is no real threat to our survival. The survival instincts lie at the base of the collective unconscious…. When those natural instincts are denied, we have a rupture between our waking consciousness and the very core of our being (Judith, 1996, p 59).
From the Yogic perspective, a first chakra trauma is akin to a crack in the foundation of a building. Everything else built upon that foundation is in peril and is built on a shaky and untrustworthy basis. Obviously, the methods of treatment to address the situation from the two perspectives will be quite different, nearly on opposite ends of the pendulum swing. In this case, wouldn’t a middle ground be an interesting meeting place?
Treatment within the Yoga of Patanjali
Within the paradigm of Yoga, the treatment for chakra imbalance is a combination of methods: certain physical postures and movements to bring awareness, strength, and balance to the body through a process called grounding; breathing exercises to foster concentration and raise energy levels, meditation practices to focus the mind, and ethical observances to structure the behavior (Dale, 1996; Judith, 1996; Judith, 1999)
Some methods one might use to address and heal an imbalance or blockage in the first chakra Muladhara are through positive affirmation or prayer; chanting of the seed Mantra Lam; holding the Apana Mudra; massage therapy or any type of sustained nonsexual touching; Yoga Asana, such as Shivasana, Sukhasana, Tadasana, Vrksasana, Balasana, Vajrasana, Malasana, and Trikonasana (Mercier, 2007; Saraswati, 1969); emotional therapy or psychoanalysis to bring the core trauma or abuse to light; Samatha meditation; outdoor physical activities such as hiking, surfing, and swimming; sea salt baths; Kegel exercises (activating the mulabandha lock); and meditating on the sacred geometry of the red Muladhara lotus sitting at the first chakra site. When the Muladhara is out of balance, activities that reconnect with the Earth and provide a sense of nurturing safety are of utmost importance. In extreme cases of Muladhara deficiency, bringing the person as close to Earth as possible is advisable, lying upon the bare ground, or even placing a cover of earth or sand over the body up to the neck as the person lays in Shivasana. The weight of the earth or sand over the body will help to reground the energy of Muladhara. If this is not possible, a long soak in a hot bath with sea salts is recommended.
The ethical principals, Yamas and Niyamas, of Patanjali’s Yoga help to form a framework that can alleviate situations and circumstances that may be retriggering to PTSD. The concept is similar in a lot of ways to cognitive behavioral therapy, one Western method that has proven very effective in PTSD treatment (Adshead, G., 2000; Foa, E. et al, 2009; Shnaider, P. et al, 2014; Cisler, J. et al, 2015; Schumm, J. et al, 2013), in that it works to solve life problems by changing the perspective of the individual to something more healthy and manageable. Combined with Yoga, CBT is incredibly beneficial in that it provides a sturdy set of coping mechanisms and practices for the patient when faced with triggers and overwhelming situations. Armed with these Western methods of coping, the patient can dabble into the more spiritual and physical practices of Yoga more safely.
The ethical principals of Patanjali’s Yoga fall within the first two limbs of the eightfold path, known as the Yamas and Niyamas. Briefly, the Yamas according to Patanjali’s Yoga Sutras (Iyengar, 1993) can be defined as the following: Ahimsa, nonviolence; Satya, truthfulness; Asteya, not stealing; Brahmacharya, energetic continence; Aparigraha, not grasping. Some texts (Aiyar, K., 1914) add on five more Yamas which are: Ksama, forgiveness; Dhrti, fortitude; Daya, compassion; Arjava, sincerity; and Mitahara, Sattvic diet. The Niyamas according to Patanjali (Iyengar, 1993) include the following: Saucha, purity of mind/body/speech/space; Santosha, contentment; Tapas, austerity; Svadyaya, self-study/introspection/study of scriptures; and Ishvarapranidhana, contemplation of God. Within the Hatha Yoga Pradipika (Sahay, 2013), these are expanded to ten including Tapas and Santosha and adding the following: Astika, faith; Dana, generosity; Isvarapujana, worship/devotion; Saiddhanta Vakya Sravana, listening to and studying scriptures; Hri; humility and acceptance of the past; Mati, reflection and reconciliation of conflicting thoughts; Japa, mantra recitation; and Huta, ritual practice.
The idea behind the Yamas and Niyamas is that through the practice and observance of these ethical principals, one may develop a balanced state of mind and spirit. The emotions will cease to dictate and control the person. Self-realization and a blissful state of existence will follow (Iyengar, 1993; Sahay, 2013). In practice, what happens when one follows these ethical standards is that the conflicts of life lessen to a great degree not only within the individual in terms of shame, guilt, rumination, regret, and so forth, but also expanding out into interpersonal relationships (Ranganathananda, 1995). Without the constant barrage of conflict caused as a consequence of unethical behavior, one may life in peace and have the space to reflect in a healthy way with a clear mind upon circumstances. Setting the stage in this way removes a fair amount of the triggers one might experience that could once again set off PTSD symptoms. After setting a stable founding based on ethical principals and positive behavior and viewpoint, one may begin with the physical practices of Asana, Pranayama, and Pratyahara.
Pranayama, the breathing exercises, can be used to raise the vital energy levels and stave off depression and anxiety. There have been positive findings regarding the use of pranayama in the treatment of PTSD (Brown, R. & Gerbarg, P., 2005). Pranayama methods consist of controlling the breathing in various different manners. For example, Anulom Vilom is the practice of breathing through one nostril and then the other to a fixed count during inhalation and exhalation. By taking control of an otherwise natural and involuntary mechanism, one may actively reset the body’s energetic state to a more relaxed and balanced level (Anulom Vilom Pranayama – Alternate Nostril Breathing, 2015).
Asana, the physical postures and poses, are used as a way to strengthen the body, raise balance, raise fitness levels, raise energy. In the subtle body, certain energy channels, called nadi, are cleared and activated by the sustaining of certain Asana. Therefore, certain Asana also open up certain chakra. It is believed that certain types of energies are held within the body: feelings, traumas, and repressed emotions are held in the physical form. The asana serve to break these up and release the person to confront and work through those repressions (Dale, 1996; Emerson, 2015; Judith, 1996; Saraswati, 1969). Depending on the type of trauma, certain Asana work better than others. For example, someone suffering from grief will respond more positively to backbends and chest openers. Someone suffering from low self esteem will respond positively to strength building poses like Navasana and Virabhadrasana 1 & 2. Someone who has a lot of fear and insecurity will respond positively to grounding poses, seated poses, and meditative poses. The Asana have been shown to be effective in relieving stress, anxiety, depression, and in raising interoception ability (Chong, C. et al, 2011; Emerson, 2015; Johnson, 2014; Kohn, M., 2013; Li, A.W. et al, 2012; Rhodes, 2014; Staples, J. K. et al, 2013; Van der Kolk, B. et al, 2014).
Pratyahara is the practice of sensory withdrawal. Studies have shown that combat veterans in particular respond positively to yoga practices that incorporate soft music or sound controlled environments with lots of meditative practice. Combat veterans with PTSD tend to have loud sound and crowds as a triggers for hypervigilance and violent outbursts. Creating a calm and sensorially non-stimulating environment to practice in has shown to be effective in reducing stress and anxiety in combat PTSD (Stoller, C. et al, 2012). Yoga nidra is an effective sensory withdrawal practice, in that it is a meditation that step-by-step relaxes every single part of the body in an almost hypnotherapeutic manner. Pratyahara practice can also include withdrawing from external stimulation such as social media, television, telephone, reading the news, eating in silence, practicing interoception (becoming mindful of physical sensations), being alone in nature, reading, and certain forms of meditation. The idea is to limit the stimuli that are clouding up the mind and emotions to be able to better focus on feeling safe and secure in the here and now. This also has the ability to positively affect interoception ability (Emerson, 2015). When the patient is able to clear the mind of external stimuli, it becomes much easier to look inwards and reconnect with sensations and emotions that may have been lost due to PTSD.
Dhyana and Dharana, meditation and concentration practices, round out the Rajayoga practice. These two, along with Pratyahara, form the practice of Rajayoga – the King of Yogas. All of the ethical practices and physical practices are done in preparation for the deeper work of meditation and concentration. Here is where one comes prepared to face one’s dragons, so to speak. Using Rajayoga as a sister therapy or adjunctive therapy to the ongoing psychotherapy and pharmacotherapy work, the patient can begin to move inwards and reconnect with the suppressed feelings, emotions, and thoughts. By turning inwards in meditation, the difficult healing work really begins. There are many different methods of meditation, and many have been shown to be quite effective in the treatment of PTSD including mindfulness meditation, vipassana meditation, and loving kindness meditation (Bribson & Lowery, 2011; Kearney, D.J. et al, 2013).
During the practice of meditation, one becomes acquainted with one’s internal dialogue, discursive thought patterns, and unconscious material. Suppressed emotions and thoughts often arise, and due to the hard work and preparation gained through the practice of the Yamas, Niyamas, Asana, Pranayama, and Pratyahara, one may face these potentially retraumatizing visions with honor and courage.
Ethical considerations
There are definitely some things to consider when approaching Yoga as an adjunctive treatment for PTSD. As of yet, the bulk of the research that has been done on the subject focuses mainly on the physical practices of Yoga, the asana, and some forms of meditation. These are done outside of the context of the holistic practice, which must include the Yamas and Niyamas or it cannot effectively be called Yoga practice according to Patanjali’s philosophy. Therefore, the research is incomplete in its assessment. As it stands, even without the ethical principals, the results look very promising. However, without the ethical principals there is a large chunk missing that could be quite effective in the lessening of trigger reactions in PTSD. Forming ones life around the Yamas and Niyamas is a part of the spiritual practice of Yoga that essentially is meant to remove conflict and upset inside and outside the person. The issue with removing this spiritual aspect of the practice of Patanjali’s Yoga is that without them, the hindrances that arise in the mind (greed, sloth, lust, gluttony, anger, pride, envy, et cetera) will continue to cloud the entire being, making it very difficult if not impossible to enter into a deeper practice of meditation. If the meditation is superficial or hounded by incessant inner dialogue, the healing work will be too slow to be very beneficial. The entirely of the Yoga Sutras of Patanjali (Iyengar, 1993) is a guidebook for stilling these fluctuations of the mind so that the person practicing Yoga can move deeper to a state of Oneness and balance.
The concern is that without the preliminary practices of the Yoga of Patanjali, one is opening a can worms: highly triggering emotions, feelings, sensations, and unconscious repressed material. The patient could be triggered and not have the coping skills to deal with what comes up during practice. If this is the case, the Yoga therapist must refer back to the psychotherapist. If one adds Yoga as an adjunctive treatment it should be the entire eight-limbed practice under the watchful eye of the patient’s GP and psychologist.
Another concern is that Patanjali’s Yoga, although not a religion in itself, does have religious overtones having matured in the cultural setting of a Hindu society. Some people who hold close to their own religion may see this as an affront to their values. However, Yoga is more like a scientific method than a religion. Every aspect that has Hindu overtones can be modified to incorporate the personal religious views of the practitioner. In fact, many Christian groups having seen the benefits of Asana and meditation practice have begun to create Christian-based yoga programs for their congregations (Sheveland, 2011; Greenwood, & Delgado, 2013). This being said, there are some Christian clergy that are vehemently opposed to Yoga practice by their congregation, and this may cause serious problems in treatment (Manjackal, 2015). Some may suggest the answer to this problem is to just remove all the spiritual aspects of Yoga within treatment (Emerson, 2015), but I would again argue then that the practice can no longer be called Yoga if that is the case. If a therapist wants to add yoga as an adjunctive treatment, he or she must be aware of the spiritual and religious values of the patient first, and take these into consideration so as not to send the patient down a road that will ultimately confront deeply held values causing cognitive dissonance and further trauma
Conclusion
The practice of the Yoga of Patanjali is a well-rounded holistic treatment program for wellness of mind, body, and spirit that has behind it thousands of years of evidence to its benefit. In a paper this short, there is not enough time and space to go deeply into the philosophical and esoteric reasons that Yoga psychology holds for the positive benefits of a Yoga practice, but I have presented many references for research that has shown a significant improvement and alleviation of the symptoms that are most often associated with PTSD. When used in conjunction with the proven methods of PTSD treatment within psychotherapy and pharmacotherapy, a patient can learn coping mechanisms and alleviate symptoms, and also begin the work of facing and overcoming the trauma itself that still exists within the body and memory. Yoga Asana is an incredibly effective method to bring awareness back into the physical body and mind in a state of dissociation, which is a symptom of so many people who have endured physically violent experiences (Emerson, 2015); the ethical principals form positive standards by which one might choose to live life; and meditation has become a very interesting topic of research in the treatment of mental illness recently due to its profoundly positive results. The combination of the Western and Eastern methods may very well create a long-term solution of integrative health for the treatment of PTSD.
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