There is a growing need for a theoretical and empirically grounded approach to support effective and safe provision of yoga to potentially vulnerable populations. Yogis In Service, Inc. (YIS), a non-for-profit community service yoga organization, in partnership with the Africa Yoga Project (AYP) and the University at Buffalo, State University of New York has developed an embodied, cognitive-relational framework for trauma-informed yoga (YIS-TIY). YIS-TIY identifies 12 key teaching points of trauma informed yoga, which can be applied when teaching yoga to stressed and potentially traumatized populations. YIS-TIY utilizes the four domains of inner resources, physical basics, self-regulation and mindful grit to empower students in a trauma-informed manner. YIS-TIY can be utilized as a framework and guidance for yoga teachers working in high-risk locations and/or in yoga classes that may include vulnerable and trauma-exposed individuals. The purpose of this article is to (1) review the body of literature of yoga and trauma that informs the YIS-TIY model, (2) outline the 12 key teaching points of trauma-informed yoga within the YIS-TIY methodology for teaching yoga to stressed and potentially traumatized populations, and (3) provide a set of practice recommendations.

Yoga is defined as a mind/body practice comprised of physical postures (asanas), breath work, meditation, and relaxation.^1–5 Through the teaching and practice of yoga, yoga teachers facilitate an experience of positive embodiment that promotes mindfulness awareness, self-regulation, and physical fitness.^1,4,6 Each year, those who practice yoga represent a progressively larger proportion of the population.^7–9 Further, yoga is increasingly used to enhance outcomes for those with mental health challenges including Post Traumatic Stress Disorder.^5,9–12 As celebrated in both academic and popular press, yoga-for-trauma classes are being offered in urban, high poverty areas; in high risk, risk poverty schools; for veterans; and within substance use and mental health rehabilitations centers.^3,6,13 For these reasons, there has been a growing need for a theoretical and empirically grounded approach to support effective and safe provision of yoga to potentially vulnerable populations.^6,14 Yogis in Service, Inc. (YIS) is a not-for-profit community service yoga organization that provides yoga teacher training in trauma-informed yoga and collaborates with other organizations to develop research-based, trauma-informed approaches to community-based yoga. Through a partnership with the Africa Yoga Project (AYP) and University at Buffalo, State University of New York, YIS has developed and embodied, cognitive-relational framework for trauma-informed yoga (YIS-TIY).

This article reviews the definition of trauma exposure and Post Traumatic Stress Disorder (PTSD) and condenses the body of literature of yoga and trauma that informs the YIS embodied, cognitive-relational framework. Next, the article explicates the 12 key teaching points of trauma-informed yoga within the YIS-TIY methodology for teaching yoga to stressed and potentially traumatized populations. Last, there is set of practice recommendations.

A growing trend is the use of yoga interventions as part of the PTSD recovery process.^6,10,15–18 Studies have also examined yoga interventions for children and adolescents who have experienced various forms of trauma exposure in different regions of the world.¹⁹ Several studies thus far have examined the effectiveness of this approach as an adjunctive treatment for trauma, including in adults.²⁰ and youth.²¹ Capturing the breadth of the work in this area, works cited in this review span the literature on trauma-sensitive yoga as well as other forms of yoga (i.e., trauma-informed yoga) designed as interventions for, and support of, individuals who have experienced trauma as well as the general literature on the impact of trauma.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), traumatic exposure includes exposure to death, threatened death, actual or threatened serious injury, or actual or threated sexual violence through both direct and indirect exposure.²² Indirect exposure incudes witnessing the trauma, learning that a relative or close friend was exposed to trauma, and indirect exposure to aversive details of the trauma, typically in the course of professional duties (e.g., humanitarian workers, first responders; APA, 2013). Exposure to traumatic events among a national sample of U.S. adults (n = 2,953) was found to be high at 89.7% and exposure to multiple traumatic event types was found to be a norm.^22,23

To be diagnosed with PTSD the individual must have: (a) experienced trauma as defined by the DSM-5, (b) persistently re-experience the trauma (i.e., intrusive thoughts, nightmares, flashbacks, and emotional distress and physical reactivity related to traumatic reminders), (c) demonstrate avoidance of trauma-related stimuli (i.e., trauma-related thoughts or feelings and trauma-related reminders), (d) experience a worsening of negative thoughts or feelings (i.e., inability to recall key features of the trauma, overly negative thoughts and assumptions about self and world, exaggerated self-blame related to the trauma, negative effect, decreased interest in activities, isolation, and trouble experiencing positive affect), (e) trauma-related arousal and reactivity (i.e., irritability, aggression, risky or destructive behaviors, hypervigilance, heightened startle reaction, trouble concentrating, and difficulty sleeping;.²²).

Many who experience trauma fair well and experience limited mental health symptoms.^6,24 For some, the experience of trauma is associated with mental health issues such as substance abuse, anxiety and anxiety disorders, depression and mood disorders, as well as more trauma-specific disorders.^6,25 A subset of trauma-exposed individuals are later diagnosed with Post Traumatic Stress Disorder.^10,23,26 According to Koenen et al.²⁴, the cross-national lifetime prevalence of PTSD was 3.9% overall and 5.6% among the trauma exposed individuals. Rates of PTSD vary depending on gender, type of trauma, and persistence of exposure.^23,26,27 Kilpatrick et al.²³ found that among adults exposed to trauma, lifetime, past 12 months, and past 6-months PTSD prevalence was at 8.3%, 4.7%, and 3.8% respectively. Among children rates are considerable (Cook-Cottone, 2004). In a meta-analysis of 72 peer-reviewed articles on 43 independent samples (n = 3,563), the overall rate of PTSD was 15.9%.²⁷ Researchers found the lowest rates among boys with non-interpersonal trauma (8.4%) and highest rates among girls exposed to interpersonal trauma (32.9%;²⁷). Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed.²⁴ Statistics suggest that it is likely that in any one studio, community, or center-based yoga class, with 20 people in attendance, there is likely to be at least one or two, yoga students with higher rates among risk populations and at high-risk locations (e.g., four or more per 20 student class).

Systematic reviews of the literature investigating the effects of yoga for trauma and trauma-related mental illness is encouraging.^6,28–31 Although the body of research is lacking in rigor as well as specificity, reviews of the literature have found yoga for trauma to be acceptable, feasible, and cost effective.^6,28 Generally, yoga was found to have minimal risks, few negative effects, and is easily adapted to those with physical and mental challenges.⁶ There are several mechanisms of action proposed to explain the benefits of yoga for those who have experienced trauma ranging from the alterations of neurotransmitter levels in beneficial ways to the regulation of the physical stress response in the promotion of wellbeing.^{6,10,15,28,32}

There are two approaches through which yoga programs address trauma: trauma-sensitive yoga and trauma-informed yoga. Both approaches emphasize key aspects of yoga delivery such as the idea of befriending the body through mindful awareness of body sensations, teaching coping tools, and emphasizing choice and relationship.^2,33 However, there are key distinctions related to the populations the approaches are intended to serve, which inform the research on the respective methodologies.

First, use of the term trauma-sensitive yoga means that the yoga instructors specifically and intentionally teach individuals who have been through trauma.³³ These types of programs partner with a treatment team including doctors and counselors who are helping the individual with their trauma recovery and yoga is viewed as complementary to psychotherapy.³³ Research on trauma-sensitive yoga approaches is done with individuals who have been through substantial trauma or have been diagnosed with PTSD. The Trauma Center, the Trauma-Sensitive Yoga (i.e., TCTSY) is a specific approach to trauma-sensitive yoga. Specifically, TCTSY is considered the most intensive yoga program for trauma, designed for individuals who were not responsive to traditional PTSD treatment.³³ The TCTSY approach emphasizes four key themes: making choices (i.e., participants choose their actions based on a set of choices), present moment experience (i.e., connecting to and noticing physical cues), effective action (i.e., doing something to increase a sense of safety or wellbeing), and creating rhythms (i.e., noticing that experiences begin and end, synchronizing breath and movement, moving as a group;.³³)

Trauma-informed yogarefers to the approach to teaching yoga in which the teachers have knowledge of trauma and the symptoms of trauma, as well as know how to provide a safe and supportive yoga class for individuals who are experiencing stress and/or have been traumatized. Often, the yoga teacher delivers open and inclusive community classes knowing that many yoga students are stressed and some of the people who come to class may have been traumatized. Trauma-informed yoga teachers refer students who are struggling for support to counselors and doctors when needed as they are not part of a treatment team. Specifically, a trauma-informed yoga teacher is trained to have knowledge of: (a) trauma and PTSD, (b) the key points of yoga delivery relevant to trauma, and (c) scope of practice issues related to the treatment of trauma and the provision of yoga.

The YIS-TIY approach is based on an embodied, cognitive-relational framework. The three aspects of this approach are positive embodiment, cognitive intention, and relational attunement (Table 1: Reactions to Traumatic Exposure and the YIS-TIY Approach).

First, embodiment is the way we live in our bodies, presence within the physical self, interoceptive awareness, responsiveness to internal cues, and decision making in the care and nourishing of our bodies.³⁴ Phenomenologically, we are our bodies.^1,34 Embodiment lies in the choices we make that affect the physical self, the food we eat, physical exercise, sexual decision-making, and more.^34,35 Similarly, positive embodiment and yoga require presence and engagement in the current moment.¹ Specifically, yoga, when practiced with open awareness, presence, attunement with the physical and emotional self, and intentional action is a practice of positive embodiment.^12,36 Through the facilitation of positive embodiment, yoga practice addresses two core sets of symptoms associated with exposure to trauma (i.e., hyperarousal and dissociation and avoidance and re-experiencing) as well as a wide range of mental health symptoms associated with trauma.^{14,6/sup> (Table 1). The 12 principles and practices offered below distill the research on trauma and yoga into essential points of practice that help facilitate positive embodiment.}

The second aspect of the YIS-TIY approach, cognitive intention, addresses the cognitive effects of trauma exposure (e.g., cognitive distortions regarding self, others and world;.³⁷). This aspect of the approach is based on an extensive body of literature showing positive effects of cognitive behavioral therapy and yoga on trauma.^5,37,38 In fact, comparative studies suggest that addressing distorted cognitions may be key to long-term outcomes in trauma recovery.³⁹ Accordingly, many yoga programs incorporate a cognitive component by incorporating trauma-recovery specific themes for class or intentionally structuring the yoga language used in class.¹⁵ The themes or statements serve as cognitive guides for the yoga students as they practice letting go of negative ruminations and adopting more positive ways of cognitively managing the present moment.¹ For example, Dick et al.¹⁵ randomized controlled study of a yoga intervention for women with PTSD integrated guidelines for specific yoga language for the yoga teachers to use in session to deliver the cognitive aspect of content. To encourage mindfulness, the teachers were guided to say, “Without judgement, notice the breath coming into your body and leaving your body. Simply observe what is happening on your mat”.¹⁵ (Table 2).

SD: Standard Deviation; BMI: Body Mass Index; WC: Waist Circumference; AC: Abdominal Circumference; HC: Hip Circumference; RER: Respiratory Exchange Ratio; HR: Hear Rate.

It is hypothesized that the positive cognitive effects develop in a two-fold process. Specifically, mindful awareness in yoga may reduce negative cognitive rumination through a promotion of adaptive thinking and a corresponding decrease in repetitive negative thoughts and ruminations.^3,5,6,32 In order to support the use of adaptive and effective cognitions during the physical practice of yoga, the YIS-TIY approach delivers yoga sessions using a set of 12 principles for growth that are based on the body of trauma and yoga literature (Table 2). These principles are shared as reminders during yoga class and as themes across the multi-session delivery of yoga (i.e., a series of 6 to 12 weeks of yoga classes). They are offered as a set of 12 “I” statements that an easily be internalized by the practitioner (e.g., “I am worth the effort,” and “I can find choice in the present moment”). Increasing the likelihood of internalization and effectiveness, the 12 principles are consistently delivered across yoga teachers and sessions to provide a positive cognitive framework for addressing challenge and growth.^3,40

The third aspect of the embodied, cognitive-relational framework, relational attunement, refers to the presence and responsiveness of the yoga teacher. Requiring mindful and empathic awareness, relational attunement occurs when the yoga teacher provides assistance and support to the yoga student in a manner that is directly aligned with the needs and experience of the student.^{2,12[. To be effective, Emerson et al. [10} suggest the teacher should be present and positive, encouraging of and open to feedback, and willing to make changes when things are not working. Among mental health clinicians and researchers, it is well accepted that the therapist/client relationship is a critical factor in successful recovery from trauma.⁴¹ In the same way, the substantial body of work on the practice of teaching yoga to those who have experienced trauma emphasizes the presence and actions of the teacher as critical to outcomes for students ^.34. Thus, the 12 principles also offer guidelines for how to effectively be with yoga students within the context of the student/teacher relationship.

The following YIS-TIY key points of delivery build on the principles of trauma-informed care and practice.⁴² Further, they are sourced from the extant body of literature on yoga and trauma as well as from the larger body of research on trauma.^6,12,34,42 Each key point of delivery addresses the relevant components of yoga class: cognitive intention, practice in the teaching of asana (i.e., teaching of yoga poses, breathing, and sequences), meditation and relaxation, and assisting and supporting yoga practices. The key points of delivery are organized in four domains: (1) Inner Resources, (2) Physical Basics, (3) Self-Regulation, and (4) Mindful Grit (Table 3).

Exposure to trauma can leave those exposed feeling powerless and without worth.^27,42,43 For example, in a study of 65 participants in South Africa, 36 participants had witnessed the violent death of a close relative (sibling, mother, or father). The remaining 29 had been tortured and detained. Researchers found that traumatic events affected the participants' basic assumptions about the meaning and benevolence of the world. Critically, the tortured and detained group and the bereaved group showed differences in their assumptions of self-worth following the trauma.⁴⁴ Across the literature, genocide, child sexual abuse, and even vicarious trauma, have all been found to be associated with a reduced sense of self-worth.^43,45,46 Further, self-worth has been indicated as an important mediator in trauma outcomes.⁴⁷

Inner resources are defined as having a sense of personal empowerment and self-worth and are enhanced through the development effective tools for coping, negotiating challenges and engaging in self-care.^2,48,49 These are developed through yoga practice as yoga students are guided to turn within for strength and support and use yoga tools such as breath, attention to body sensations, and active engagement or relaxation of the muscles.^2,12 Published empowerment programs for trauma have been found to decrease symptoms of powerlessness, low self-esteem, interpersonal difficulties, and trauma symptoms, as well as increase self-efficacy.^50,51 Empowerment is associated with the practice of a sense of personal agency and initiative taking or the “ability to see oneself as the primary source of action and initiative in one’s life”.³⁷ As empowerment provides the initiative, self-worth supports the effort.⁵² Yoga has been found to increase self-efficacy among those with trauma including abuse and domestic violence survivors.^12,53–55 The YIS-TIY approach provides individuals in need of empowerment practice a forum in which they can develop their inner resources and the ability to approach yoga and life from the cognitive intention of, “I can” and “I am worth the effort.” The yoga teacher can support the student in his or her efforts in each pose, encourage breath, and embody the dialectic of acceptance and change for the student.¹⁴

Individuals with a history of trauma often experience disconnection from the physical aspect of self- their bodies, physical sensations, breath, and emotions.^{22, 27} It is believed that the body can store traumatic memories.^14,20,27 In some cases, individuals working toward recovery may feel as though trauma is reoccurring in their bodies. Further, it has also been observed that people who have experienced trauma have a tendency to chronically hold their breath or to breathe in a shallow, erratic way, not able to access the experience of breathing freely.³⁴ For some, being aware of and present in the physical body can be extremely challenging – whether sitting, standing, moving, or simply being- the body can be experienced as a source of great strife and pain.²⁰ Following trauma, the body is often experienced as a source of dysregulation. Illustrating the challenge, Emerson & Hopper.⁵⁶ quote a yoga participant, “I have learned that my body is the enemy.” Seeing the path to recovery, the student states, “…but in order for me to live this life now, I must find a way to befriend my body” (p. 36).

As traumatic experiences at their core involve a lack of physical and emotional safety, yoga can be an opportunity to experience the body, feelings, and relationships in a safe manner.^2,15 Intentionally, the YIS-TIY approach is physical. It is the active delivery of a yoga class with the principles for growth delivered during the practice. These include safety, breath, physical presence, and feelings.^1,2,34,42 Cultivating an environment that emphasizes safety allows for yoga students to experiment with being present in their bodies and feeling what they feel ^{.1 20,34}. Next, breath work, similar to practicing yoga postures, can create opportunities for new experiences that are distinct from than those experienced during trauma.^{5,20,34,51,57,58} Breath work is an opportunity to notice the body (rather than attempt to control it), and to make choices as they correspond to what one notices.^{5, 34,58} Further, intentional breathing can activate/deactivate the sympathetic and parasympathetic nervous system (the former to energize, the latter to calm down), which can be useful in intervening in trauma responses, such as dissociation.^{5,12, 34,59}

The last two aspects of physical basics within the YIS-TIY approach are physical presence, or interoception, and experiencing of emotions.²⁰ Following exposure to trauma, some individuals may feel as if they have no sense of an inner self at all. Interoception is paying mindful attention and becoming aware of what is experienced in the body. In paying such attention (i.e., open awareness and monitoring), the goal is not to make meaning out of an experience in one’s body, but rather to simply notice it, as it is right now, and once it is felt, to choose what to do with it, to take action ^.5,15,34. For those who have experienced trauma, feeling a certain way in one or more parts of one’s body may be experienced as dysregulating and unsafe. Yoga practice allows yoga students to gradually and carefully experience feelings so they can feel safe again in their own bodies.^5,34 Learning to tolerate and regulate feelings, rather than avoiding them, can lead to a change in one’s perspective of the self and can also increase affect tolerance, emotion regulation, and overall wellness.^5,12,20,58

Exposure to trauma can lead to a negative neurological cascade that begins with involuntary shifts in the brain toward survival mode in which attempts to manage the experience evolve into a protracted preoccupation with threat detection and survival ^.25. Living in survival mode can overwhelm the system with a high allostatic load (i.e., wear and tear on the body associate with managing chronic stress), increasing risk for physical and psychological illness and chronic dysregulation of the nervous system.^2,25 Specifically, a persistent survival orientation compromises three key self-regulating centers of the brain (a) reward/motivation system, (b) distress tolerance system, and (c) executive system involved in emotion and information processing.²⁵ The experience of trauma is often characterized by an extreme lack of choice.^10,20,34 Those suffering from trauma effects often experience the survival orientation as if they have no choice to live another way.^2,34

Self-regulation involves the ability to develop competencies to negotiate stress, regulate the states of the body, as well as one’s relationship to the physical and interpersonal environment.^5,25 For example, students in a trauma-sensitive program reported being able to feel calm in stressful situations as a result of their yoga practice.¹² It is theorized that yoga practice may help cultivate self-regulation via the development of the neurological circuits that integrate emotion awareness, cognitive control over the physiological stress response, and contextual cognitive processes.³ Accordingly, the YIS-TIY approach emphasizes the development of self-regulation through the principles and practices of grounding (i.e., utilizing the body as a source for connection, guidance, and coping), choice (i.e., engage in intentional action that serve one’s present moment safety and longer term goals), ownership (i.e., taking responsibility for the creating the conditions in which one can be safe and grow), and sustainability.

In grounding, the goal is to practice experiencing the body as being a safe place and effective source of connection, guidance and self-regulation.^2,5,12,34,58 Going beyond interoceptive awareness, practicing yoga targets the neurocognitive processes affected by trauma by replacing experiences of feeling overwhelmed in one’s body with a present moment and somatic focal point that may be experienced as safe.²¹ The body shifts from being the holder of stress and trauma memories to a source of information, guidance, calm, and connection with others.^1,2,12,25,34 Next, self-regulation involves choice.²⁵  This requires a necessary shift from either being passive (i.e., unresponsive) or reactive (i.e., automatic response tendency) to findings and selecting an intention plan of action.^12,15,25,58 The YIS-TIY approach provides students with non-trauma somatic experiences and the opportunity to recognize that they have choice ^.57. In practicing yoga, one may practice making choices that are within one’s control and that are kind and caring toward the self, achieved through making minute and manageable choices in relation to one’s body and in response to internal sates, through the practice.⁵⁶

The YIS-TIY approach emphasizes an individual’s personal agency, or ownership of their experience as they create the present moment conditions for safety and growth in each yoga pose, through breath work, and within relationships.^2,56 For example, in one yoga-based study, participants who had experienced trauma noted that feeling empowered and in control of their process, such as choosing to participate or decline participating, made a yoga program helpful to them.⁵⁸ Within the structured framework of a yoga class, yoga students can begin to experiment with what is familiar and unfamiliar as well as what is comfortable and uncomfortable, knowing they have choice and ownership and can take appropriate action to fit their needs as experienced in their bodies, in the present moment.^10,12,15,56 Ownership of effective action, as it may be taken in this moment, is a choice that the yoga student can make that allows them to feel better physically and empowered psychologically.¹⁵ Finally, sustainability involves the ongoing awareness of the need to balance routine, structure, and rest with change, growth, and recovery.² Dick et al.¹⁵ refer to this combining “ease and edge” (p. 1174).

Mindful grit is a new concept that refers to the combination of compassion for self and others and the pursuit of meaning and possibility in life.² Within the YIS-TIY approach, this is comprised of the principles and practices of compassion and self-determination. Supported by research exploring yoga and these constructs, the YIS-TIY approach emphasizes goal setting as well as fostering feelings of care and kindness toward oneself, a nonjudgmental and accepting attitude toward perceived inadequacies and failures, and an appreciation of the greater collective human experience of suffering.^{2,15,12, 60} Next, self-determination emphasizes that each individual’s experience is as valid as another’s, and no one person is imposing his or her experience or perspective on someone else’s.³⁴ Further, what is learned through this practice can translate to a greater understanding, acceptance, and trust in one’s self.⁵⁶ Ultimately, as stated by a yoga student with PTSD, “…it seems like more things are possible”.⁵⁸

The YIS-TIY program is based on the current body of literature on yoga and trauma. The YIS-YIY program’s embodied cognitive-relational framework and 12 principles and practices can be used as guidance for yoga teachers working in high-risk locations and classes that may include vulnerable and trauma-exposed individuals. Currently, The YIS-TIY approach is being field tested in Kenya and Somalia among individual at-risk for trauma related to civil unrest, war, and poverty in a study titled, The Africa Yoga Project Mind and Body Wellbeing Program (Cook-Cottone & Guyker, manuscript in preparation). Preliminary analyses indicate a reduction in symptoms associated with trauma and increases in measures of wellbeing (Cook-Cottone & Guyker, manuscript in preparation). The YIS-TIY approach is also being implemented across Western New York as part free community yoga program for those who do not have access to yoga due to geographic location and poverty.^61&1ndash;64

Yoga students are encouraged to attend 2 to 3 yoga classes per week to receive a sufficient dosage of yoga to affect change. It is also of value for yoga teachers have a clear sense of the role of the yoga teacher (i.e., to deliver the YIS-TIY program), and the role of community mental health professionals (i.e., to create and support those with mental health conditions such as substance abuse, anxiety, PTSD, and depression). Further, YIS-TIY yoga teachers have referral resources for yoga students looking for additional support through counseling or trauma-services and enthusiastically share these resources with yoga students in need. Future directions include publication of the feasibility and acceptability studies (i.e., Cook-Cottone & Guyker, manuscript preparation), which includes a controlled trial comparing yoga student outcomes of students taking classes taught by teachers trained in the YIS-TIY approach and those who were not.

None.

The authors declare that there are no conflicts of interest.

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