A Yoga Intervention Program for Patients Suffering from Symptoms of Posttraumatic Stress Disorder: A Qualitative Descriptive Study

Abstract

Objective:

To understand how individuals with symptoms of posttraumatic stress disorder (PTSD) perceive a trauma-sensitive Kundalini yoga (KY) program.

Methods:

Digitally recorded telephone interviews 30–60 minutes in duration were conducted with 40 individuals with PTSD participating in an 8-week KY treatment program. Interviews were transcribed verbatim and analyzed using qualitative thematic analysis techniques.

Results:

Qualitative analysis identifies three major themes: self-observed changes, new awareness, and the yoga program itself. Findings suggest that participants noted changes in areas of health and well-being, lifestyle, psychosocial integration, and perceptions of self in relation to the world. Presented are practical suggestions for trauma-related programming.

Conclusion:

There is a need to consider alternative and potentially empowering approaches to trauma treatment. Yoga-related self-care or self-management strategies are widely accessible, are empowering, and may address the mind–body elements of PTSD.

Introduction

Posttraumatic stress disorder (PTSD) is a significant health issue resulting from exposure to traumatic events. Prior traumas are often re-experienced in the present with accompanying psychological and physiological distress. These can manifest as intrusive and distressing recollections of the original event, sleep disturbances, flashbacks or hallucinations, distress, and reactivity when exposed to triggering cues of the original trauma.¹

Prevalent interventions for PTSD include cognitive behavioral therapy and prolonged exposure treatments. Outcomes of some verbal therapies are favorable,² but many clinicians hesitate to use exposure therapies concerned that patient symptoms will worsen, resulting in treatment attrition.³ Some early exposure therapies are contraindicated for trauma survivors at the onset of therapy as they may awaken implicit memories or trauma-related bodily sensations, thereby retraumatizing the individual rather than resolving the trauma.⁴ While exposure treatment can be beneficial in reducing PTSD symptoms, studies generally find that this reduction is not associated with overall improvement in social, health, and occupational functioning.⁵ There has been increased interest in complementary treatments for PTSD that consider the relationship between mind and body.

Yoga is a comprehensive system of practices for physical/psychological health and well-being. Brown et al.⁶ suggest that mind–body interventions benefit both mental and physical stress-related disorders. Positive effects of yoga in patients with stress-related conditions in primary healthcare are demonstrated.^7,8 Studies further substantiate the efficacy of yoga as a primary or adjunctive treatment for a number of psychiatric disorders.^9
–11 Participants in the present study were intervention group and wait-list control participants suffering from PTSD symptoms in our Kundalini yoga (KY) & PTSD randomized control trial (RCT), in which 80 participants were randomized to either a KY PTSD intervention group (n=59) or wait-list control (n=21). Both groups demonstrated changes, but the yoga group showed greater symptom reduction.¹²

While mind–body practices may offer vast benefits for PTSD, few studies explore the qualitative perceptions of those participating in yoga treatment.^8,13,14 To our knowledge, no studies have investigated the experiences of yoga treatment for patients suffering from PTSD. Rather than evaluating the effectiveness of yoga, the primary objective of the current study was to understand the experiences of participants with PTSD symptoms partaking in trauma-sensitive KY treatment.

Methods

The University of Toronto Office of Research Ethics (protocol reference #26992) approved the study procedures. Informed consent was obtained at program onset. Scheduling conflicts and medical reasons were primary causes of participant dropout. The RCT was conducted between March and August 2012 at the University of Toronto. Interviews were completed within 1 week following conclusion of the RCT. All 40 participants who completed the 8-week KY program were invited to participate in telephone interviews.

Eligibility criteria

Individuals not residing in a treatment facility with self-perceived symptoms of PTSD were recruited for study participation via (1) postering in public locations in the Greater Toronto area (GTA), (2) an online bulletin for patients at the Centre for Addiction and Mental Health (CAMH), and (3) advertisements at social services agencies in the GTA.

Participants able to commit to an 8-week yoga program were scheduled for a telephone screening to assess preliminary entry criteria. Demographic information was collected and is presented in Table 1.

Table 1.

Characteristics of Subjects

Characteristic	Total, n=40
Sex
Male	9
Female	31
Age (range in years)	18–63
Median age (years)	44
Type of trauma
Sexual abuse (including childhood sexual abuse)	11
Physical trauma (e.g., illness, motor vehicle accidents)	8
Emotional abuse	13
Compassion fatigue (e.g., vicarious trauma, secondary trauma)	4
Adverse life circumstances (e.g., employment, relationships)	4
Medication
Antipsychotics	3
Mood stabilizers	2
Benzodiazepines	7
Total	12
No medication	28
Education
Less than high school	2
Undergraduate/college	33
Postgraduate	5
Employment status
Unemployed/retired	16
Part time	17
Full time	7

Qualifying participants met in person with a researcher (F.J.) to determine PTSD eligibility using the Post-Traumatic Stress Disorder Checklist (PCL-17). Participants with a PCL-17 score under 57, a current yoga/meditation practice, inability to abstain from substance consumption 24 hours before class, or those at safety risk were ineligible.

Participants were randomly assigned to either the experimental (yoga) or the waitlist control group. Waitlist control participants were offered KY participation after the 8-week waiting period, and the responses of both groups after yoga participation are included in present study analysis. Participants were 18 years or older and fluent in English. Interviews were conducted within one week of study completion.

Intervention

The lead researcher, a psychologist working with war veterans, a war veteran, and KY yoga teachers designed the intervention. Seven yoga groups were conducted and taught by three female KY teachers. Two of the instructors each taught one class and the third teacher taught five classes. The style of yoga was consistent with KY, a form of yoga that emphasizes integration of the endocrine and nervous systems and includes breathing, physical postures, and meditation. The program was designed using guidelines for trauma-sensitive yoga,¹⁵ inviting participants to try poses with ample modifications and focusing on mind–body awareness, safety, and nonjudgment.

The intervention consisted of weekly 90-minute group practice sessions over the course of the 8-week program. Groups ranged in size from 3 to 8 participants. Participants practiced warm-up exercises, postures, relaxation, breathing techniques, and meditation. The practice sessions consisted of yogic mind–body techniques of increasing rigor, dedicated to cultivating self-efficacy, self-awareness, and relaxation skills. A 15-minute home practice was assigned to the participants. The home practice consisted of three KY meditations with designated breathwork, mantra, mudra, and postures.

The program was designed to begin with short postures and meditation. To enable capacity for self-mastery, length of time for postures, meditations, and relaxation increased throughout the program. The protocol is available by request.

Interview approach

All participants who completed the yoga program took part in a semistructured, audio-recorded telephone interview. Participants were invited to discuss the yoga program in which they had participated. The average length of interviews was 30 minutes.

The semistructured interview guide included the following:

1. What are your overall thoughts/feelings about the yoga classes?

2. Describe your general feelings of well-being at this point in your life.

3. How do you perceive your stress in relation to your stress 8 weeks ago?

4. Have you noticed any shifts in relation to your thoughts, feelings, emotions, behaviors, etc., over the course of the program?

5. What have been your recent experiences of feeling down, anxious, angry, anxiety, and problems sleeping?

6. Did you learn any techniques/ways to calm yourself when feeling overwhelmed?

7. Were you able to maintain the home practice?

8. Were you participating in any other form of treatment/therapy over the last 8 weeks?

9. Is there any additional support that I can provide you at this point/resources?

10. Do you have any recommendations/final thoughts?

Methods of analysis for qualitative data

Qualitative thematic analysis is well accepted for yielding useful information for policy makers and healthcare practitioners regarding topics about which little is known.¹⁶ This approach also allows for the emergence of new themes and was deemed the most appropriate analytical approach.

Data collection and analysis was carried out in an iterative manner by the principal investigator (F.J.). Forty interviews were transcribed and the accuracy of the transcripts was verified. Inductive thematic analysis described by Braun and Clark¹⁷ was utilized to understand participant perceptions of the yoga program. The transcribed data were read and re-read, and the recordings were listened to several times to ensure transcription accuracy. This process of “repeated reading”¹⁸ and using audio recordings of the data promotes data immersion and researcher closeness with the data.

Using Nvivo10 (QSR International, 2010) software, interview transcripts were initially coded, giving full attention to all data. Codes, categories, themes, and outlier data were identified in this process. The initial coding phase resulted in the emergence of over 300 codes from the data. Following the extensive exploratory coding process, three final and purposeful distillation processes occurred. The original 300 codes were reduced to 12 major codes. Codes were clustered into groups or categories (i.e., codes that shared similar meanings) with predominant themes identified as indicated in Figure 1. Emerging themes were analyzed and grouped together according to similar motifs. A coding framework was developed and subsequently used to code all transcripts.

FIG. 1.

Methods of analysis for qualitative data.

Results

Sample characteristics

A total of 40 interviews were conducted. Characteristics of participating individuals are reported in Table 1.

Themes

Analysis of interviews reveals three themes of interest shared by all participants: (1) self-observed changes, (2) new awareness, and (3) the yoga program. These themes include subthemes that were identified during the data analysis.

Self-observed changes

Consideration of linkages between associated themes of mental, physical, and social awareness as noted by participants allows for an understanding of the overall dynamic of personal transformation in this program. Data reveal that participants experienced life changes that included (1) changes in the mind–body relationship, (2) emotional changes, (3) changes in their capacity for self-reflection, (4) cognitive changes, (5) action-behavioral changes, and (6) psychosocial changes. Representative participant quotes may be found in Table 2.

Table 2.

Representative Quotes from Self-Observed Changes Themes

Mind–body relationship (Participant #13)	“In the past, I was consumed by emotions. With yoga, I could breathe and link my body and mind. I could feel my legs shaking at times, my arms aching. For the first time, I could sense my breath. I noticed that with this yoga, overall, I felt better afterwards. Everywhere in me…my mind and body.”
Emotional (Participant #10)	“I would say my biggest benefit has been that I am more emotionally balanced. Often after class, I would feel really strong and balanced and really, really alert, but like deep calm. I would be able to return to that feeling the days I wasn't in class.”
Self-reflection (Participant #11)	“Emotional shifts were coming from the practice. I would have emotional patterns come up especially like kind of the middle point of the class. I would be more aware and could then think more clearly how best to respond. When I would do that I'd feel really peaceful after and just be able to work with my emotions and experiences in a healthier way.”
Cognitive (Participant #04)	“There are certain practices and techniques that make total sense. That in itself has stopped a lot of my negative thought loops.”
Action/behavioral (Participant #36)	“When things happen, you know I get really annoyed and aggravated, I would walk away and get away from the situation. But now I would say ‘Oh, that is really annoying.’ I would verbalize it, to try to change and improve the situation. It's definitely a lot better, but like I said, sometimes I wonder, ‘Is this me?’ So it's kind of strange and it's amusing. I am finding myself kind of like…laughing at my behavior because it's just so different from where I was a few months ago.”
Psychosocial (Participant #33)	“I feel stronger…also more, gentle…just a lot more hope. A lot of my…thinking was very…stunted. This was very empowering. I do not feel so small anymore. It brought me a long way…a lot more positive behaviors and helped me to be more independent and less needy.”

Mind–body relationship

Across 39 of the 40 interviews, participants reported that the physical practice of yoga supported an intimate mind–body connection that for many was a very new experience. Rather than feeling consumed by emotions, participants stated learning ways to connect emotions and feelings within mind and body (i.e., feeling anxiety within stomach) and then choosing a healthy response. Study participants discussed additional subthemes of (i) physical exercise, (ii) clarity/cleansing, (iii) breath, (iv) relaxation, (v) body awareness, (vi) diet, (vii) sleep, and (viii) energy.

Emotional

All participants noted changes in mood (n=40). Descriptions of life stressors and changing responses were reported. Participants associated emotional regulation shifts with feelings of enhanced wellness (i.e., calmness, stability, hope, and balance) and confidence.

Self-reflection

Heightened awareness of body, mind, and emotions was related to developing new habits of self-reflection. Several participants noted the ability to sit with emotions and act with awareness, behaviors that had been challenging to achieve in the past. The ability to respond nonreactively by first becoming aware of thoughts and feelings was a new experience for the majority of participants.

Cognitive

The implementation of self-reflection strategies was related to mindfulness and present moment awareness. Toward the end of the program, 30 participants reported greater control of thought patterns and mental clarity. When a disturbing thought arose in the present, participants reported becoming aware and labeling it as a “thought” and breathing deeply to gain present moment control.

Action/behavioral

Thirty-seven participants expressed generally positive behaviors at program completion, attributing changes to emotional well-being and self-perception. Some participants were making lifestyle changes that included career transitions, communicating in new and productive ways, and dealing explicitly with challenging situations as they arose. Participants expressed surprise and awe at their own positive feelings and behaviors.

Psychosocial

Another theme related to the category of self-observed changes and overlapping with the mind–body dimension includes participants' experiences of psychosocial changes. This theme included subthemes of confidence/self-esteem, self-care, openness to new experience, motivation/determination, resilience, and feeling better about themselves.

New awareness

Data reveal that program participation was associated with new perceptions of life experiences and these life views had changed since program start. New awareness subthemes are defined as those related to (a) prior trauma perceptions, (b) medical stigmatization, and (c) spirituality. Representative participant quotes may be found in Table 3.

Table 3.

Representative Quotes from New Awareness Theme

Perceptions of prior trauma (Participant #19)	“I've had all this really, really deep opportunity for learning and it's kind of come full circle, to me being able to identify the lessons and feel more at peace with it. Like some of it's really old stuff that I've been you know, kind of identifying for years and now, now the way I feel is part of my experiences is just like, ‘Wow, okay so I had this really, really deep opportunity for growth.’ Like, okay, this actually needed to happen that way for me to be able to kind of come to this process and understand myself more deeply.”
Medical interventions (Participant #2)	“Psychotherapy is very emotionally taxing because you have to rehash and rehash and bring it up again, the trauma. I stopped going to a psychotherapist because I did not want to talk about things anymore, and that's what I liked about this because I did not have to talk about those things 'cause that can get exhausting! And it re-traumatizes. In this, you didn't have to rehash the story.”
Spirituality (Participant #11)	“With yoga, I had a connection of mind, body, and spirit. During the practice and when you become aware of those three things, or be aware of them, it seems like things are more possible. I had more peace, the idea of finding increased peace of mind. I mean what could be richer than a sense of you know a spirit; my spiritual self.”

Perceptions of prior trauma

Participants shared that they were identifying new ways to relate to their prior traumatic experiences that included self-compassion, attending to health needs, and learning to not blame themselves for negative life circumstances. For some, traumatic life experiences were viewed as opportunities for growth and development of purpose. Reports of forgiveness of others were noted.

Medical interventions

Participants spoke about how labels of PTSD were stigmatizing leading to negative views of self. The yoga program offered an opportunity to recover in an empowering manner.

Spirituality

A new relationship with self and prior traumas led to new awareness of spirituality as an empowering process. Some stated feeling a connection to a higher self and many expressed that, in light of all that had been experienced, they were extremely grateful to be alive. This realization was profoundly empowering.

Perceptions of the yoga program

Participants provided an understanding of valued aspects of the program by discussing subthemes of (a) program development, (b) home practice, and (c) group support. Representative participant quotes may be found in Table 4.

Table 4.

Representative Quotes from Yoga Program Theme

The program (Participant #4)	“I was really pleased with the way everything was structured; I thought it was very simple and well laid out. I felt really well supported through the program. It was a really beautiful experience to do intentional work as part of a study, because we did have the questions at the beginning and then in the middle and then in the end, so it was really neat to have this reference throughout.”
Home practice (Participant #22)	“At the end of the home practice, the feeling that I actually get when I let myself do them…is really powerful. Part of it was just spending ten minutes of your day by being really present by, you know, doing something you focus on. I think of the brain like any other muscle and it is practicing something again and that's part of it. It's like mental hygiene. I was able to do the exercises, like sometimes I was just doing them, but I think it kind of improved my self-esteem overall you know quite consistently. I did them every day for a month at least, I kept doing it, I found it very helpful. I felt more energy, I felt better and it helps center me, you know, it really did. I think these exercises are helping on a physical level as well as on emotional level.”
Group support (Participant #26)	“There was really incredible value of going through that process with the group and having the opportunity to hear other peoples experiences of what it is that comes up and where they were experiencing shifts and changes. It was therapeutic to be in a class, of people who I knew and we knew about each other very little, except that we all survived trauma and we were all committed to being in this class.”

Program development

Participants stated that they found the yoga program to be helpful and effective for their recovery. This theme was discussed in all 40 interviews and was the third most frequent theme. Participants shared that physically, emotionally, mentally, and spiritually, they were feeling more connected to themselves and the world, expressing that strategies had been learnt in the program that they could practically implement in their lives.

Home practice

Thirty-seven of 40 interviewees discussed the home practice theme. Overall, participants stated that the home practice was critical to the yoga program. It was expressed that while initially a challenge to discipline oneself, the consistency, structure, and routine of having a self-healing practice that could be done anytime were vital to feelings of self-improvement and well-being.

Group support

Thirty-five of 40 participants discussed aspects of group support extending to teacher connection, group relationships, and overall programmatic support. Shared feelings of strong connectedness, openness, and transparency within the group fostered a sense of security for the majority of program participants.

Discussion

In exploring treatment options for PTSD, it is important to understand the perceptions of program recipients. This study assesses the experiences of participants suffering from PTSD symptoms involved in a trauma-sensitive yoga program. The qualitative analysis revealed three themes with subthemes. A summary of aspects of the yoga program in relation to self-care strategies for trauma programming is presented in Table 5.

Table 5.

Summary of Identified Yoga Benefits, Corresponding Self-Management/Care Components, and Implementation Considerations for Posttraumatic Stress Program

Identified benefits of yoga program	Suggested self-management/self-care program components/modules	Implementation considerations
Teacher/facilitator support	Empathic	Adequate trauma training
	Encouraging and empowering	Mind–body knowledge
		Compassionate
Group support and feedback	Peer support component	Peer matching based on demographics and clinical characteristics/mentorship model
Program logistics and organization	Clear vision and programmatic goals	Structure and continuity between sessions and instructors/facilitators
Empowerment/positive outlook and acceptance	Focus on strengths of participants with PTSD, self-efficacy	Focus on resilience and traumatic growth rather than trauma narrative
Physical exercise	Mindful breathing and movement	Focus on movement and breath, mind–body awareness, relaxation
Breathing techniques	Focus on various breath practices	Slow deep breathing/specific breathing practices for PTSD
Accessibility	Creation of funding models for integrative therapies and physical spaces to support them	Health system factors (funding, space accessibility, safety, etc.) optimized for individuals with PTSD

PTSD, posttraumatic stress disorder.

Anxiety and emotional overwhelm associated with PTSD lends to difficulty attuning to the body. At program outset, participants expressed high amounts of stress and inability to cope with situations of daily life. Awareness of breath and body attunement may be skills learned that supported feeling reduced stress at program completion.

Yoga practice allowed those with PTSD symptoms to learn strategies to slow down, attune to mind and body, become aware of thought patterns, and regulate emotions. Application of strategies learned in the program resulted in skills of self-mastery and internal locus of control. Yoga self-care strategies were reported to be empowering, accessible, and healing. Findings substantiate prior literature suggesting that successful environmental adaptation and feelings of self-efficacy require understanding of self, and emotions as well as adequate coping skills.^19,20

As helplessness is a defining emotion experienced during and after an original traumatic event, the yoga teachers made an effort to help participants feel empowered and in control of their own healing. Participants, in turn, said that they found the program to be helpful because, while the yoga teachers instructed them to try their best, they always felt in control of their bodies and felt safe to participate or decline from participating. This finding is important in trauma programming because self-mastery and locus of control are crucial for the re-learning of responses and behaviors and to develop comfort with the body.

As individuals presenting PTSD symptoms are generally isolated due to physiological and emotional struggles, an opportunity to belong to a group and feel socially supported by others is also crucial for PTSD treatment. Participants expressed that, while the group did not process traumatic experiences verbally, their involvement allowed for feelings of normalcy, peer support, and commitment to both one's own growth and the healing of the group.

Home practice was also vital to the yoga program and emphasizes the importance of repetition, consistency, and self-care for individuals with PTSD symptoms. As a behavior is repeated and practiced, it becomes automatic and is empowering. Those that completed the practices expressed heightened well-being in various facets of life.

Comparison of the findings with other qualitative studies of yoga demonstrates many interesting points of similarity and divergence. One similarity is the increased awareness of the mind–body. Here, as well as in previous studies, yoga supported individuals in developing enhanced awareness of stress-related bodily sensations and strategies to effectively cope.^9,14 Overall participants in yoga treatment report greater self-efficacy and the capacity to regulate symptoms irrespective of health condition. This is demonstrated by a range of recent studies on the effects of yoga for a minority population with lower back pain and stress-related symptoms, as a treatment for smoking cessation among women, and as a treatment to help an elderly population regain balance self-efficacy after a stroke.^21
–23

Where the KY program seems to differ from prior studies was participant formation of new self-reflective habits. Greater self-awareness was often expressed as being related to the meditation component of the program and the regular home practice. Overall, participants also expressed new, empowering awareness in regard to their prior trauma, acceptance, and insight of their trauma treatment and an evolving sense of connectivity or spirituality.

Limitations

The current study acknowledges some limitations. In terms of the recruitment, individuals presenting PTSD symptoms who chose to participate in a yoga intervention may have been healthier and/or had more interest in alternative treatment approaches. Similarly, a certain level of intrinsic motivation was required to complete the yoga program because participants were required to attend 8-week classes and encouraged to participate in a home practice. The small sample size and lack of an active control are also limitations of this preliminary study.

Future research

Trauma-based therapies incorporating the mind and body require further investigation to understand the various physiological processes that are involved in trauma and recovery. Body-based interventions may be a complement for currently existing trauma interventions or could be a precursor to reflective therapies. Debates currently exist in the field of trauma treatment regarding the stage of trauma treatment in which mind–body interventions should be introduced.²⁴ Future studies may focus on determining optimal stages for intervention as well as tracking participants' recovery over the long-term.

Consistent with many intervention-based studies, participants stated that a group-based yoga intervention was highly effective. Future research may investigate aspects of yoga group dynamics to understand improvement related to the intervention and aspects of group participation.

Conclusions

Acquisition of self-care tools was cited as critical for recovery from PTSD symptoms. Trauma treatment programs may consider incorporating mind–body components into treatment programming. This research suggests that yoga may offer self-care skills individuals presenting PTSD symptoms can learn and implement for themselves to manage their symptoms and emotions when under stress. The insights gained from this study may be useful in improving trauma-related service treatment and enhancing the quality of life for individuals presenting symptoms of PTSD.

Footnotes

Acknowledgments

We sincerely thank KY teachers and participants for their valuable contribution to this work.

Author Disclosure Statement

No competing financial interests exist.

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