Trauma Center Trauma Sensitive Yoga Intervention (TCTSY). Improving Conditions for Incarcerated Women in Latin America

Introduction

Latin American prisons rank among the most violent globally, a condition exacerbated by the COVID-19 pandemic. ¹ The pandemic had a devastating impact on these already strained institutions, which were grappling with mass incarceration, overcrowding, violence, and inadequate access to essential services such as healthcare and rehabilitation programs. ² In most Latin American countries, prisoners heavily rely on family and friends for food, medicines, and clothing. The lockdowns and suspension of visits during the pandemic significantly worsened the psychological, emotional, and physical conditions of inmates. ²

Chile exemplifies these challenges, ranking as the second Latin American country with the highest number of COVID-19 cases and deaths in prisons. ³ With one of the highest prison population rates in Latin America, Chile's incarceration rate is more than double the worldwide and South American average, ⁴ and actual prison occupancy exceeds 100%.^3,5 Chilean prisons suffer from severe deficiencies in infrastructure, healthcare, and living conditions, including a shortage of adequate beds, electrical problems, lack of ventilation, humidity, poor hygiene, inadequate medical care, violence, and mental health issues. ⁶

Despite these poor conditions, the population of incarcerated women in Chile has grown significantly, increasing by 53% in the 21st century, ⁷ with a rate twice as high as the global average. ⁸ This surge is attributed to punitive anti-crime policies that heighten incarceration rates and extend prison sentences, leading to overcrowding, violence, and recidivism. ⁹ The overuse of pretrial detention has also contributed to the increase in women's incarceration, with many women in Latin American countries languishing in prison for months or years before their trials. ¹⁰

Incarcerated women typically come from the most disadvantaged sectors of society, often experiencing extreme poverty, limited education, and informal employment. These conditions imply low income and a lack of social benefits. Most female prisoners are the sole or primary caregivers of young children and other dependents. Latin America, one of the most unequal and violent regions in the world, has high rates of violence against women and imposes harsher punishments on female prisoners. Latina women are expected to conform to traditional roles as good wives and mothers, and failure to meet these expectations results in dual punishment by both the legal system and society.^11–13

The negative impacts of incarceration on women are profound, particularly in the contexts of motherhood, homelessness, and employment. Many women are detained far from home, affecting family and child visitation. ¹⁴ Female prisoners are five times more likely to experience mental health difficulties than women in the general population, including anxiety, depression, stress, grief, trauma, and suicide attempts.^15,16 Approximately 30% of female prisoners engage in self-harming behaviors and are up to 20 times more likely to commit suicide compared to the general population. ¹⁴ A recent study on female prisoners in Chile revealed that stress and loss of autonomy negatively affected their mental well-being, exacerbated by the lack of safe friendships and limited contact with family. ⁸

Mental health issues in female prisoners are more severe than in male prisoners, with higher rates of psychosis, depression, and PTSD. Female prisoners report a PTSD rate of 21.1% compared to 6.2% in male prisoners, strongly correlated with previous maltreatment and adverse childhood experiences. ² Over 50% of female prisoners report exposure to traumatic events, including physical and/or sexual violence, and 21.8% reported experiencing sexual violence in childhood, a significant trigger for mental health disorders. ¹⁶ Research indicates that women who attempt suicide are more likely to have lower education levels, substance abuse issues, victimization histories, and higher levels of mental distress. ¹⁷

This evidence underscores significant differences in demographic characteristics, health status, and types of criminal behavior between female and male prisoners. It is crucial to consider gender-specific symptoms and mental health needs when proposing interventions for the prison population. Addressing the specific needs of female prisoners is essential, given the evident disparities in their experiences and mental health challenges. To approach these significant mental health challenges, we propose the implementation of Trauma Center Trauma Sensitive Yoga (TCTSY) as a therapeutic intervention for incarcerated women. Considering its effectiveness, the feasibility of implementation in reduced spaces and crowded populations, application to different types of bodies and capacities, and low-cost implementation.

Trauma sensitive yoga: an interoceptive tool for mental health and well-being

Recently, some countries have adopted more positive criminology. ¹⁸ This approach goes beyond punishment, emphasizing attitudes such as acceptance, compassion, hope, and spirituality, which help the person renounce the behaviors that led to imprisonment. ¹⁹ Among these programs, yoga has become popular in many correctional institutions as a complementary rehabilitation tool offered to prison inmates. Yoga is a holistic health discipline designed to bring balance in all individual dimensions and is recognized as a form of mind-body medicine.^20,21 Previous studies have shown that yoga improves mood, stress, impulse control, antisocial behavior, and aggression,^22,23 helping with somatization and social interactions and decreasing depression, anxiety, and obsession. ²⁴ Moreover, yoga helps to reduce symptoms in prisoners with depression and PTSD^19,23,25,26 especially prevalent in women.^27,28

Additionally, Yoga leads to neurobiological changes related to the sympathetic and parasympathetic functions of the Autonomic Nervous System (ANS), as well as to the regulation of the hypothalamus-pituitary-adrenal (HPA) axis.^29,30 Regular yoga exercise can reduce the levels of cortisol and catecholamines (adrenaline and noradrenaline), increasing serotonin, melatonin, brain-derived neurotrophic factor (BDNF), and gamma-aminobutyric acid (GABA), which are key for the regulation of mental health. ²⁸ Reductions in sympathetic activity, such as heart rate, are associated with improved self-esteem and mental and emotional states, as well as with better memory and concentration capacities, ³¹ better sleep, and reduced aggression. ³²

Functional studies have also reported differences in insula activation or connectivity in yoga practitioners.^33–37 The insula is critical for interoceptive body awareness (IA), which involves sensing internal body states (e.g., increased heart rate, sweaty skin) and plays a role in empathy and potentially metacognition.^38,39 It is engaged during meditation, postural changes, and slow breathing. ⁴⁰

Studies have shown that higher IA, linked to effective stress coping, is often lacking in individuals with depression. ⁴¹ Yoga may enhance functional connectivity between the insula and regions involved in affective and sensory processing, such as the prefrontal cortex, potentially increasing gray matter density in the insular cortex. A recent review concluded that Yoga has produced structural and functional changes in brain regions associated with interoception, posture, motivation, and higher executive functions. The most consistent structural changes were found in the hippocampus and insular cortex, while functional studies primarily noted increased activity in frontal areas related to executive function and attention. ⁴²

Both Yoga and Trauma-Sensitive Yoga (TCTSY) are considered interoception-based interventions. TCTSY, in particular, has been applied to various psychological disorders, with a strong focus on those related to PTSD.^43–45 TCTSY is a mind-body therapy emphasizing IA and empowering individuals to perform conscious actions that promote well-being. ⁴⁶ It has also been called Trauma Center, Trauma-Sensitive Yoga (TCTSY), and it helps trauma survivors feel safer and less vulnerable during practice. The TCTSY adaptations involve changes to the environment, exercises, teacher qualities, avoiding physical assistance for proper anatomical alignment, and the language typically used in Western yoga classes is adapted to change power dynamics during the session.^47,48

Research suggests that increasing IA may be a key mechanism behind the beneficial effects of yoga and TCTSY. This awareness is often impaired in individuals with chronic stress, trauma exposition, and PTSD.^{44,45,49–51} Difficulties in recognizing and interpreting bodily sensations, emotions, and physical states are believed to impair individuals’ ability to manage PTSD symptoms. ⁵¹ IA has also been linked to the development and persistence of various mental health issues, including stress, anxiety, suicidal ideation, depression, and chronic pain. Avoiding uncomfortable bodily sensations and lacking trust in bodily signals specifically exacerbate symptoms across these conditions.^52,53

Recent studies provided evidence that a yoga-based intervention improved IA and reduced symptom severity in populations with exposure to trauma, chronic stress, and PTSD.^43,45,47 Furthermore, findings suggest that it enhances mental health through psychological, physiological, and neurobiological processes, likely by reducing stress reactivity, ⁵⁴ and may have a positive impact on reducing symptoms of anxiety, depression, and psychological distress in women who have experienced traumatic events. ⁴³ Enhancing IA can also potentially improve social cognition, such as empathy,^55,56 and may serve as a protective factor against recidivism. ⁵⁷

Some TCTSY programs implemented in prisons have demonstrated significant physiological and psychological benefits.^58–60 These benefits include reductions in negative emotional states, anxiety, phobic anxiety, paranoid thoughts, interpersonal sensitivity, hostility, and overall psychological distress. Additionally, TCTSY interventions in forensic psychiatry settings have proven feasible and have resulted in several positive patient health outcomes. ⁵⁸

Key factors influencing the relapse of inmates include mental health and violence, making these areas crucial for focus in correctional institutions. Typically, prison environments address physical needs while neglecting higher-order mental, spiritual, relational, and connectedness needs. ⁶¹ This commentary aims to highlight the potential positive impact of TSY on the mental health and recovery of female prisoners. By emphasizing these benefits, the goal is to advocate for implementing TSY programs in female prisons across Latin America.

Discussion

We are currently in an era of mass incarceration, with a significant and growing increase in the imprisonment of women. Internationally, it is acknowledged that women in prison are highly vulnerable, often suffering from mental health issues such as substance misuse and PTSD. ⁶² In Latin America, governmental policies and penal systems tend to favor increased incarceration with longer sentences, which exacerbates pressure on these institutions and heightens violence within them.^63,64

Stigma and oppression are constant aspects of life for incarcerated women. Once imprisoned, they often endure a range of punishments (in addition to those received outside prison), including losing multiple aspects of their identity, ceasing to be recognized as mothers, daughters, or feminine, which compromises their sense of self and autonomy; also being placed in unsuitable environments and receiving inadequate treatment. ¹² Research and health approaches to mental health prevention and treatment interventions within prisons remain limited. Incarcerated women, who often face high rates of trauma-related experiences and mental illness, may particularly benefit from trauma-sensitive approaches. Likewise, it highlights the importance of bottom-up approaches, i.e., working from the body to stimulate subcortical brain areas that are affected by the trauma and that traditional psychological treatments cannot influence, except for controlled medication, which often does not help to address the cause of the PTSD, but only the symptoms.

TCTSY has demonstrated promise in alleviating PTSD symptoms in women who have experienced chronic stress and trauma.^65–67 TCTSY, as an interoceptive tool that might increase interoceptive awareness (IA), has the potential to improve mental health, social cognition, and well-being.^43,47,54 The involvement of interoceptive mechanisms in traumatic stress further underscores the importance of addressing these aspects, highlighting the potential benefits of TCTSY for women in prison.

Previous studies have shown that female prisoners are better organized, exhibit higher self-acceptance and awareness of mistakes, and demonstrate greater spirituality, resilience, and planning skills than their male counterparts. ⁶⁸ They also tend to develop more profound and more lasting bonds, are less violent, and are more responsive to prison programs, though they generally have fewer opportunities to participate.^69,70

Given the above, the authors of this commentary consider that TCTSY is a suitable option for female prisoners suffering from high levels of PTSD. TCTSY is easy to implement, cost-effective, and offers long-lasting positive outcomes beyond the physiological.

Controlled trial studies that describe quantifiable outcomes in female prisoners in Latin America are scarce. Therefore, future research must address and improve this population's mental health and prosocial behavior.