Research Assignment – Adore Graduate Certificate in Yoga Therapy
Author: Angela Freeman
Question: “Can Yoga Therapy positively impact the symptoms of PTSD in first responders”
PTSD, post-traumatic stress disorder, is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. (American Psychiatric Association (2013).
Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. (American Psychiatric Association (2013)
These symptoms last for more than a month after the event. (American Psychiatric Association (2013) Young children are less likely to show distress, but instead may express their memories through play. (American Psychiatric Association (2013)
Persons suffering from PTSD will have ongoing flashbacks and reoccurring trauma. A person with PTSD is at a higher risk of suicide and intentional self-harm. (Bisson et al. 2015). Someone can suffer a traumatic incident without developing PTSD. (American Psychiatric Association (2013)
It is estimated that 75% of Australian adults have experienced a traumatic event at some point in their life (Productivity Commission estimates using ABS 2009).
While experiences of a traumatic event are common, most people do not go on to develop a mental illness, such as PTSD. According to the National Study of Mental Health and Wellbeing 2020–2022, an estimated 11% of Australians experience PTSD in their life (lifetime prevalence), with women being at almost twice the risk of men (14% and 8%, respectively) (ABS 2022).
Psychological distress increases absenteeism (unexpectedly absent) and presenteeism (present at work but not working) in the workplace (Holden et al. 2011). The 2020 Productivity Commission Inquiry on Mental Health estimated mental ill-health cost Australia between $13 and $17 billion per year. The typical compensation payment per claim for a mental condition was reported to be $25,650 (compared with $10,600 for all other claims) while the typical time off work was 16.2 weeks (compared with 5.7 weeks for all other claims) (Productivity Commission 2020).
There are approximately 400,000 emergency service workers across Australia, including 200,000 volunteers (first responders are 2.7% of the workforce of 14,514,300 as at September 2024) (ABS 2024). Current statistics indicate that 1 in 10 will experience symptoms of post-traumatic stress related to critical incidents (Lawrence et al, 2018).
Cumulative exposure to work-related traumatic events is associated with increased risk of PTSD. This is particularly the case for first responders, such as emergency service workers, where the rates of the disorder may be more likely among long-term employees than new recruits (Phoenix Australia 2013). This finding is also supported by a study of the mental health of current and retired Australian firefighters, where the prevalence of PTSD was more than 2 times higher in retired than current firefighters (18% and 8%, respectively) (Harvey et al. 2016).
Yoga and PTSD:
In 2014 Bessel Van Der Kolk published a study Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. This was the first quality study that showed that yoga positively impacted people with a PTSD diagnosis.
In this study 64 women with chronic treatment resistant PTSD were randomly assigned to either a ten-week trauma aware yoga class or supportive women’s health education. The measure was the Clinician-Administered PTSD Scale (CAPS).
52% of the yoga participants compared to 21% of the control group experienced improvements in their PSTD symptoms, however, whilst both groups exhibited significant decreases in PTSD symptoms during the first half of treatment, these improvements were maintained in the yoga group, while the control group relapsed after its initial improvement. (van der Kolk et al, 2014).
Since this study, an increasing number of studies have been conducted about yoga for PSTD. Given the prevalence of PTSD in first responders, increasing numbers of studies focused on the benefits of yoga for this cohort, and this is the literature that I have focused on.
Literature reviews:
This review examines literature submitted from studies of the effectiveness of yoga and yoga therapy in the treatment and maintenance of symptoms experienced by people suffering from PTSD and trauma, with particular reference to first responders.
The literature used various means to record the effectiveness of the treatment, including saliva testing for cortisol levels and questionnaires answered pre and post intervention.
Study 1: Yoga for Veterans with PTSD: Cognitive functioning, Mental Health and Salivary Cortisol (Zaccari et al, 2020)
Persons suffering PTSD often have impaired cognitive function, indicated by poor memory, language skills and the ability to reason. This study examined the effectiveness of yoga in improving cognitive function, reducing the symptoms of PTSD, and the biological stress response in Veterans diagnosed with PTSD.
Participants were assessed for cognitive function, and salivary cortisol, as well as self-reported on their mental health, two weeks before commencing a ten-week yoga program, then the same testing was repeated afterwards.
Results provided preliminary support for the practice of yoga to improve cognitive functioning (response inhibition) related to symptoms of PTSD while also improving mental health symptoms, sleep, and quality of life. The study noted the improvement in sleep for participants and affirmed the significant role sleep has in affecting mood symptoms.
Study 2 - A Qualitative Study Exploring Yoga in Veterans with PTSD Symptoms (Cushing et al, 2018)
This study examined the potential resistance towards yoga as a therapy for PTSD and the effectiveness of yoga compared to other treatments, particularly drug treatments in reducing the symptoms of PTSD.
Many veterans feel that the current PTSD treatments are not meeting their needs. One reason is that many military service members suffering from PTSD have not had success with conventional treatments. Another reason is that many service members would like to be drug-free and try a self-care practice. Negative stigma also continues to be attached to seeking behavioural healthcare among service members and veterans.
Although only five of the nine participants completed the study the benefits identified by veterans were finding mental stillness, body awareness, and social connection. The effect of mind-body therapies—including seated or gentle yoga that used breath work, meditation, mantra repetition, or breathing exercises—on veterans with PTSD symptoms found these interventions to significantly reduce symptoms.
The barriers were perceptions that yoga is socially unacceptable, especially for men, and physically unchallenging.
Therefore, understanding these benefits and barriers can help to make yoga more attractive to service members and veterans.
Study 3 - Yoga therapy for military personnel and veterans: Qualitative perspectives of yoga students and instructors (Hurst et al 2018)
Instructors and participants alike agreed on the importance of breathing exercises as fundamental to the activation of the body’s relaxation response and ability to control stress. Breathing and seated meditation during yoga were commonly described by students and instructors as important elements allowing for the safe release of stored emotions such as relief from anger, grief, and the rumination of negative traumatic thoughts. Using elements such as breathing, mindfulness, and meditative postures, students cultivated the ability to focus on the present and control feelings or at least understand them as temporal and transient.
It was further stressed that the yoga be presented in a trauma sensitive way: noting preferences to the layout of the room, where the instructor would be sitting, the positioning of mats, and consideration for students who may not want to be touched or manually adjusted during a yoga session.
These features were seen not only as a safety precaution for a trauma-informed class but to increase trust and comfort for the students during their yoga practice.
Many of the students expressed their initial resistance to trying yoga and the disbelief that it would help with their symptoms, believing that yoga was not strenuous enough and required incredible feats of flexibility.
Study 4: Yoga Resilience Training to Prevent the Development of Posttraumatic Stress Disorder in Active-Duty First Responders: A Cluster Randomized Controlled Trial (Tan et al, 2024)
Objective: Evidence on effective prevention of posttraumatic stress disorder (PTSD) is sparse, particularly among first responders. This study evaluated the effectiveness of a Tactical Mind–Body Resilience Training program on PTSD symptoms in first responders.
Method: Active-duty first responders (n=80; Mage= 41.8 years, 82.5% men) were randomized to the intervention group or the waitlist control condition. PTSD symptoms as measured by the PTSD-8 were the primary outcome assessed at postintervention and at 3-month follow-up. Secondary outcomes were cognitive and emotional coping strategies, resilience, somatic symptoms, work performance, and sickness absence.
Results: At postintervention, the intervention group had significantly reduced PTSD symptoms compared to the control group (d=−0.26, difference =−2.52, 95% confidence interval [CI] [−4.93, −0.11], p= .040); however, this difference was attenuated at 3-month follow-up (d =−0.07, difference=−1.41, 95% CI [−3.83, 1.01], p=.248). The intervention group had significant improvements in cognitive reappraisal and resilience at postintervention compared to the control group, which were sustained at 3 months. The remaining secondary outcomes had statistically nonsignificant improvements.
Conclusions: This workplace-delivered intervention shows potential in preventing the development of PTSD in first responders.
Summary of literary reviews:
The studies I reviewed were in the U.S and mostly involving ex-military. I personally would love to see more studies conducted in Australia, to account for cultural and societal differences. And with particular attention to first responders and service personnel.
The common deficiency in the studies is the small number of participants and the lack of control groups (3 of the 4 studies selected) and except for the salivary test most results were measured by a survey of how participants felt, which is less quantifiable.
All the studies mentioned that larger numbers of participants with control groups were required to confirm the effectiveness or not of yoga in the prevention or treatment of PTSD. However, all study results were encouraging as to the benefits of yoga in the prevention and treatment of PTSD and trauma especially in the long-term.
Practicum hours participants – Overview:
Total number of participants: 19
% Females: 84% % Males: 16%
Age Range: 16-81 Average Age: 52
% Acquaintances: 53% % New clients: 47%
% With previous experience in Yoga and or Meditation: 84%
% With a physical issue: 26%
% With a mental health issue: 74%
Practicum hours participants – Results:
One participant withdrew after the initial consult due to family circumstances.
18 completed at least 3-5 sessions.
9 continued sessions either one on one or joined in with group classes.
1 experienced improvements physically *
9 experienced improvements mentally *
9 experienced improvements both mentally & physically *
Results were assessed via a questionnaire completed either at the end of their program or in the last month leading up to the research project being submitted.
10 - number of completed surveys returned.
Not all participants were asked to complete a survey as they were new clients, and sufficient time hadn’t passed to accurately record any results, or it wasn't in their best interests
Practicum hours participants – Summary:
I found that although a participant initially came to me for yoga therapy for a physical ailment, through discussion we realised that their body was reflecting held trauma that they had experienced, often relating to a chronic illness or disease diagnosis that hadn’t been addressed previously with their treatment.
I have also realised that there is a need to present slightly different Trauma aware yoga practises for first responders as opposed to members of the public. First responders generally prefer a more structured and directed approach.
As most of my participants had previous yoga or meditation experience, and already had a positive bias towards yoga, it was interesting that they too were surprised by the improvements in their mental and or physical health.
One participant was amazed that “a few exercises” had such a positive impact on her upper spine and neck, improvements noticed and commented on by her chiropractor.
Several participants recognised that the breathing and “finger touch” technique was particularly helpful in reducing anxiety, enabling them to think clearer and make difficult decisions, one participant used the technique to calm down during a panic attack experienced at work.
I know from the literature review that yoga therapy can benefit people affected by PTSD. I was overwhelmed by the positive results that participants achieved. I am excited about using the tools of yoga to help people manage the symptoms of PTSD and trauma and hopefully the prevention of developing PTSD.
TESTIMONIALS:
“I wasn’t sure what to expect, but after the first consultation I felt listened to and understood. She explained the process and said she would have a 10–15-minute routine for the following session.
The following session she gave me 4 exercises which worked my shoulders cervical, thoracic and lumbar region…… To my surprise I found the exercises released tension in my shoulders and thoracic region and stretched my glutes which helped with lumbar pain.
I am seeing a chiropractor, and she has noticed that difference through out my whole spine, so I told her about the yoga therapy, and she said to keep doing it as she could feel the difference and I have been able to go from weekly, fortnightly, 3 weekly and now monthly sessions.
Angela also gave me some ideas the help with the anxiety that I was getting from the situation I am in. Which was deep breathing and feeling my fingertips. I found this extremely helpful…….
Overall, I have found this experience surprisingly helpful for my backpain and anxiety,……
And helped me live more in the moment.
I did not expect ‘a few exercises’ to help me the way it has.” MW 23.8.24 (Client)
TESTIMONIALS CONTD:
“I am evaluating as the therapist who invited Angela to support my clients. I believe my clients found the therapy yoga beneficial, Angela was always respectful, appropriate and trauma informed with my clients. They reported enjoying the experience and tried to practise what was learned at home.
I would have no hesitation in working with Angela again or recommending her to clients or other therapists” KC 17.10.24 (Therapist – observing)
REFERENCES:
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. pp. 271–80. ISBN 978-0-89042-555-8
Australian Bureau of Statistics. (2020-2022). National Study of Mental Health and Wellbeing. ABS. https://www.abs.gov.au/statistics/health/mental-health/national-study-mental-health-and-wellbeing/latest-release.
Cushing RE, Braun KL, Alden S. A Qualitative Study Exploring Yoga in Veterans with PTSD Symptoms. Int J Yoga Therap. 2018 Nov;28(1):63-70. doi: 10.17761/2018-00020. Epub 2018 Aug 17. PMID: 30117759. Yoga therapy for military personnel and veterans: Qualitative perspectives of yoga students and instructors
Bisson JI, Cosgrove S, Lewis C, Robert NP (November 2015). "Post-traumatic stress disorder". BMJ. 351: h6161. doi:10.1136/bmj.h6161
Cushing RE, Braun KL, Alden S. A Qualitative Study Exploring Yoga in Veterans with PTSD Symptoms. Int J Yoga Therap. 2018 Nov;28(1):63-70. doi: 10.17761/2018-00020. Epub 2018 Aug 17. PMID: 30117759.
Hurst S, Maiya M, Casteel D, Sarkin AJ, Libretto S, Elwy AR, Park CL, Groessl EJ. Yoga therapy for military personnel and veterans: Qualitative perspectives of yoga students and instructors. Complement Ther Med. 2018 Oct;40:222-229. doi: 10.1016/j.ctim.2017.10.008. Epub 2017 Nov 8. PMID: 30219455; PMCID: PMC6935718.
Lawrence, D, Kryon, M, Rikkers, W, Bartlett, J, Hafekost, K, Goodsell, B & Cunneen, R 2018, ‘Answering the Call: national survey: Beyond Blue’s National Mental Health and Wellbeing Study of Police and Emergency Services – Final report’, research repository,uwa.edu.au.
Tan L, Deady M, Mead O, Foright RM, Brenneman EM, Bryant RA, Harvey SB. Yoga resilience training to prevent the development of posttraumatic stress disorder in active-duty first responders: A cluster randomized controlled trial. Psychol Trauma. 2024 Mar 7. doi: 10.1037/tra0001667. Epub ahead of print. PMID: 38451716.
van der Kolk BA, Stone L, West J, Rhodes A, Emerson D, Suvak M, Spinazzola J. Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. J Clin Psychiatry. 2014 Jun;75(6):e559-65. doi: 10.4088/JCP.13m08561. PMID: 25004196.
Zaccari B, Callahan ML, Storzbach D, McFarlane N, Hudson R, Loftis JM. Yoga for veterans with PTSD: Cognitive functioning, mental health, and salivary cortisol. Psychol Trauma. 2020 Nov;12(8):913-917. doi: 10.1037/tra0000909. Epub 2020 Aug 10. PMID: 32772534; PMCID: PMC7880235.
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