Journal of Creativity in Mental Health

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Treating Complex Trauma Survivors: A Trauma-

Sensitive Yoga (TSY)-Informed Psychotherapeutic
Approach

Isabelle Ong

To cite this article: Isabelle Ong (2020): Treating Complex Trauma Survivors: A Trauma-Sensitive
Yoga (TSY)-Informed Psychotherapeutic Approach, Journal of Creativity in Mental Health, DOI:
10.1080/15401383.2020.1761498

To link to this article: https://doi.org/10.1080/15401383.2020.1761498

Published online: 18 May 2020.

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JOURNAL OF CREATIVITY IN MENTAL HEALTH
https://doi.org/10.1080/15401383.2020.1761498

Treating Complex Trauma Survivors: A Trauma-Sensitive Yoga

(TSY)-Informed Psychotherapeutic Approach
Isabelle Ong
National Institute of Education, Nanyang Technological University, Singapore, Singapore

ABSTRACT KEYWORDS
Trauma-sensitive yoga (TSY) is a body-oriented yoga practice, inten- Trauma-sensitive yoga (TSY);
complex trauma;
tionally designed to help complex trauma survivors recover by devel-
posttraumatic stress disorder
oping self-awareness, self-regulation, and a benevolent relationship (PTSD); trauma recovery;
with their bodies. There is a growing body of evidence supporting trauma-informed approach;
TSY’s efficacy in reducing participants’ posttraumatic stress disorder TSY-informed interventions;
(PTSD) symptoms and facilitating holistic trauma recovery beyond creativity in counseling
conventional psychotherapies. Given the promise shown by TSY as an
adjunct trauma intervention that is consistent with a trauma-
informed approach, it is timely to discuss how counselors can inte-
grate TSY into their psychotherapeutic interventions to optimize
trauma recovery. This article begins with a review of the TSY litera-
ture, followed by recommendations for counselors to weave TSY-
informed interventions into psychotherapy with complex trauma
clients, further illustrated in a case vignette.

Introduction
Sixty-one percent of men and fifty-one percent of women have reportedly experienced at
least one traumatic event in their life (Substance Abuse and Mental Health Services
Administration [SAMHSA], 2019). Trauma is defined as a single event, multiple events,
or circumstances that a person experiences as harmful and life-threatening; it produces
severe stress reactions and has negative implications on one’s well-being emotionally,
physiologically, socially, and spiritually (SAMSHA, 2014). Some individuals who have
been exposed to a traumatic event(s) may go on to develop posttraumatic stress disorder
(PTSD), a psychological disorder characterized by the development of stress reactions and
symptoms such as arousal or dissociation (American Psychiatric Association, 2013). In
mental health settings, 90 percent of clients have experienced trauma (SAMHSA, 2019).
In contrast to acute trauma, which is a single traumatic experience such as a car
accident, complex trauma manifests when individuals are subject to tremendous stress
perpetuated interpersonally and cumulatively over prolonged periods of time (Briere &
Lanktree, 2012; Emerson & Hopper, 2011; Herman, 1997). Individuals with complex
trauma may also develop PTSD after exposure to traumatic events of an interpersonal
nature such as long-term child abuse, neglect, or domestic violence (Herman, 1997).
Complex trauma presents numerous obstacles to successful treatment due to the
complicated nature of the condition (Emerson & Hopper, 2011; Van der Kolk, 2006).

CONTACT Isabelle Ong jennsabelle@gmail.com Psychology and Child & Human Development Academic Group,
National Institute of Education, NIE 2-03-84, 1 Nanyang Walk, Singapore
© 2020 Taylor & Francis Group, LLC
2 I. ONG

Individuals with complex trauma may also experience additional symptoms, such as
difficulties with emotional regulation and interpersonal relationships with others
(Herman, 1997). Therefore, individuals impacted by complex trauma commonly do not
complete treatments for PTSD due to complicating factors such as dysregulated emotions
and impulses (Van der Kolk et al., 2014) that tend to overwhelm them and compromise
their feelings of safety, resulting in them opting out of treatment. Thus, work with clients
who have complex trauma requires a purposeful approach established not only at the
onset of psychotherapy, but throughout therapy. As a result, it is critical that complex
trauma treatments focus on restoring control and power and empowering clients through
healthy relationships that promote safety and reconnection with daily life (Herman, 1997).
Over the last few decades, an increasing array of treatment interventions for PTSD has
surfaced and experts share the consensus that Cognitive Behavioral Therapy (CBT) and
EMDR (Eye Movement Desensitization and Reprocessing) treatment are two capstone
treatment interventions that demonstrate more effective and sustained PTSD intervention
outcomes (Bradley et al., 2005; World Health Organization, 2013). Despite this,
Schottenbauer et al. (2008), based on a review of 55 empirical studies on CBT or
EMDR treatment, found that existing research has key limitations. Serious limitations
such as a high variability of dropout rates ranging from 0 percent to 54 percent and high
nonresponse rates as high as 100% on some measures persist in studies that use these
interventions, suggesting that CBT and EMDR may not be effective for all trauma
survivors (Schottenbauer et al., 2008).
In recent years, neuroscientists such as Porges (2001, 2003) have shed new light and
understanding on trauma as a condition where the physiological, emotional, psychologi-
cal, and social dimensions of an individual are intricately interconnected. Trauma memory
is registered in the body (Van der Kolk, 2014), and messages sent from the body have
a significant reign over the mind (Scaer, 2005). Hence, a central part of recovery entails
traumatized individuals first gaining physical self-awareness by experiencing bodily sensa-
tions, before connecting these physical sensations to psychological events (Scaer, 2005;
Van der Kolk, 2014). Until traumatized individuals increase such body awareness, con-
ventional trauma treatment approaches that are cognitively oriented may have restricted
effectiveness (Emerson & Hopper, 2011; Scaer, 2005). Emerging unconventional
approaches that reconcile ‘bottom-up approaches,’ or approaches that help traumatized
individuals forge mind-body connections by focusing on the body so as to develop
somatic awareness through body-oriented treatment modalities such as yoga, have gained
attention in the scholarly literature (Van der Kolk, 2014). It is thus important for
counselors to be aware of the limitations of cognitive-based approaches and recognize
the need for body-oriented approaches in treating complex trauma.
Trauma-sensitive yoga (TSY), a nascent complementary intervention, is one such body-
oriented treatment designed for complex trauma survivors. As TSY continues to grow in
popularity and finds its way into various mental health treatment facilities, it is timely to
address the prospect of pairing TSY with conventional psychotherapeutic interventions
(Ong et al., 2019). Accordingly, the three-pronged purpose of this article is to first, define
TSY and review the TSY empirical literature; second, describe evidence-supported recom-
mendations for counselors to apply TSY-informed interventions in their work with
complex trauma survivors; finally, through a case study, we illustrate how counselors
can use a TSY-informed approach to complement their psychotherapeutic work with
 JOURNAL OF CREATIVITY IN MENTAL HEALTH 3

clients. We conclude with a discussion of the implications of adopting TSY as an adjunct

intervention for counselors.

History and definition of TSY

TSY was developed to facilitate trauma recovery among war veterans (Emerson & Hopper,
2011). Psychiatrist Van der Kolk and yoga teacher David Emerson founded TSY based on
extensive clinical experience working with complex trauma survivors and drawing from
trauma recovery theories. TSY is a body-oriented practice designed to help complex
trauma survivors develop self-awareness, self-regulation, and nurture a benevolent rela-
tionship with their bodies (Emerson & Hopper, 2011). It was crafted to select specific
aspects of yoga that can facilitate trauma healing in response to the recovery needs of
complex trauma survivors, and to conduct the practice in a guided setting. Some of the
mechanisms or key components of TSY include breathing, forms, and mindfulness.
Breathing entails trying out various ways of inhaling and exhaling; forms encompass
attempting various body positions and gentle movements; and mindfulness is the
increased awareness of the here-and-now by paying attention to the self in relation to
the environment (Emerson, 2015). TSY principles were also designed to ensure that
students experience yoga in a safe space by recommending specific yoga instructor
dispositions and guidelines for the class environment (Emerson, 2015; Emerson &
Hopper, 2011).

Empirical literature on the efficacy of TSY

TSY has been found to significantly reduce participants’ PTSD symptoms (Dick et al.,
2014; Mitchell et al., 2014; Van der Kolk et al., 2014). Van der Kolk et al. (2014) conducted
one of the studies investigating the efficacy of TSY with women who had chronic PTSD
and were not responding to traditional psychotherapy treatment. Based on a comparison
between a TSY intervention group and a women’s health psychoeducational control
group, Van der Kolk et al. (2014) found that not only did PTSD symptoms of TSY
group participants abate significantly, this reduction was also sustained over time. This
was unlike control group participants whose PTSD symptoms reverted to baseline scores
after a temporal decrease. In their sample of civilian and veteran women who had full or
subthreshold PTSD, Dick et al. (2014) found that participants in a TSY yoga group could
also apply greater psychological flexibility, and could be more fully present and accepting
of how they feel and think, compared to control group participants. Participants in the
yoga group also had decreased expressive suppression – a negative emotional regulation
strategy where one restricts the expression of their emotions during emotional arousal
(Dick et al., 2014).
Beyond testing the efficacy of TSY by measuring participants’ PTSD symptoms and
associated psychological constructs, researchers have also conducted mixed or qualitative
research to investigate its impact (Ong et al., 2019; West et al., 2016). West et al. (2016)
measured participants’ reported gains from participating in TSY, in other areas, such as an
increased compassion for the self and toward others. Through qualitative interviews
conducted with 31 female adult participants who attended a 10-week TSY program,
West et al. (2016)’s analyzes revealed five major themes describing the therapeutic gains
4 I. ONG

reported by participants. The first theme was ‘gratitude and compassion,’ defined as
greater wellness and care for one’s physical body, self-love, and tolerance in response to
change. The second theme was ‘relatedness,’ characterized as connection to the self and
with others, where participants reported a stronger connection with the self in terms of
increased interoceptive awareness and being more in touch with their physical sensations
and emotions. Participants also indicated the ability to appreciate greater physical and
psychological intimacy with significant others in their lives. The third theme was ‘accep-
tance,’ where participants shared that they could better embrace the self, their physical
body, and their lives. Acceptance of the self also encompassed integrating traumatic
experiences as part of one’s life narrative. The fourth theme was ‘centeredness,’ where
participants experienced augmented feelings of calm and quiet that created space for
increased positivity, receptivity to alternative perspectives at perceiving their circum-
stances. The final theme was ‘empowerment,’ where participants experienced greater
agency and body confidence, as well as greater motivation to engage in an active lifestyle.
In an eight-week TSY- intervention study conducted by Ong et al. (2019) the researchers
used a collective case study research design to study five participants’ recovery experiences
from intimate partner violence and trauma. Quantitative measures such as the Clinician-
Administered PTSD Scale-5, and qualitative measures comprising of pre- and post- inter-
views were utilized to capture participants’ subjective trauma recovery processes (Ong et al.,
2019). Although the quantitative findings indicated reduced intensity and severity of PTSD
symptoms, they need to be considered in the context of the small sample size (Ong et al.,
2019). The researchers found that the qualitative findings not only substantiated the quanti-
tative findings, but also expanded the scope of benefits participants gained from the TSY
intervention (Ong et al., 2019). Some of the ten qualitative themes reported in their study
include the following: (1) physiological benefits in terms of improved sleep quality and
increased physical strength; (2) emotional benefits with an increase in positive feelings and
a reduction of negative feelings; (3) an enhanced perception of self and others; (4) a start or
increase in self-care activities; and (5) the use of positive coping strategies that helped them to
relax and self-regulate. Taken together, these research studies demonstrate the growing
evidence on the effectiveness of TSY as a trauma intervention. Not only were participants’
PTSD symptoms reduced, but the intensity and severity of the symptoms abated (Ong et al.,
2019; Van der Kolk et al., 2014). Additionally, Ong et al. (2019) have also suggested that the
TSY intervention may impact clients differently where clients who may present with more
severe and intense PTSD symptoms may appear to benefit more from TSY than other clients
who present with less severe and intense PTSD symptoms. However, the qualitative research
findings suggest that TSY benefits participants in varied ways that may not be captured in
their PTSD scores alone. Apart from the reduction of PTSD symptoms, scholars have
reported that multifaceted connections between body and cognitive healing, facilitated by
a TSY program, can enhance trauma survivors’ functioning in multidimensional ways. This
feature is particularly critical for clinical practice to ensure trauma is not undertreated, given
that that trauma recovery is a holistic process (Allen & Wozniak, 2010). For example,
participants in these studies reported improved functioning in various ways, ranging from
improved psychological functioning (psychological flexibility, acceptance, empowerment),
emotional functioning (emotional regulation, centeredness), and social functioning (strong
intra- and interpersonal connections). Despite the benefits of TSY for trauma survivors that
were established in these studies, counselors should be aware of current gaps in the current
 JOURNAL OF CREATIVITY IN MENTAL HEALTH 5

state of knowledge about TSY and inform clients of these gaps before introducing TSY into
their psychotherapy sessions, as part of their ethical commitment to professional competence
(Standard C.2.; American Counseling Association, 2014). We explore some research gaps in
the following section.

Gaps in TSY research

Despite the many purported benefits of TSY in facilitating the recovery of clients with
complex trauma, gaps in the current literature can present challenges for counselors to
incorporate TSY in psychotherapy. An area of TSY research that has received less attention
is a study of the various roles of the discrete mechanisms that make up TSY. At present, only
Dick et al. (2014) is known to have examined the mechanisms of TSY, (namely breathing,
forms and mindfulness) and the specific contributions of these mechanisms to reduce PTSD
symptoms (Van der Kolk et al., 2014). More research in this area may help counselors and
researchers develop a greater understanding of how TSY’s discrete mechanisms work
individually and in concert with each other, to increase the efficacy of TSY.
Further, most of the research studies investigating the impact of TSY are short-term
and typically only span between 8 and 12 weeks (Clark et al., 2014; Dick et al., 2014;
Jindani & Khalsa, 2015; Van der Kolk, 2014; West et al., 2016). Hence, it is uncertain if
TSY can help sustain the reduced PTSD symptoms in individuals impacted by trauma
in the long run once TSY is discontinued. Researchers have also not determined the
likelihood of trauma survivors continuing TSY practice at home, independent of the
guidance of a TSY instructor, or considered which resources could increase their
likelihood of participants doing so consistently. The lack of longitudinal studies in
TSY also means that counselors need to explain to clients that this intervention is still
in its nascent stages. Counselors who plan to introduce TSY as an adjunct intervention
should also consult with their supervisors to monitor the progress of outcomes.
Last but not least, it is imperative that researchers closely consider sample size and
other possible confounding variables in future quantitative research evaluating TSY
interventions. Studies that did not find evidence for TSY’s efficacy, compared to other
control interventions, tended to experience several methodological limitations which
future studies should pay heed to. For example, Mitchell et al. (2014) found that
participants in both the control and TSY intervention groups indicated significant
decreases in reexperiencing and anxiety symptom measures in the PTSD Checklist-
Civilian (PCL-C). The authors attributed the results to insufficient statistical power due
to a small sample size. Similarly, in their study, Van der Kolk et al. (2014) found that both
the control and TSY intervention groups reported significant decreases in depression
symptoms but could not identify nuanced differences between the groups. The authors
admitted that the presence of confounding variables such as the supportive elements of
the control group, where participants shared food and kept in contact with one another
outside of the TSY intervention setting, could have inflated participants’ mood levels in
their study.
6 I. ONG

Incorporating TSY in psychotherapy for complex trauma treatment

How can counselors incorporate TSY into psychotherapy in their work with trauma
survivors? The goals, principles, and techniques in TSY overlap with a trauma-informed
care of clients currently used in the helping professions. Although basic, these essential
principles, albeit compatible, have not been explicitly discussed in the contexts of counsel-
ing, training, and supervision. In the next section, we consider how TSY can be incorpo-
rated in principle, and applied in practice through a case vignette.

TSY goals and principles: incorporating TSY practice in complex trauma treatment
TSY seeks to provide a context and opportunities for the individual to notice visceral
feelings and make self-directed body-based connections (Emerson, 2015). For our pur-
poses, five selected underlying principles support the overarching goal of TSY alongside
three techniques responsible for facilitating trauma recovery, namely, breathing, mind-
fulness, and forms (Emerson et al., 2009). These techniques were intentionally selected
and modified to fit survivors’ trauma recovery needs in line with the Substance Abuse and
Mental Health Services Administration (SAMHSA, 2014)’s trauma-informed approach.

Establishing a safe environment

The first TSY principle is to create a safe environment for yoga students to develop a sense
of safety, consistency, non-judgment, and gentleness (Emerson et al., 2009). The notion of
safety is aligned with the safety principle in trauma-informed care (SAMHSA, 2014). In
regular yoga classes, yoga students may find the yoga instructor moving around the room
and appearing unexpectedly (Emerson et al., 2009). This may trigger feelings of unpre-
dictability and violate students’ personal space. To circumvent this problem, a TSY
instructor aims to create a welcoming environment for their students and promotes safety
in ways such as giving students the freedom to opt out of poses whenever they experience
any discomfort (Emerson et al., 2009).
Likewise, counselors can set the stage for a safe and welcoming therapeutic environment
for clients by ensuring that their emotional, physical and psychological safety are maintained
during a TSY-informed session. Apart from avoiding abrupt and sudden physical move-
ments, physical safety can be achieved by ensuring that clients are greeted with a warm smile
by the counselor, and feel comfortable with conditions in the room, such as lighting and
thermal conditions. If the air-conditioning in the room cannot be adjusted for the client’s
comfort, the counselor may provide a blanket or remind the client to bring a scarf or sweater
for future sessions. Counselors also play an important role in promoting emotional safety by
offering a consistent schedule for sessions or building predictability into sessions by co-
creating a ritual with clients in every session. For example, clients can be invited to participate
in a few moments of silence while holding a rock in their hands or inhaling lavender
aromatherapy oil at the end of the session, to aid in relaxation.
 JOURNAL OF CREATIVITY IN MENTAL HEALTH 7

Personal qualities
The second principle integral in TSY is the yoga instructor’s personal qualities that can
foster a safe and welcoming environment for their students (Emerson et al., 2009). This
principle ensures that yoga instructors’ model positive relationships, consistent with the
principle of trustworthiness and transparency in a trauma-informed approach (SAMHSA,
2014). Emerson et al. (2009) suggested a list of yoga instructor dispositions: being present,
approachable, inviting, positive, accepting, open to feedback, adaptable when things are
not unfolding as planned, and being willing to go at a slower pace. Counselors working
with clients with complex trauma could build trust with clients by developing these
dispositions.
Another disposition important for counselors to develop for trust-building with clients,
is being open to feedback. Counselors could foster transparency by inviting clients to
share verbal feedback on what is working and what is not working out for them in
sessions. This is critical as clients with complex trauma may suffer from PTSD symptoms
such as hyperarousal and flashbacks of the traumatic event(s) (5th ed.; DSM-V; American
Psychiatric Association, 2013). As a result, triggers may inadvertently occur during
therapy. Counselors could invite clients to complete written feedback sessions that include
a combination of rating scales and open-ended responses after every session or every three
to four sessions, so that clients can articulate their concerns. Examples of (trauma-)
focused questions include “How safe do you feel during counseling sessions?” or ‘What
triggers come up for you during session that make you feel uncomfortable or unsafe?” It is
important for counselors working with trauma survivors to not continually solicit feed-
back from clients about their trauma symptoms during sessions, and demonstrate recep-
tivity toward this feedback, to model a, trusting, and transparent relationship.
Other personal qualities important for counselors to possess and develop when working
with clients with complex trauma, are adaptability and patience. For example, slowing
down the pace of counseling does not mean delaying treatment progress. Rather, it
demonstrates that the counselor is able to meet the client where she or he is to process
a trigger observed during session or be ready to adapt and discard any planned structured
activities in any session. It is critical that counselors exercise patience with the treatment
recovery process by taking small steps with the client during initial stages of treatment.

Invitatory language
The third principle in TSY is invitatory language, where TSY instructors are encouraged to be
intentional about their verbal communication to help students feel welcome (Emerson et al.,
2009). The use of invitatory language underscores the trauma-informed principle of colla-
boration and mutuality where direct care providers initiate and facilitate healing and the
sharing of power and decisions in the context of the therapeutic relationship (SAMHSA,
2014). In conventional yoga classes, it is common to hear yoga instructors utilizing words
that convey the message of pushing beyond pain and trying harder (Emerson et al., 2009).
However, trauma survivors may already have a history of aversive and disconnected relation-
ship with their bodies (Emerson et al., 2009). Thus, directives that coerce yoga students to
follow instructions could trigger their PTSD symptoms and lead to attritions from yoga
practice (Emerson et al., 2009). To encourage trauma survivors to develop amiable and
8 I. ONG

tender relationships with their bodies as part of the trauma recovery process, TSY instructors
are selective about their choice of vocabulary and utilize invitatory language such as “if you
are ready” or tentative words such as “maybe” (Emerson et al., 2009). Counselors can help
clients feel welcome at the beginning and throughout the session by including invitatory and
tentative words and phrases that give them a sense of autonomy and control, while helping
clients develop an amiable and compassionate relationship with themselves.

Making choices
In tandem with one of the trauma-informed principles, empowerment, voice, and choice,
clients are supported in the experience of regaining their voice and self-empowerment
through choice-making (SAMHSA, 2014). Traumatized individuals have undergone the
experience of not having control and a lack of choice, which leads to a sense of hopelessness
and wrecked sense of agency in their world (Emerson et al., 2009). To address these issues,
TSY instructors gently remind their students to make choices around reducing the amount of
discomfort, pain, or tension in their bodies when students get into their forms during TSY
sessions (Emerson, 2015). Similarly, counselors can also incorporate choice-giving as
a therapeutic tool to empower clients to rely on their internal experience and govern
decisions on their level of readiness in counseling. Not only is choice-giving aligned with
the collaborative nature of the therapeutic relationship, it is distinct in that it requires the
counselor to explicitly articulate the options available to clients, thus giving them the option
of trying new experiences and activities that they may otherwise miss out on. Counselors can
help clients develop the strength to take the lead in counseling and grow in self-confidence
and personal autonomy. For example, counselors could provide clients with the option of
two structured activities they could work on for the session, or within any given activity,
options on how clients could approach the activities differently based on their own ther-
apeutic goals. Clients who exercise autonomy through the process of choice-making in
therapy can be invited to consider the options they have in any given situation, and process
what it takes for them to exercise either option.

Verbal assists
A key principle in TSY is the use of verbal assists, and this principle distinguishes TSY
from other yoga styles (Emerson et al., 2009). Other yoga styles may incorporate both
verbal and physical assists, but only verbal assists are used in TSY. A non-TSY instructor
may not always seek permission to physically assist their yoga students and may place
their hands on a part of students’ bodies to adjust them so they can achieve what the
instructor considers an ‘ideal’ bodily posture (Emerson et al., 2009). Since such physical
assists involve entering a yoga student’s space and manipulating the student’s body in
some way, they are antithetical to TSY’s approach of helping individuals develop personal
knowledge of and compassion toward their bodies. It may, in some instances, also risk re-
traumatizing students (Emerson et al., 2009). Verbal assists are applied in TSY as they
serve the function of guiding and facilitating students’ practice in a nurturing way while
demonstrating respect for their physical boundaries (Emerson et al., 2009). Hence,
counselors should encourage clients seeking a yoga studio, to have a conversation with
its instructors on their approach to assists.
 JOURNAL OF CREATIVITY IN MENTAL HEALTH 9

Mindfulness
Mindfulness aids one’s ability to increase self-awareness and be in the present moment
through visual observations or making visceral connections with a surface (Eliade, 1958;
Emerson, 2015). Through mindfulness, trauma survivors can pay attention to their somatic
experience such as feeling their muscles stretch, a process known as interoception (Emerson,
2015). Counselors can facilitate the practice of mindfulness by guiding clients’ attention to
the here-and-now in various ways. A popular exercise that counselors are familiar with is
grounding. Counselors can give clients the option of sitting or standing for this mindfulness
practice. If clients are standing, they can gradually add some pressure to their feet such that
they can feel the ground beneath them; sitting clients can be invited to gently lean back
against the wall or back of their chair and feel the support against their backs. Another
mindfulness exercise that counselors can guide clients to practice is the ‘five senses’ exercise.
Counselors can invite clients to bring awareness to their environs by focusing on one thing
that they see, followed by one thing that they hear, smell, feel, touch and taste.

Breathing
Although breathing is fundamental in TSY and most mainstream yoga practice, introdu-
cing breath work to counseling is not novel. The use of breathing in counseling is most
common in relaxation exercises. The importance of returning to the breath cannot be
understated in TSY as it plays a critical role in emotional regulation and helps trauma
survivors get in touch with their bodies, a connection that trauma survivors may have lost
during trauma. In TSY, breathing is considered an opportunity for one to experience
a shift from trauma to a new bodily experience by experimenting with various breathing
options (Emerson, 2015). A TSY breathing activity counselors can use to help clients make
that somatic connection is to invite them to notice the physical characteristics of their
breath such as by counting each inhale and exhale and gradually equalizing their inhales
with their exhales (Emerson, 2015).
Amidst a busy client schedule, it can sometimes be challenging for counselors to be
present with their clients. Counselors could practice mindful breathing at their own time
to aid in their focusing during TSY interventions or psychotherapy, or by practicing
breathing with clients to focus on the present moment and mirror this mindfulness
practice to clients. An example of a mindful breathing prompt may be, “breathing in,
I am ready to be here; breathing out, I let go of my stress,” allowing the breath to sync with
the words. After the counselor has led the prompts a couple of times, both counselor and
client can practice mindful breathing together without the prompts. Syncing breath
patterns promotes inter-brain coupling between counselor and client in psychotherapy,
and could strengthen therapeutic alliance (Koole & Tschacher, 2016).

Forms
It is vital for counselors to be aware that TSY instructors use the concept of forms in place
of poses. Originally called ‘asanas’ in Sanskrit, a yoga pose refers to a bodily posture that
one enters and inhabits for a few moments (Kaminoff & Matthews, 2012). On the other
hand, ‘forms’ draw emphasis on the student’s internal somatic experience and perspective
10 I. ONG

of the physical position (Emerson, 2015). Similar to breathing, TSY centers on students’
self-discovery process of trying out various gentle body movements within the context of
a yoga form. The use of forms in TSY highlights the salience of the skillful use of yoga for
it to attend to trauma survivors’ recovery needs (Emerson et al., 2009). In their review of
various popular yoga practices commonly practiced throughout the country, Emerson and
Hopper (2011) found many of these practices inappropriate for facilitating trauma recov-
ery or were contraindicative to trauma survivors’ recovery needs. For example, the
emphasis placed on the ‘correct’ alignment in Iyengar yoga strongly suggests that the
body requires correcting because it is inherently an anomaly. This focus contradicts the
key healing conditions that trauma survivors need in their recovery, mainly, trust,
acceptance, and self-appreciation of their body that does not require external approval
(Emerson & Hopper, 2011).
TSY forms are flexibly catered to survivors’ needs, and options for each form are
offered to students to develop greater self-awareness and a more compassionate relation-
ship with their bodies (Emerson, 2015). Thus, counselors could suggest that clients request
to observe a yoga class or meet with instructors to understand the latter’s teaching
approach and determine if options for alternative or modified yoga forms are available
to them. One should however note that it is advisable that counselors consult TSY training
resources such as The Trauma Therapist Project and their supervisors before introducing
any yoga forms in therapy sessions. We will now share a case vignette to illustrate how
basic TSY can be integrated into a TSY-informed counseling session.

A case study illustrating a trauma-sensitive yoga (TSY)-informed counseling

approach
Amelia is an African American woman in her late thirties with one young child. She
sought counseling after leaving an abusive relationship of three years. She was diagnosed
with posttraumatic stress disorder (PTSD) and recently found her counselor, Zann, in the
hopes of recovering from her trauma. Zann is an Asian American woman in her thirties
who is guided by existential theory and utilizes complementary alternative therapies,
including yoga and mindfulness. Amelia was very interested in incorporating yoga in
her weekly regime and needed some guidance on which types of yoga classes and
instructors could best meet her needs. Amelia’s therapeutic goals included the following:
(1) regaining a sense of power and control in her life through the various roles she played
as a mother, daughter, sister, and accountant, (2) restoring the trust she had lost in that
abusive relationship within herself and the relationships she shares with her family and
friends, and (3) reducing her hypervigilance and difficulties concentrating that were
significantly impeding her work productivity.

Informed consent
In their first session together, Zann went over the informed consent with Amelia and
explained that she would use a TSY-informed approach with Amelia in addition to RCT,
a theory that is both empowering and focused on relationship dynamics, in their work
together. As outlined in the informed consent form, Zann discussed some of the TSY-
informed principles she would harness during therapy, such as the use of continual
 JOURNAL OF CREATIVITY IN MENTAL HEALTH 11

feedback in both written and verbal forms to develop a healthy and trusting therapeutic
relationship with Amelia. The feedback would also allow Zann to assess any progress
pertaining to Amelia’s three therapeutic goals.
Zann also explained that she applies a TSY-informed approach in the form of verbal
responses and that as therapy progressed, Amelia will have a choice of applying selected
TSY techniques in the form of mindfulness and breathing techniques whenever she
wanted to and was ready. Zann asked if Amelia had any issues and concerns regarding
the approach before they embarked on the therapeutic work together, and Amelia con-
sented to this approach.

Therapeutic approach and strategies

Zann also invited Amelia to join a women’s psychoeducational group focused on healthy
relationships in the counseling agency where Zann was based. In addition to providing
a societal perspective of gender role expectations and a source of emotional support, the
group would also equip her with important skills such as assertiveness and inform her of
her rights to a healthy relationship. In their individual therapeutic sessions, Zann also
planned on applying TSY-informed principles and strategies to address her therapeutic
goals. Zann thus sets the stage for a TSY-informed approach by introducing specific
principles and strategies to help Amelia orient to therapy and create the conditions for
therapeutic growth and potential flourishing. Specifically, she illustrated the use of estab-
lishing a safe environment, invitatory language, choice making, and normalizing Amelia’s
concerns, in the following exchange.
Zann: This room can get a little chilly at times. If it gets too cold and you need
a blanket or a scarf, please help yourself to the one on the couch. (Establishing
a safe environment)
Amelia: Oh, thank you. It is quite chilly in here. I will help myself to that blanket.
Zann: Amelia, we have talked about the reasons for coming in for counseling and the
trauma you experienced in your previous abusive relationship that continue to
affect you. Of the three goals that you indicated, which of the three do you
consider a priority that you would like to focus on? (Choice-making)
Amelia: Hmmm, let me see. It’s hard to know. (Laughs nervously)
Zann: It is a really tough choice. You can think it through in your mind or verbalize
it if that helps you more. (Choice-making) Take your time here. (Invitatory
language)
Amelia: Uh huh. These are all priority in a sense but if I really had to choose one that
affects me the most, it would be the hyper-alertness I carry with me everywhere
I go. It affects me in the daytime and I have trouble sleeping because of it. Like
earlier, I was in sitting in the waiting room and was looking outside and
around me, worried that at any time, he might just show up and drag me
away. I know that does not sound realistic since he is being put away but I still
worry a lot about the personal safety of myself and our three-year old. Once,
he showed up at work and dragged me out of my office and into the car, in
front of my colleague. That is why I don’t like sitting with my back facing the
door. I never know what might happen and if my back is facing the door due
12 I. ONG

to the lack of options, I turn my head around every few minutes just to make
sure he is not there.
Zann: Gosh, that must be terrifying. Most people would have trouble feeling rested
and comfortable in those situations. (Normalizing) Do you feel safe right now
and how can I help increase your sense of safety in this room? (Establishing
a safe environment).
Amelia: Thank you for asking. Everything is fine here and I can see the door from here.

Practical considerations
This article has illuminated the core principles and strategies of TSY-informed care and
demonstrated the importance for counselors to familiarize themselves with TSY-informed
care to better cater to clients’ treatment needs. However, beyond the confines of this article,
the authors highly recommend that counselors interested in incorporating TSY-informed
care in their practice, advance their knowledge base of TSY by engaging in continuing
education on TSY or attending TSY classes if those come available. Currently, there is no
literature discussing the ethical considerations of incorporating complementary alternative
therapies in psychotherapy although there is growing interest in applying these therapies.
When explaining the function of TSY to clients, counselors may need to preface to clients
that TSY research is still emerging although empirical research has supported the benefits of
TSY. Thus, it would be beneficial for counselors practicing TSY-informed care to continually
reflect on their practice, gather clients’ feedback, as well as seek clinical supervision for
feedback on the effectiveness of their interventions in relation to therapeutic outcomes.
We have also attempted to highlight key characteristics of yoga classes and instructors that
facilitate a TSY session. The majority of mainstream yoga classes publicly available are not
TSY-informed. Thus, gaining access to TSY classes may be challenging for clients. In such
cases, counselors trained in TSY could facilitate a TSY-informed session using the principles
exemplified in this paper or empower clients to be advocates for their yoga practice if clients
wish to experience TSY in classes outside the counseling session. Counselors could for
instance, guide clients to make informed choices in regard to assists and form modifications,
when selecting yoga classes, instructors, and studios. They could also help clients generate
a criteria list of the desired characteristics of yoga classes and instructors that can meet
clients’ therapeutic needs and have a preliminary interview with candidate yoga instructors.
Additionally, counselors could invite clients to process their TSY practice in session or yoga
class experiences with them (Ong et al., 2019). For example, clients could share how
a positive interaction with their body during TSY influenced their emotions. Counselors
could encourage clients to practice these feel-good forms or breathing practices at home or at
work and keep a record on the practice frequency and their mood. In this way, clients can
start to make meaningful connections between TSY and psychotherapy in ways that
strengthen their treatment outcomes (Ong et al., 2019).

Conclusion
Pairing novel complementary therapies with psychotherapy is still a relatively new
endeavor that requires considerable exploration, professional dialogue, reflection, and
further research However, evidence-based research has indicated the critical role that
 JOURNAL OF CREATIVITY IN MENTAL HEALTH 13

TSY has in trauma care. In this paper, we have attempted to integrate TSY-informed care
in psychotherapy. We have shown how TSY- informed care complements psychotherapy
by promoting safety, trustworthiness, transparency, empowerment, collaboration, and
choice making. Given advances in knowledge about the multi-faceted nature of trauma
recovery and the complementary role that body-based therapies such as TSY can play,
now is the time for the counseling profession to respond to the call for ethical and best
practices in trauma care by sparking conversations in training, continuing education, and
research.

ORCID
Isabelle Ong http://orcid.org/0000-0003-2482-9916

Acknowledgement
The author is very grateful to Dr. Corinne Ong for instructing the TSY classes in her original
research project with much care and dedication. She is also thankful to her for generously sharing
her time to review and edit this article.

Funding
This article is part of a dissertation study that was partially funded by a grant from the Chi Sigma
Iota Counseling Academic and Professional Honor Society International.

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