Person-Centered Trauma-Informed Yoga Therapy with Holocaust Survivors and their Family Caregivers

Alyssa Reiner, MSW, LSW, RYT200

More than seventy years after the Holocaust, the complete impact of pervasive trauma on Survivors continues to be under investigation. An increased sense of fragility results in a mind-body relationship characterized by pain, misunderstanding, and lack of control. A childhood signified by extreme malnutrition, life-threatening illness, physical assault, disruption of basic health education, and traumatic attachment disturbances created irreparable damage to the mind-body connection. After the war, many Survivors endured further traumatic events by experiencing stunted growth, chronic health issues, and the inability to have children. The mind-body relationship has been largely overlooked by physical and mental wellbeing culture and research. However, the heightened levels of anxiety, depression, and numerous psychosomatic issues frequently reported by Survivors and caregivers indicate a need for further investigation (Shmotkin & Barilan, 2002).

Yoga is a comprehensive system of postures, breathing exercises and meditation techniques that typically incorporate spiritual philosophies originating from India (van der Kolk, Stone, West, Rhodes, Emerson, Suvak et al., 2014). Now widely practiced across the United States and Canada, researchers have begun to discover the numerous benefits of a regular yoga practice. Studied as an adjunct treatment to other physical and mental health therapies, yoga has been shown to help increase the effectivity of treatment of chronic pain, heart disease, depression and anxiety. Specific to trauma therapy, numerous studies have shown that yoga significantly reduces posttraumatic stress disorder symptoms. One randomized control study found that a 10-week yoga program significantly decreased PTSD symptomology in women who have not responded to other types of treatment (van der Kolk, Stone, West, Rhodes, Emerson, Suvak, et al., 2014). Numerous studies have demonstrated that yoga utilized with other evidence-based interventions can significantly increase the overall health and wellbeing of trauma survivors.

The benefits of yoga practiced by older adults has been well- researched regarding physical but not mental health. No longer an obscure Eastern philosophy shrouded in mystery- almost every older adult has a granddaughter, a neighbor or a doctor who has suggested a modified chair yoga class. Now regularly offered in institutionalized care facilities and senior daycare centers- yoga has become widely accessible. Research has shown that yoga can benefit older adults’ physical health in a variety of ways, including the decrease of fall risk and improving sleep hygiene habits (Spiewak, Steffen, Hicks, Little & Pickett, 2017). Although many studies have concluded the benefits of yoga on positive mental health outcomes in children and adults, there is a significant gap in research addressing this in the older adult population (Lee, Tang, & Bressington, 2019).

Despite extensive research of the benefits of yoga practiced by trauma survivors; and the positive physical health impact of yoga on older adults- there remains a significant gap in research that investigates how trauma-informed yoga impacts older adults who are also survivors of trauma. Jewish Family Service of Central New Jersey (JFSCNJ) is an inter-disciplinary community health agency which received funding through the Jewish Federation of North America’s Center for Advancing Holocaust Survivor Care to provide innovative interventions for Holocaust Survivors and their family caregivers. Therapeutic yoga was included in this intervention, with the goal of positively impacting the biopsychosocial needs of the Holocaust Survivor community- including addressing depression, anxiety, emotional regulation and social isolation in Survivors and their family caregivers.

Trauma-informed chair yoga was provided in group classes and in-home individual sessions, impacting a total of 16 Holocaust Survivors and nearly 50 family caregivers. The premise of trauma-informed yoga is a simple one: provide options, use strengths-based language, and avoid movement which may retrigger latent PTSD symptoms. For instance, instead of prompting a demand, “lift your hands in the air!” a trauma-informed teacher would say, “if it feels right to you, you can lift your hands in the air.” A trauma-informed yoga teacher will remind their students that yoga cues are just offerings, and students are free to take them or leave them. This applies to postures as well as the closing of the eyes during meditations. Trauma-informed yoga teachers encourage the identification and empowerment of intuition and trust of the inner voice. This is especially relevant for a population which is rapidly losing their sense of independence. Teachers also actively avoid triggering certain chakras (loosely translated as energy centers) through poses until they know the student is ready. For instance, a survivor of sexual assault should avoid hip openers, which activates the sacral chakra.

A full discussion of trauma-informed yoga, and their benefits on Holocaust Survivors and family caregivers is still being investigated and outside the scope of this paper. However, anonymous surveys indicated that both Holocaust Survivors and family caregiver groups were receptive to yoga programming. Chair yoga has become one of the highest attended programs in both groups- with an average participation rate of 15 for Holocaust Survivors and 23 for caregivers. Both groups preferred group yoga classes at the agency as opposed to in-home sessions, with the exception of those who had mobility issues.

 All chair yoga sessions were trauma- informed, with a focus on empowerment. Each class followed a similar routine, beginning with a 10-minute meditation which included the introduction of a classic yoga breathing technique, intention setting, and a simple poem. This was followed by gentle spinal movement, such as cat/cow and seated twists. Every posture introduced was cued with an inhale or exhale, which is customary in many schools of yoga. Some standing poses are incorporated, depending on the group. The yoga instructor labels every pose with their English name (horse pose, Warrior I, etc.) and notes some of the physical and mental benefits of each pose. Every yoga session ends in a progressive muscle relaxation exercise, meditation, and reminder of intention. The class concludes in a lunch and discussion with the yoga instructor, which is a chance for participants to ask questions and discuss with each other and amongst themselves.

Traditional yoga breathing exercises were identified as the most useful tools given in the yoga sessions. The ones highlighted in classes include ujaii, or ocean breathing; alternate nostril breath and wave breathing. Holocaust Survivors identified that practical meditations were the most useful for them. For instance, they were able to focus more on meditation which emphasized actual physical sensation of breath over a guided imagery where they were prompted to visualize healing blue light. Survivors were also more likely to state that breath was what they utilized at home outside of class, more than any other posture or mindfulness technique.

Yoga therapy can be widely used and easily modified to work with Holocaust Survivors and caregivers of all kinds. The following are brief vignettes of people who have participated in the yoga therapy program, their names have been changed for privacy:

Adele is a 93-year-old Holocaust Survivor with dementia, she is not oriented to person, place or time. Although she has difficulty in following the verbal cues, she can follow some of the postures when guided through demonstration. Her Certified Home Health Aide caregiver benefits from the yoga instructor’s home visit, as she is given some respite as well as practical tools to manage her own stress.

Hannah is a 91-year-old Holocaust Survivor with pervasive PTSD symptoms which are frequently activated. As a result, she suffers from chronic hyperarousal and has enormous difficulty falling asleep, with an average of only 3 hours of sleep per night. Although she does not necessarily enjoy yoga, she is able to fall asleep in the meditation portion of the session, and naps throughout the class.

Holly is the wife of a Holocaust Survivor who is on hospice care. With his dementia, she finds it difficult to care for herself, or prioritize her own needs in any way. Through in-home yoga, Holly has been able to carve out a space in her own home that helps her create a place of tranquility that she can access every day. With a personalized yoga approach, she has been able to develop her own practice that helps her manage her stress throughout the day.  

Boris is a Survivor from the Former Soviet Union. At 91 years old he identifies as experiencing both social isolation and pervasive poverty. In-home yoga therapy has been a way for him to decrease social isolation, and experience practical tips for managing his anxiety when it comes to paying bills. His case manager has noticed a difference in his temperament, which over time has become more empowered and resilient.

There are many important lessons that we can learn from the accomplishments and challenges of initiating a therapeutic yoga approach with Holocaust Survivors and their caregivers. Accessibility to yoga is much easier than previously thought. When defined as, an ancient practice which emphasizes linking movement and breath with acceptance and no judgment, yoga becomes an easily obtainable concept. Religious concerns about the practice of yoga, specifically avoda zara, idol worshop, did not arise at any point for any participants despite varying religious observances.

The mind-body connection is a critical piece in addressing the psychosocial needs of this population. All professional caregivers need to understand that cultural and historical circumstances created bodily disempowerment for Holocaust Survivors. This has resulted in devastating aftereffects that are not necessarily being addressed by many providers. Survivors may not trust their own bodies, or they have internalized the negative characteristics that were infused in their developing minds during the early 1940’s. To counteract this, yoga students will often hear, “Learning how to listen to your body is yoga. Deciding to not do a pose because you decide it doesn’t work with you right now is yoga. I have never lived in your body before, what feels good to me might not feel good to you, so feel free not to listen to anything I say! Just make sure you do it without speaking negatively to yourself.” Creating a culture of body empowerment does not have to be done only within a yogic setting, but is in part of a PCTI approach.

There are still numerous challenges that need to be addressed. The study of the mind-body connection in older adults who have experienced pervasive trauma is a severely understudied subject. How yoga can positively impact Survivors is a topic that should be studied and well-understood, especially considering the astounding positive effects it has had with other populations. There are also numerous barriers for Survivors and caregivers to obtain trauma-informed chair yoga, as there are not many providers with both mental health backgrounds and yoga instructor certification. To promote sustainability, it was more useful and less expensive to encourage a staff member to obtain their yoga certification than contracting with an outside instructor, which is something that administrators may want to consider. Lastly, as older adults reach into the category of the old old, engaging them in any movement-based activities or introducing them to new concepts becomes increasingly difficult. Familiarizing any mindfulness practice while they have more ability and resilience is imperative.

Person-centered, trauma-informed yoga therapy with Holocaust Survivors is an emerging promising practice. Given the parallel research that indicates its effectivity in treating both trauma survivors and older adults, the benefits of treating Holocaust Survivors could be significantly beneficial. Although more research needs to be completed to understand the scope of such an intervention, preliminary qualitative feedback from one small scale intervention at Jewish Family Service of Central NJ has demonstrated that both Survivors and their family caregivers have had numerous benefits; including decreasing social isolation, stress relief, and tertiary effects on physical health. Participants from both groups indicated that breathing exercises were the most beneficial and accessible to them. Utilizing an empowerment approach, providing accessible yoga therapy can be an impactful and sustainable way to significantly increase the quality of the lives of Holocaust Survivors and their family caregivers.

References

Lee, K.C., Tang, W.K., & Bressington, D. (2019). The experience of mindful yoga for older adults with depression. Journal of Psychiatric and Mental Health Nursing, 26(3-4).

Shmotkin, D., & Barilan, Y.M. (2002). Expressions of Holocaust experience and their relationship to mental symptoms and physical morbidity among Holocaust survivor patients. Journal of Behavioral Medicine, 25(2), 115-134.

Spiewak, C., Steffen, S., Hicks, B., Little, K., & Pickett, K. (2017). A systematic review of the outcomes of therapeutic yoga with older adults. American Journal of Occupational Therapy, 71.

van der Kolk, B.A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak, M. et. al. (2014). Yoga as an adjunctive treatment for posttraumatic stress disorder: A randomized controlled trial. J Clinical Psychiatry.