Yoga for PTSD: The Trauma-Sensitive Approach

The Body Keeps the Score — and Yoga Helps It Let Go

Post-traumatic stress disorder is, at its core, a disorder of the body. The traumatic event may be over — sometimes decades in the past — but the body continues to respond as if it is still happening. Heart racing. Muscles bracing. Breath holding. Startle reflexes firing at benign stimuli. The body is stuck in the moment of the trauma, replaying its emergency response in an endless loop.

Bessel van der Kolk, whose 2014 book The Body Keeps the Score transformed our understanding of trauma, has been at the forefront of researching yoga as a treatment for PTSD. His central insight: trauma is not primarily a disorder of memory or cognition. It is a disorder of the body’s autonomic and sensorimotor systems. The traumatic experience is encoded not as a narrative (which can be processed through talk therapy) but as a pattern of autonomic activation, muscular tension, and sensory experience that resists verbal processing.

This insight has profound treatment implications. If trauma lives in the body, then the body must be involved in its resolution. Talk therapy alone — regardless of how skilled the therapist — reaches only the cognitive and narrative dimensions of trauma. The somatic dimension requires a somatic intervention.

Van der Kolk’s Landmark RCT (2014)

Van der Kolk et al. (2014) published a randomized controlled trial in the Journal of Clinical Psychiatry comparing trauma-sensitive yoga (TSY) with supportive women’s health education in 64 women with chronic, treatment-resistant PTSD. Key findings:

• The yoga group showed significantly greater reductions in PTSD symptom severity compared to the control group, as measured by the Clinician-Administered PTSD Scale (CAPS) — the gold standard assessment
• 52% of the yoga group no longer met diagnostic criteria for PTSD at the end of the 10-week intervention, compared to 21% of the control group
• The improvements were in all three PTSD symptom clusters: re-experiencing (flashbacks, nightmares), avoidance (emotional numbing, withdrawal), and hyperarousal (startle, insomnia, irritability)
• The participants had an average of 13 years of chronic PTSD and had not responded to previous treatments

These results are remarkable. A 10-week, twice-weekly yoga program produced remission rates that rival the best pharmacological and psychotherapeutic interventions for PTSD — in a treatment-resistant population that had already failed other treatments.

The Neurobiology of Trauma and How Yoga Addresses It

1. Autonomic Dysregulation

Trauma produces a characteristic autonomic signature: the sympathetic nervous system is tonically hyperactivated (producing hypervigilance, exaggerated startle, insomnia, and irritability), while the parasympathetic nervous system is suppressed (producing reduced HRV, impaired digestion, and inability to self-soothe). In severe or chronic trauma, the dorsal vagal system may activate, producing dissociation, numbness, and collapse.

How yoga addresses it: Every aspect of yoga practice modulates the autonomic nervous system. Slow breathing activates the vagal brake. Supported poses reduce muscular effort and signal safety. Gradual exposure to physical challenge (holding poses, tolerable discomfort) teaches the nervous system that activation does not equal danger. The progression from sympathetic activation (challenging pose) to parasympathetic recovery (rest) trains autonomic flexibility — the ability to shift between states rather than being stuck in one.

2. Interoceptive Disconnection

Trauma fragments the connection between the brain and the body. Traumatized individuals often report feeling disconnected from their bodies — unable to identify what they are feeling, unable to locate emotions in the body, unable to distinguish hunger from anxiety or fatigue from sadness. This alexithymia (inability to identify emotions) and interoceptive deficit is a core feature of PTSD.

The neurological basis is impaired insular cortex function. The anterior insula, which processes interoceptive signals and generates the conscious experience of bodily feelings, shows altered activation in PTSD — either hyperactive (producing overwhelming body sensations) or hypoactive (producing numbness and disconnection).

How yoga addresses it: Yoga is, fundamentally, an interoceptive training program. Every instruction to “notice the sensation in your right hand” or “feel the breath in your belly” is an exercise in insular cortex activation — the deliberate reconnection of awareness with the body’s internal signals. This reconnection proceeds at the practitioner’s own pace, in a safe environment, with the support of a trauma-informed teacher.

3. Impaired Self-Regulation

Traumatized individuals have difficulty regulating their emotional and physiological states. They cannot calm themselves when activated. They cannot energize themselves when shut down. The regulatory circuits — connecting the prefrontal cortex to the amygdala, the vagus nerve to the heart, the hypothalamus to the adrenals — are damaged or dysregulated.

How yoga addresses it: Yoga provides a toolkit of self-regulation techniques that the practitioner can use outside of class:

• Extended exhalation breathing for calming (activates the vagal brake)
• Kapalabhati or rapid breathing for energizing (activates the sympathetic system when needed)
• Grounding poses for stability (proprioceptive input that signals safety)
• Forward folds for turning inward (parasympathetic activation)
• Backbends for opening up (countering the protective contraction of trauma)

Over time, the traumatized individual develops an internal regulatory capacity that replaces the external regulation they previously sought through substance use, self-harm, or dependent relationships.

4. Thwarted Defensive Responses

During traumatic events, the body mobilizes for fight or flight. If neither is possible — if the person is pinned, restrained, frozen, or overwhelmed — the defensive response is initiated but not completed. The energy mobilized for action remains trapped in the body, producing the chronic muscular tension, hyperarousal, and intrusive re-experiencing of PTSD.

Peter Levine’s Somatic Experiencing model describes trauma resolution as the completion of these interrupted defensive responses. The body needs to discharge the survival energy that was mobilized but never expended.

How yoga addresses it: Yoga provides structured, safe contexts for completing defensive movements:

• Pushing movements (Plank, Chaturanga): Complete the thwarted “push away” response
• Standing poses (Warrior I, II, III): Complete the thwarted “stand your ground” response
• Twisting poses: Complete the thwarted “turn away” response
• Running-like movements (dynamic lunges): Complete the thwarted flight response
• Trembling and shaking (which sometimes occurs spontaneously during challenging holds): The body’s natural mechanism for discharging survival energy

Trauma-Sensitive Yoga (TSY): Principles and Practice

David Emerson and Elizabeth Hopper developed Trauma-Sensitive Yoga at the Trauma Center at Justice Resource Institute (founded by van der Kolk). TSY is not simply “yoga for people with trauma” — it is a fundamentally redesigned approach to yoga that addresses the specific needs of traumatized individuals.

Core Principles

1. Invitational Language

Standard yoga instruction is directive: “Raise your arms. Straighten your legs. Hold for five breaths.” For traumatized individuals, directives can trigger compliance patterns established during abuse — doing what the authority figure says because refusal was not safe.

TSY uses invitational language: “You might choose to raise your arms.” “If it feels okay, you could straighten your legs.” “You’re welcome to hold this or come out whenever you choose.” The emphasis is on the practitioner’s agency — their capacity to choose — which is precisely what trauma took away.

2. No Physical Adjustments

Standard yoga classes often involve hands-on adjustments — the teacher touching the student to correct alignment. For trauma survivors, unexpected or unwanted touch can be retraumatizing. TSY eliminates all physical adjustments. The teacher uses verbal cues and demonstrations only.

3. No Forcing, No “Pushing Through”

Standard yoga culture sometimes valorizes pushing through discomfort, “going deeper,” or “finding your edge.” For trauma survivors, these instructions reproduce the dynamic of the traumatic experience — enduring something painful because someone tells you to. TSY explicitly permits the practitioner to stop, modify, or skip any pose at any time without explanation.

4. Predictability and Routine

Trauma disrupts the sense of predictability and safety. TSY classes follow a consistent format, in a consistent space, at consistent times. The practitioner knows what to expect. Predictability is safety for a traumatized nervous system.

5. Interoceptive Inquiry, Not Achievement

Standard yoga often focuses on alignment, depth, or aesthetic form. TSY focuses exclusively on the practitioner’s internal experience: “What do you notice?” “What sensations are present?” The goal is not to achieve a pose but to develop awareness of what the body experiences in the pose. This interoceptive inquiry is the therapeutic mechanism.

6. Choice-Making as Practice

TSY offers choices within each pose: “You might keep your eyes open or closed.” “Your hands could be on your hips or by your sides.” These micro-choices are therapeutic: they exercise the agency that trauma eroded. The traumatic experience was defined by the absence of choice. TSY is defined by the presence of it.

A Sample TSY Sequence

1. Seated centering (3 minutes): Seated in a chair or on the floor. Feet on the ground. Noticing the contact points between the body and the support surface. “You might notice where your body is making contact with the chair.”

2. Gentle neck movements (3 minutes): Slow head turns, tilts, and circles. “If you choose, you could turn your head to the right. Notice what that’s like.”

3. Seated twist (3 minutes each side): Gentle spinal rotation. “You’re welcome to place your hand on the opposite knee, or not.”

4. Standing mountain pose (2 minutes): Standing with feet hip-width apart. “Notice the ground under your feet. You might shift your weight slightly from side to side.”

5. Warrior II (2 minutes each side): A powerful standing pose that embodies strength and groundedness. “You could choose to bend your front knee, finding an amount that works for you.”

6. Forward fold (2 minutes): Standing or seated. “If it feels okay, you might let your head drop. You could keep your knees as bent as you like.”

7. Bridge pose (2 minutes): Supine with feet on the floor, hips lifted. “You might press through your feet and lift your hips, or you might choose to stay here.”

8. Supported rest (5 minutes): Supine or seated, with eyes open or closed. “You could rest here in whatever position feels comfortable.”

The Polyvagal Framework for Trauma-Sensitive Yoga

Stephen Porges’ polyvagal theory provides the most comprehensive neuroscientific framework for understanding both trauma and its resolution through yoga.

The Three States in Trauma

Ventral vagal (safety): This is the state that trauma disrupts. The traumatized person’s ventral vagal system is unreliable — they cannot consistently access the feelings of safety, connection, and calm that ventral vagal engagement provides.

Sympathetic (fight-or-flight): This is where most PTSD patients spend most of their time. Hypervigilance, startle, insomnia, irritability — the sympathetic system is stuck in the “on” position.

Dorsal vagal (freeze/collapse): When sympathetic arousal becomes overwhelming, the nervous system drops into dorsal vagal shutdown — dissociation, numbness, fatigue, depression. Many trauma survivors oscillate between sympathetic hyperarousal and dorsal vagal collapse without spending adequate time in ventral vagal safety.

How TSY Activates the Ventral Vagal System

The ventral vagal complex innervates the muscles of the face, head, and neck — the muscles involved in social engagement (facial expression, vocalization, listening). TSY activates this system through:

• The teacher’s voice: A calm, warm, prosodic voice activates the middle ear muscles (which are innervated by the ventral vagal complex), promoting a sense of safety
• Gentle neck movements: The sternocleidomastoid and trapezius, innervated by the accessory nerve (CN XI, which shares brainstem nuclei with the vagal complex), are gently mobilized
• Breath practices: Extended exhalation activates the vagal brake
• Social context: Being in a room with other people who are calm and regulated provides co-regulation — the nervous system entrains to the calm of others

Integration with Other Trauma Therapies

TSY is most effective as part of a comprehensive trauma treatment plan:

Phase 1 (Stabilization): TSY, breath practices, and grounding exercises establish the somatic foundation of safety and self-regulation. This phase may last weeks to months for individuals with complex trauma.

Phase 2 (Processing): Once stabilization is established, trauma-processing therapies (EMDR, CPT, Somatic Experiencing, Internal Family Systems) can safely access and reprocess the traumatic material. The regulatory capacity built in Phase 1 prevents retraumatization during processing.

Phase 3 (Integration): Ongoing yoga practice supports the integration of processed material and the rebuilding of a relationship with the body, with others, and with life.

TCM and Functional Medicine Perspectives

In traditional Chinese medicine, trauma disrupts the Heart (which houses the shen, the spirit/consciousness) and the Kidney (which stores the jing, the constitutional essence that is depleted by extreme stress). PTSD symptoms map to specific TCM patterns:

• Hypervigilance: Heart Fire blazing (shen disturbed)
• Insomnia: Heart and Kidney not communicating (Fire and Water separated)
• Dissociation: Shen leaving the body (spirit not anchored)
• Chronic fatigue: Kidney Jing depletion (constitutional exhaustion)

Yoga practices that settle the shen (meditation, Yoga Nidra), nourish Kidney Jing (restorative poses, deep rest), and re-establish the Heart-Kidney axis (grounding practices combined with breath regulation) address these patterns directly.

From a functional medicine perspective, PTSD involves HPA axis dysregulation, chronic inflammation, gut-brain axis disruption, and oxidative stress. Yoga addresses each of these through the autonomic, anti-inflammatory, and neuroendocrine mechanisms described throughout this library.

The Four Directions and Trauma

Trauma disrupts all four directions:

• East (new beginning): Trauma makes every morning feel like a return to the same nightmare. TSY offers the possibility that today could be different — one pose, one breath, one moment of safety.
• South (the body): Trauma turns the body into a battlefield. TSY begins the work of reclaiming the body as home.
• West (letting go): Trauma creates hypervigilance — the inability to let go of threat detection. Restorative yoga and Yoga Nidra teach the nervous system that it is possible to rest.
• North (wisdom): The elder’s perspective recognizes that what happened is over. The body has not yet received this message. Yoga delivers it — not through words but through the body’s experience of safety, strength, and agency.

The healing journey in the Four Directions moves through all four: from the South (reconnecting with the body), to the East (new beginning), to the North (perspective and meaning-making), to the West (release and integration). This is not a linear path but a spiral — revisiting each direction at deeper levels as healing progresses.

References

• Emerson, D., & Hopper, E. (2011). Overcoming Trauma through Yoga: Reclaiming Your Body. North Atlantic Books.
• Emerson, D. (2015). Trauma-Sensitive Yoga in Therapy: Bringing the Body into Treatment. W. W. Norton & Company.
• Levine, P. A. (2010). In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. North Atlantic Books.
• Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. W. W. Norton & Company.
• Rhodes, A., Spinazzola, J., & van der Kolk, B. (2016). Yoga for adult women with chronic PTSD: a long-term follow-up study. Journal of Alternative and Complementary Medicine, 22(3), 189-196.
• van der Kolk, B. A. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Viking.
• van der Kolk, B. A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak, M., & Spinazzola, J. (2014). Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. Journal of Clinical Psychiatry, 75(6), e559-e565.
• West, J., Liang, B., & Spinazzola, J. (2017). Trauma sensitive yoga as a complementary treatment for posttraumatic stress disorder: a qualitative descriptive analysis. International Journal of Stress Management, 24(2), 173-195.