May/June 2017 Issue

Yoga For Addiction — Tapping the Body's Wisdom
By Kate Jackson
Social Work Today
Vol. 17 No. 3 P. 18

Experts suggest that less talk and more action may help people with substance use disorders.

In 2014, roughly 21.5 million people over the age of 12 had a substance use disorder in the past year, according to the Substance Abuse and Mental Health Services Administration's 2014 National Survey on Drug Use and Health. Alcohol abuse affected 17 million people and illicit drug use 7.1 million, while 2.6 million had both. And the Centers for Disease Control and Prevention confirms that overdose deaths from heroin have been on the rise, increasing more than fivefold from 2002 to 2014. Equally concerning are the increasing numbers of individuals abusing prescription opioid drugs. The National Institute on Drug Abuse estimates that crime, health care, and lost productivity related to tobacco, alcohol, and illicit drug abuse cost the nation more than $700 billion each year. These statistics suggest that the need for effective care is more urgent than ever, yet outcomes of existing therapeutic strategies for addictive behaviors are disappointing.

Therapists, who primarily are trained to use language to help their clients overcome challenges, appeal to the mind to encourage new ways of thinking and bring about changes in beliefs or behaviors. Standard therapeutic approaches to addiction—talk therapies such as cognitive behavior therapy or 12-step programs—rely on words and the sharing of information. Results have been less than ideal, and relapse rates are exceedingly high. These unsatisfactory outcomes, coupled with the widening heroin and opiate addiction crisis, make the need for innovative approaches increasingly desirable.

Social workers and other practitioners are exploring complementary strategies that involve less talk and more action. Yoga therapists, for example, suggest that a better path to releasing emotional pain and promoting healing is through the body. They emphasize the need to focus not on new ways of thinking, but on new ways of feeling.

Yoga is progressively being incorporated into treatment and recovery programs for individuals with substance use disorders, in inpatient and outpatient rehabilitation settings, prisons, 12-step programs, and other community environments. At the same time, many health care professionals and therapists in private practice, including social workers, are adding yoga to their therapeutic toolboxes, becoming trained themselves to employ yoga therapy as an adjunct to their work with people in treatment and recovery. These techniques also are being used to help individuals with eating disorders as well as sex, gambling, shopping, and nicotine addictions.

Yoga chiefly combines breathing exercises, physical postures known as asanas, strength exercises, and the cultivation of mindful attention, sensory awareness, and intense concentration. Regular practice is known to contribute to optimal wellness and provides multiple benefits, both physical and emotional, including the development or reinforcement of discipline, improved impulse control, relief from stress, reduction in blood pressure, easing of muscle tension, reduced emotional distress, and the generation of new neural connections. And considerable research shows that yoga therapy—the use of yoga principles and poses within the therapeutic setting—is an effective complementary approach to a range of illnesses and psychological conditions.

Although there isn't a large body of research supporting yoga therapy's direct effect on people with addiction, there's significant evidence supporting its benefits for those with conditions believed to underlie addiction, including depression, anxiety, and trauma. Yoga activates the parasympathetic nervous system and increases levels of neurotransmitters that improve mood and enhance relaxation. Studies have shown that it increases blood levels of gamma-aminobutyric acid, which are often low in people with substance use disorders and anxiety, and reduces levels of the stress hormone cortisol. Consistent practice has been shown to disrupt neural pathways that may reinforce drug use. It also alters brain density and can even change the size of certain areas of the brain, which may contribute to improved decision-making, better concentration, and even increased self-awareness. The practice of yoga further contributes to self-regulation as well as self-efficacy because clients can learn to incorporate yoga into their daily lives to calm and center themselves and learn to sit with, rather than act on, urges and cravings.

Yoga's value for people in addiction treatment and recovery, experts say, is chiefly its ability to bypass the barriers of language, whether it involves the discipline of hatha yoga (the most commonly practiced form), kundalini yoga, trauma-sensitive yoga, an approach influenced by the 12-step principles, or a combination of approaches.

Trauma-Sensitive Yoga
Giving a boost to the use of yoga for addicts in treatment and recovery has been the work of Bessel A. van der Kolk, MD, a professor of psychiatry at Boston University Medical School and medical director of the Trauma Center at Justice Resource Institute in Brookline, MA; and author of Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society and The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. His research demonstrates that trauma and sensory experience are linked by the residue of trauma residing in the body. His work points both to the limitations of language in the counseling of individuals who have experienced trauma and its lingering somatic consequences and to the value of employing nonlinguistic methods.

Yoga therapist David Emerson, E-RYT, a former social worker and founder and director of yoga services for the Trauma Center, developed the curriculum for the discipline he named trauma-sensitive yoga. A contributor to the center's research on yoga and PTSD, he's also the author of Overcoming Trauma Through Yoga and the more recent Trauma-Sensitive Yoga in Therapy: Bringing the Body Into Treatment. Trauma-sensitive yoga, according to the center's website, "has foundations in trauma theory, attachment theory, and neuroscience as well as hatha yoga practice with an emphasis on body-based yoga forms and breathing practices." The Trauma Center offers a Trauma-Sensitive Yoga DVD and a three-part e-course by Emerson, Healing Trauma Through Yoga, which teaches therapists how to employ trauma-sensitive yoga in their practices. It also offers a certification program for yoga teachers and mental health career professionals.

In one of the studies conducted at the Trauma Center, women with chronic PTSD who did not respond to treatment showed reduced symptoms after a 10-week program of trauma-informed yoga. A follow-up study demonstrated that a longer intervention with the addition of the assignment and monitoring of home practice was even more beneficial. Emerson, who contributed to that research, says, "What we know, based on our studies, is that our yoga model clinically reduced PTSD symptoms in a group of women who survived early-life physical and sexual abuse. We also know, based on a very small cohort, that our yoga model, after 20 weeks, may contribute to increased activity in interoceptive brain regions (parts of the brain that help us sense our body experience and then be able to interact with it successfully, e.g., pull your hand away from a hot stove in response pain). A picture of a brain scan demonstrating this, he says, appears in van der Kolk's The Body Keeps the Score. "Finally," Emerson adds, "there have been a few really good qualitative studies (interviews with the women in our PTSD study) that suggest our yoga model contributes to key areas of global life functioning like increased agency and increased self-worth."

Although limited, research more specifically focusing on yoga in addiction treatment and recovery was performed as early as 1993, when Howard Shaffer, PhD, CAS, director of the division on addiction at Harvard Medical School, explored the role of yoga in methadone maintenance treatment. In 1997, along with other researchers, he explored the relative effectiveness of hatha yoga and dynamic group psychotherapy in a randomized clinical trial. In addition to noting yoga's physical benefits, including feelings of well-being and release of physical tension, the researchers observed, "Yoga allows a release of tension that is more direct and immediate than one experiences in verbal therapy. When yoga is practiced, a release of tension occurs that is not always in the body alone, but can be in the heart, the mind, or in feeling states. Release of that tension can put one back in touch with oneself on a very deep level." The researchers further note that yoga therapists had reported greater levels of self-awareness and emotional insight among participants. In a clinical trial, Shaffer demonstrated that 75 minutes' practice of hatha yoga along with one group therapy session was as effective as individual counseling in reducing cravings and drug use among heroin addicts enrolled in a methadone maintenance clinic.

Yoga and the 12-Step Philosophy
Nikki Myers founded Yoga of 12 Step Recovery (Y12SR) to integrate the two practices she credits with facilitating her own recovery—yoga and the 12-step program—into a holistic approach to addiction. Y12SR now certifies individuals to lead community-based meetings all over the country. Yoga therapist Blakey Elkhart Kornfeld, C-IAYT, a certified leader of Y12SR who trained with Myers, explains that in a meeting "there's a sharing circle in the style of 12-step meetings." Participants have the option of sharing on a topic after the 12 steps are read, and then a breath-centered practice goes along with the yoga movements. Elkhart Kornfeld, who in her own recovery found that yoga was a perfect companion to 12-step meetings, defines trauma as something that overwhelms the system and degrades the ability to cope. Thus, she believes, addiction is self-inflicted trauma. Because addiction results from trauma and addicts experience trauma, she relies on the use of trauma-sensitive yoga as the appropriate means through which to support individuals in treatment and recovery.

One thing yoga has in common with the 12-step experience, according to Elkhart Kornfeld, is that it's an internal process. "It's a journey that has to be done by the individual," she says, "and it's inside that the transformation takes place." The 12 steps, she explains, "are very cerebral, and while there's a spiritual component to them, they mostly work through behavior and intellectual changes, like those achieved through cognitive behavior therapy. But trauma affects parts of the brain that can't be reached by CBT [cognitive behavioral therapy], by talking, or by going to meetings. Those things can help, but you have to work with the body to be able to achieve long-term change."

In addition to working with Y12SR, Elkhart Kornfeld is training director for the Transformation Yoga Project, which provides mindfulness-based trauma-sensitive yoga within veterans' centers, the criminal justice system, and addiction treatment centers in five counties around Philadelphia.

The 12-step principles are profound and amazing, says Aruni Nan Futuronsky, who teaches Yoga of Recovery: 12-Step Spirituality at Kripalu Yoga Center in Stockbridge, MA. However, the one thing the 12 steps don't acknowledge, she adds, is that addiction is a body-centered process. Adding a practice of yoga to the principles of the 12 steps "is a remarkable marriage of success." In recovery herself and sober 30 years, Futuronsky largely credits the principles of Yoga Off the Mat—"the practice of being present, living skillfully, extending the space between the stimulation and the response."

A hallmark of trauma, and thus of addiction, is a sense of disconnection with the body, and one of the benefits of yoga is that it integrates mind and body. Yoga Off the Mat, Futuronsky says, "is about changing the brain, the body, and the behavior." She recalls that she drank and took drugs because she didn't know how to simply feel the sensations in the body. "Yoga enlarges our capacity to be present with sensations, and, as that happens, we become more present in life, we have more choices." In on-the-mat practice, for example, she says, "We mindfully make a decision to experience tension in the arms, and then find ways to relax with that tension. As we relax, we feel the tension pushing away. We can watch it, let it come and go."

Bringing Yoga Into Social Work
Yoga therapy has the potential to expand upon and enlarge the ways in which social workers help individuals struggling with addiction. That might be as simple as gathering resources so that they can refer clients to practitioners of yoga therapy for addiction, or training to become yoga therapists themselves.

Effie Mitskopoulos, HBSc, MSW, RSW, CYT-500, a holistic counselor in private practice who's been working with individuals with addiction since 2009, says yoga strengthens the nervous and immune systems and liberates energy and blood flow. Physically moving the body, she explains, brings up trauma and emotions to be released. Therefore, it's important to note that yoga therapy for addiction employs a very specific and specialized form of yoga, so it's not enough to advise clients to go to their local yoga studios, Elkhart Kornfeld says. Social workers interested in bringing the benefits of yoga to their clients must either study yoga themselves—specifically trauma-informed strategies geared for people in treatment and recovery—or be able to refer clients to trained yoga therapists. Without being grounded in a trauma-sensitive approach, she suggests, instructors risk retraumatizing participants.

There are great benefits to becoming a yoga instructor, Futuronsky says, "but you have to be a body-centered person yourself before being able to help others through yoga." Like Mitskopoulous and Elkhart Kornfeld, she recommends specific training in trauma-sensitive yoga.

"Yoga is a healing technique, and if I'm doing therapy, I'm helping people heal, so it's just another toolbox I use, just like CBT [cognitive behavioral therapy], mindfulness, or DBT [dialectical behavior therapy]," Mitskopoulos says. "I was a therapist before I became a yoga teacher, and becoming a yoga teacher helped me become a better therapist."

— Kate Jackson is an editor and freelance writer based in Milford, PA, and a frequent contributor to Social Work Today.

SELECTED TRAINING RESOURCES
American Viniyoga Institute: www.viniyoga.com
Kripalu Center for Yoga & Health: www.kripalu.org
Transformation Yoga Project: www.transformationyogaproject.org
Trauma Center at Justice Resource Institute: www.traumacenter.org