Lauren Mansell, DPT, CLT, PRPC is the author and instructor of Trauma Awareness for the Pelvic Therapist, a course now available remotely. Lauren's next offering of her course is coming up this May 1-2, 2021
Working with survivors of sexual violence has been the most challenging and rewarding aspect of my pelvic rehabilitative work. I am fortunate to have been trained as a legal and medical advocate for sexual assault survivors and worked within mental health prior to becoming a physical therapist. I hope to give everything I know about being a patient centered trauma aware practitioner. Can we talk about how common sexual violence is within our society and within our work? I can spout the statistics: 1 in 3 females and 1 in 7 males report unwanted sexual attention; 1 in 6 females and 1 in 33 males experience sexual assault.* But in our rooms, sexual violence is pandemic.
Please feel empowered to provide appropriate, trauma-informed support to these patients. It starts with our wellness and self-care. We cannot empower others if we have not empowered ourselves. We don’t have to be perfect. Practice self-forgiveness. Know your triggers. Commit to impeccable self-care. Be well. Keep ourselves safe by practicing empowered choice. If you have empowered choice, you can provide and teach empowered choice to your patients. What is empowered choice? Empowered choice is saying: we don’t do anything you don’t want to do or I don’t do anything I don’t want to do. Ever. Give your patient the power of directing their healing while providing extensive physiology and anatomy education with trauma-focused, patient-centered care. With information, patients choose what they want treated when. And with empowered choice, they tend to choose higher level treatment quicker. Additionally, they may show up to more appointments and, from my experience, they get better faster. I know we all do this with informed consent, but I have found success with being immensely purposeful in repeatedly telling the patient that they are in control of the treatment. Patients are completely in control of the treatment, not to be confused with being in control of me.
After empowered choice, normalizing their experience is valuable for our treatment relationship. This is possibly the saddest part of this work- how normal it is for my patients to have sexually violent experiences. I say over and over how typical it is for patients to have experienced sexual violence and how it negatively affects pelvic function. I also say they don’t need to tell me anything about their trauma and that I don’t require they go to counselling to participate in pelvic rehab. I do however let them know if they want to disclose their traumas or be connected to resources, I will gladly assist in their support. I do let them know that there are times I have to report (I live in a mandated reporting state) and tell them exactly what my rules are. Being clear and informative while being supportive and trauma-informed helps reduce the SHAME patients who experienced sexual violence carry. These patients typically feel embarrassed and ashamed by the abuse perpetrated against them in addition to the physical somatization from the trauma. And that their response during treatment is a normal response to an abnormal situation.
Take care of you. Empowered choice for all involved. Normalize the survivors’ response. Disempower Shame. And join me for Trauma Awareness for the Pelvic Therapist if you want more science and skills for patient care!
* Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, National Crime Victimization Survey, 2018 (2019).
Last week- on May 6 amid a pandemic- the Department of Education released changes to Title IX. Title IX is a 1972 Civil Rights Act that bans sexual discrimination within the educational system. Sadly, the new provisions within the 2,033 page document include the following changes:
23% of undergraduates and 11% of graduate students report having experienced sexual violence, AND we know survivors under-report assaults. We talk extensively about medical and legal considerations for sexual violence survivors in my "Empowering the Sexual Assault Survivor" course. Participants who took my course will need to know those protections we discussed just a few days ago are slated to be rolled back. Today, in my remote course "Trauma Informed Care", we lay the physiological and neurobiological framework for empowering the sexual assault survivor. Following that, in addition to how to continue empowering for survivors, we elaborated on the legal changes listed above.
Outrageously, these Title IX deregulating provisions are to go into effect August 14, 2020 while schools are struggling to keep students safe amid coronavirus pandemic. Again, let us look at these percentages (23% of undergraduates, and 11% of graduate students) and think about who needs safety and protection.
Schools do have choice in whether they roll back their protections to survivors of sexual violence. If you're looking for ways to help, you may want to reach out to your alma mater and ask what changes they are planning to make in the context of this new deregulation and disempowerment of Title IX protections. Maybe contact your local sexual assault coalition and see how you can become involved. You could also contact your legislature and/or leave comment on www.regulations.gov (search title IX and education).Empower yourself so that you can empower others! As a physical therapist specialized in pelvic rehabilitation, empowering survivors of sexual violence happens every day in my practice. I hope you feel empowered, supported and successful in doing this challenging work too!
It’s OK to be feeling (insert feeling) right now. (maybe: sad, fearful, angry, denial, numb, anxious, avoidant, bored?)
It’s OK to acknowledge those feelings.
It’s also OK to create a plan and direction about what we may do about our feelings, thoughts, and actions.
We can change how we think, what we do and ultimately how we feel.
Breathe. Place a hand on your chest and a hand on your abdomen. Practice inhaling long and deep as if you were pouring the air into your body- first filling the lower hand and then filling the top hand. Pause for a moment when you feel your canister is full and then exhale slowly (top to bottom or bottom to top- either works fine). I prefer breathing through my nose for inhale and exhale but know if you are congested, mouth breathing is fine or you can inhale through the nose and exhale through the mouth- find what works for you. Work on increasing the number counted (silently in your mind) while you inhale, pause briefly and then exhale- making that number count on exhale the same or even longer. Make it a game to see how long and deep your breath can become. Reduce intensity if feeling lightheaded.
Focus on your breath and feel calmness. Return to this breathing whenever you can.
Body Scan/Progressive Relaxation. Take a moment and scan your body for pain or tension. You can start at the top of your body or where your feet are grounded to floor. Notice your body and allow it to be, without judgement. Then starting from the top of your body or the bottom, contract your muscles systematically and then relax. Or focus on the muscle group and allow the muscles to relax and slacken. Maybe send your long, deep breath to each area? Maybe think of color washing each area? Make your scan personal and positive for you. Check-in to your body without judgement and send gratefulness for the work your amazing body does.
Stand Big. Find a wall and place your backside onto it. Pretend there is a string at the crown of your head and imagine your head being pulled up towards the ceiling. Lift your chest as you are standing tall and use your slow, steady, deep breathing to create bigness and calmness. Relax your shoulders. Maybe place the back of your hands onto wall and feel the opening of your chest. Once you have practiced this posture, you can refer to this posture during your day. Stand big, breathe big, be big.
Intentionally SCHEDULE into your life what you love. Schedule time listening to your favorite music. Maybe take up playing an instrument? Practice singing in the shower or car. Set a timer and dance fervently. Create time to draw or paint or write. Make a recipe. Get frozen berries and make smoothies. Maybe add frozen spinach to your smoothie?
Pick up a book. Play a game, cards or even solitaire. Practice Sudoku. Take a bath or shower. Go for a long walk while keeping your distance from others. Find a workout you can do at home that makes you feel powerful. Whatever you love, turn it into a scheduled ritual. Make one small goal and work towards it. Focus on what we can do instead of what we cannot. Find some activity and fulfill a passion just for you. Make sleep a priority and know if you have a bad night, that the next night you will likely sleep better. Perhaps create a sleeping ritual? Call others and ask what they are doing for themselves? Remember to forgive yourself and to feel or express the feelings that are within you. We are all going through this together. Make you a priority and schedule yourself some HAPPY.
Lastly- try to limit the news, your phone and the frig. All of these can create negative feelings that do not fulfill us.
Breathe. Find love in positive activities. Be brave. Be grateful. Forgive.
We are all in this together.
Lauren Mansell DPT, CLT, PRPC is the author and instructor of the Trauma Awareness for the Pelvic Therapist course. She is also offering several courses via Zoom video conference during the Covid-19 pandemic, which can be found on our Remote Learning Opportunities page. Prior to becoming a physical therapist, Lauren counseled suicidal and homicidal SES at-risk youth who had survived sexual violence. Lauren was certified as a medical and legal advocate for sexual assault survivors in 1999 and has advocated for over 130 sexual assault survivors of all ages in the ED. Lauren's physical therapy specialty certifications include Certified Lymphedema Therapist (CLT), Pelvic Rehabilitation Professional Certificate (PRPC) and Certified Yoga Therapist (CYT). She is a board member of Chicagoland Pelvic Floor Research Consortium, American Physical Therapy Association Section of Women's Health and Section of Oncology.
This is part two of a three-part series on self-care and preventing practitioner burnout from faculty member Jennafer Vande Vegte, MSPT, BCB-PMD, PRPC. Part One is available here. Jennafer is the co-author and co-instructor of the along with Nari Clemons, PT, PRPC.
Augh, I was so frustrated with myself. I fell for it again. Here’s the scenario: a patient came in suffering excruciating pain. She had been to see a pelvic health professional as well as various medical professionals and was unable to get relief and answers for her rectal pain. She was desperate and called me “her last hope.” Phrases used included, “I need you! Fix me! I hear you are a miracle worker! If you can’t help me no one can!” And just like that I took on the role of Rescuer.
In 1968 a psychiatrist named Stephen Karpman developed a model of personal interaction that he called the Conflict Triangle. It has also become known as the Karpman Triangle, The Drama triangle or the Victim triangle. Per Wikipedia:
The Victim: The Victim's stance is "Poor me!" The Victim feels oppressed, helpless, hopeless, powerless and ashamed. They seem unable to make decisions, solve problems, take pleasure in life or achieve insight. The Victim, if not being persecuted, will seek out a Persecutor and also a Rescuer who may save the day, but may also perpetuate the Victim's negative feelings.
The Rescuer: The Rescuer's line is "Let me help you." A classic enabler, the Rescuer feels guilty if they don't rush to the rescue. Yet their rescuing has negative effects: It keeps the Victim dependent and gives the Victim permission to fail. The rewards derived from this rescue role are that the focus is taken off of the Rescuer. When they focus their energy on someone else, it enables them to ignore their own anxiety and issues. This rescue role is also pivotal because their actual primary interest is really an avoidance of their own problems disguised as concern for the victim’s needs.
The Persecutor: (a.k.a. Villain) The Persecutor insists, "It's your fault." The Persecutor is controlling, blaming, critical, oppressive, angry, authoritative, rigid, and superior.
What is interesting about this triangle is that the roles are constantly shifting. In full rescuer mode, I gladly took on this patient, intent on solving her problems. Over time, I saw that my consistent coaching for lifestyle change and self-care was falling on deaf ears. My patient was not following through with anything I asked of her; therefore my treatment plan was not working. The patient began to get frustrated with me. I then cast myself as the victim. She became my persecutor! While perhaps in her mind, I had failed as the rescuer, she was still the victim and I had become her persecutor. At the time, I did not have the skills to know how to navigate this situation in a positive or helpful way. Finally I sought the advice of my supervisor and my therapist to draw up a contract with this patient. The contract outlined each of our responsibilities. If either of us didn’t fulfill our responsibilities, the consequence would be ending our professional relationship. When she persisted, unwilling to do her part, I discharged her per our agreement.
I learned so much from this experience. Here are some things that I have implemented and may be helpful in your practice if you have similar challenges.
- In an initial visit with a new patient I explain that the patient and I make a team and we each have a role to play in reaching the patient’s goals.
- If someone says, “Fix me!” I say, “Think of me as your coach, I can show you how to help your body heal, but it’s your job to do the work.”
- When I hear, “Everyone says you are a miracle worker.” I say, “That is so kind, but it doesn’t work that way. Healing is complicated and everyone has their own journey.”
- In this way, with baby steps, we can get OUT of the drama triangle and into healthy relationships with our patients and the people in our lives.
- Consider the Winner's Triangle published by Acey Choy in 1990.
In her blog NextMeCoaching, Jessica Vader coaches on turning Drama and Control into a Winning situation.
The three roles in the Winner’s Triangle.
Vulnerable – a victim should be encouraged to accept their vulnerability, problem solve, and be more self-aware.
Assertive – a persecutor should be encouraged to ask for what they want, be assertive, but not punishing.
Caring – a rescuer should be encouraged to show concern and be caring, but not over reach and problem solve for others.
If you struggle with professional and personal boundaries, you are not alone, and you can get support. Consider talking with your supervisor, a counselor, reading a good book on the subject, and or taking Boundaries, Mediation and Self Care, a course offering through Herman and Wallace that was designed to help pelvic health professionals stay healthy and inspired while equipping therapists with new tools to share with their patients.
We hope you will join us for Boundaries, Mediation and Self Care this November 9-11, 2019 in San Diego, CA.
Look forward to my next blog where saying no takes an unexpected turn.
The number of individuals who identify as transgender is growing each year. The Williams Institute estimated in 2016 that 0.6% of the U.S. population or roughly 1.4 million people identified as transgender (Flores, 2016). This was a 50% increase from a 2011 survey which estimated only 0.3% or 700,000 people identified as transgender (Gates, 2011). Though these numbers are growing each year, due to increased visibility and social acceptance, it is presumed that these numbers are underreported due to inadequate survey methods, stigma/fear associated with “coming out” and deficient definitions of the multitude of options for gender identity (Flores, 2016).
With the rise of individuals who identify as transgender, gender non-binary and intersex, healthcare professionals have equally seen an influx of patients who require care throughout their discovery and transition. Though medical intervention for these individuals is not new, the first documented surgery was in 1922 to Dora Richter, it has often been segmented and lacking in evidence-based treatment strategies (“Dora Richter,”2019). In 1979 The World Professional Association for Transgender Health (WPATH) was founded and published their first version of the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People (“WPATH,” 2019). Currently, WPATH is on their seventh version of the SOC which is opening doors for the treatment of this population.
Though organizations such as WPATH have attempted to standardized care, the patient experience and reception of quality care are significantly lacking. In 2015 the National Center for Transgender Equality performed a groundbreaking survey of 27,215 respondents with the aim to “understand the lives and experiences of transgender people in the United States and the disparities that many transgender people face” (“About,”n.d., para. 1). This survey revealed that 33% of individuals who saw a health care provider had at least one negative experience related to being transgender (National Center for Transgender Equality, 2015). Negative experiences included; being refused treatment, verbal harassment, physically or sexually assault, and teaching the provider about transgender people in order to get appropriate care (National Center for Transgender Equality, 2015). Alternatively, 23% of respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person (National Center for Transgender Equality, 2015). Though these statistics are staggering and affronting there is hope for a better future.
Research for the care of these patients, specifically related to pelvic floor physical therapy, is on the rise. In the Annals of Plastic Surgery, an article was published with the purpose to capture incidence and severity of pelvic floor dysfunction pre-surgery, monitor any progression of symptoms with standardized outcome measures and highlight the role of physical therapy in the treatment of patients undergoing vaginoplasty (Manrique, et al., 2019). While in the Journal of Obstetrics & Gynecology a retrospective case series similarly focused on physical therapy pre and post-operatively highlighting dilator selection and success, pelvic floor dysfunction including bowel and bladder as well as reported abuse history (Jiang, Gallagher, Burchill, Berli, & Dugi, 2019). Through articles such as these clinicians can expect an uptick in calls questioning if they treat these patients. This begs the question of, "How can you best prepare?"
The answer is simple, attend continuing education. It is where you can not only learn evidence-based evaluation and treatment but also connect with other providers and mentors that care for these patients. In 2020 Herman & Wallace will be offering a continuing education course that serves this exact purpose. Keep your eyes on next years offerings, as spaces will surely fill quickly.
About. (n.d.). Retrieved May 15, 2019, from http://www.ustranssurvey.org/about
Dora Richter. (2019, May 09). Retrieved May 15, 2019, from https://en.wikipedia.org/wiki/Dora_Richter
Jiang, D. D., Gallagher, S., Burchill, L., Berli, J., & Dugi, D. (2019). Implementation of a Pelvic Floor Physical Therapy Program for Transgender Women Undergoing Gender-Affirming Vaginoplasty. Obstetrics & Gynecology,133(5), 1003-1011. doi:10.1097/aog.0000000000003236
Manrique, O. J., Adabi, K., Huang, T. C., Jorge-Martinez, J., Meihofer, L. E., Brassard, P., & Galan, R. (2019). Assessment of Pelvic Floor Anatomy for Male-to-Female Vaginoplasty and the Role of Physical Therapy on Functional and Patient-Reported Outcomes. Annals of Plastic Surgery,82(6), 661-666. doi:10.1097/sap.0000000000001680
National Center for Transgender Equality. (2015). Annual report of the U.S. Transgender Survey. Retrieved May 15, 2019, from https://transequality.org/sites/default/files/docs/usts/USTS-Executive-Summary-Dec17.pdf
Wpath. (n.d.). Standards of Care version 7. Retrieved May 15, 2019, from https://www.wpath.org/publications/soc
In July of this year, I was invited to present in Christchurch, New Zealand as part of a teaching tour that took in Singapore, Australia and Tasmania. The topic of my class was female pelvic pain, so we discussed Endometriosis, Vulvodynia, Sexual Health and many other sub-topics but we had several discussions about the effects of trauma on pelvic pain. For those who have visited Christchurch, it is a beautiful city but it is still reeling from a series of massive earthquakes, that started in September 2010. The most devastating was in February 2011, when 185 people were killed and 6600 people were injured. Everywhere you go in Christchurch, there are reminders – from the constant buzz of ongoing construction, to structures that are waiting demolition, like the beautiful old cathedral that was beside our hotel. Usually, when I teach, we do some ‘housekeeping’ announcements about fire drills and exits; in Christchurch it was ‘In the event of an earthquake…’. I wondered how the near constant reminders were affecting the inhabitants, so I read of how ‘…people called living with continual shaking, damaged infrastructure, insurance battles and unrelenting psychological stress ‘the new normal’. There are several ongoing research studies, looking at the effects of this trauma and how it is still having an effect on the people of Christchurch.
If you’ve attended Pelvic Floor Level 1 with Herman & Wallace, you’ll remember we quote a study from Van der Welde about the effects of perceived danger on muscle activity in the upper trapezius and pelvic floor muscles. We also discuss the work of Levine, of ‘Waking the Tiger’ fame, who explores the somatic effects of trauma in our bodies – and how trauma, much like pain, is whatever we say it is.
I became intrigued with the topic, so I was delighted to hear that Lauren Mansell has created a course to deal exactly with this topic. I was even more delighted when she sat down for a chat with me to explore the nuances of trauma awareness, boundary setting and self-care for therapists, especially pelvic therapists, who work with those who have experienced trauma of any kind.
I hope you find this conversation as interesting as I did! Here is our conversation:
1. ‘Vaginismus, a Component of a General Defensive Reaction. An Investigation of Pelvic Floor Muscle Activity during Exposure to Emotion-Inducing Film Excerpts in Women with and without Vaginismus’ van der Velde, J & Laan, Ellen & Everaerd, W. (2001)
2. ‘Waking The Tiger’ by Peter A. Levine (1997)
In a previous post on The Pelvic Rehab Report Sagira Vora, PT, MPT, WCS, PRPC told us how "women with sexually adverse experiences tend to have impaired genital response when in consensual sexual situations, however, women who do not have sexual abuse histories and but have sexual pain tend to have appropriate genital response." Today Sagira helps us understand how the pelvic floor responds to consensual sexual activity in women with a history of sexual trauma.
Today we try to look for answers for questions that came up during the last blogs.
How does the cohort that has had adverse sexual experiences present? How do women with history of sexual trauma process sexual experiences? How does the pelvic floor present or respond to consensual sexual situations when a woman has been abused in the past?
To answer these questions, it’s important to understand two facts about the pelvic floor. 1) the pelvic floor plays a role in emotional processing1, and 2) muscle activity in all muscles, including the pelvic floor, increases with exposure to stress and during anxiety evoking experiences2.
We explored in the last blog that women with sexual abuse histories responded with increased pelvic floor overactivity when watching movie clips with sexually threatening and consensual sexual content. Apparently, for women with sexual abuse history even consensual sexual situations can be experienced as threatening1.
Lehrer et. al. found overactivity in the neuronal and hormonal circuits that increase sexual arousal and activity. These circuits are already overactive in individuals who have Post Traumatic Stress Disorder (PTSD), and increased activity can increase anxiety, fear and other symptoms of PTSD instead of normal sexual arousal and excitement during a sexual experience2. For the woman with PTSD this means that sexual arousal signals impending threat rather than pleasure1. And as we already learned in previous blogs and above that when humans feel threatened they respond by tightening muscles and most notably the pelvic floor muscle.
Significant co-relation is found between sexual abuse, subsequent PTSD and chronic pelvic pain3. Hooker et. al, found irritable bowel syndrome, pelvic pain, and physical and sexual abuse to be the most commonly diagnosed together4. More importantly, when patients were successfully treated for PTSD they continued to be 2.7 times more likely to have pelvic floor dysfunction and 2.4 times more likely to have sexual dysfunction. This builds the case for interventions that are multidisciplinary to help patients of abuse and sexual assault, with the pelvic floor therapist playing a significant role.
In the next blog, lets explore how the pelvic floor therapist can work with a counselor and a sex therapist to help the woman with sexual pain dysfunction.
Anna Padoa and Talli Rosenbaum. The overactive pelvic floor. Springer. 1st ed. 2016
Yehuda R, Lehrner A, Rosenbaum TY. PTSD and sexual dysfunction in men and women. J Sex Med. 2015:12(5):1107-19
Blok BF. Holstege G. The neuronal control of micturition and its relation to the emotional motor system. Prog Brain Res. 1996; 107:113-26
Para ML, Chen LP, Goranson EN, Sattler AL, Colbenson KM, Seime RJ, Et. al. Sexual abuse and lifetime diagnoses of somatic disorders. JAMA. 2013; 302:550-61
Hooker AB, van Moorst BR, van Haarst EP, Van Ootegehem NAM, van Dijken DKE, Heres MHB, Chronic pelvic pain: evaluation of the epidemiology, baseline characteristics, and clinical variables via a prospective and multidisciplinary approach. Clin Exp Obstet Gynecol. 2013; 40:492-8
In a previous post on The Pelvic Rehab Report Sagira Vora, PT, MPT, WCS, PRPC shared that "cognitive-behavioral therapy appears to play a significant role in improving sexual function in women". Today, in part three of her ongoing series on sex and pelvic health, Sagira explores how sexual pain affects sexual dysfunction in women.
After having explored what allows for women to have pleasurable sexual experiences including pain-free sex and mind-blowing orgasms, we now turn towards our cohort that have pain with sex and intimacy. How does this group differ from women who do not have pain with sex? Are there some common factors with this group of women, and perhaps understanding these factors may help the pelvic floor therapist render more effective and successful treatment?
There are few studies exploring sexual arousal in women with sexual pain disorders. However, their findings are remarkable. Brauer and colleagues found that genital response, as measured by vaginal photoplethysmography and subjective reports, was found to be equal in women with sexual pain vs. women who did not have pain, when they were shown oral sex and intercourse movie clips. This and other studies have shown that genital response in women with dyspareunia is not impaired. Genital response in women with dyspareunia is however, effected by fear of pain. When Brauer and colleagues subjected women with dyspareunia to threat of electrical shock (not actual shock) while watching an erotic movie clip they found that women with dyspareunia had much diminished sexual response including diminished genital arousal. But Spano and Lamont found that genital response was diminished by fear of pain equally in women with sexual pain and women without sexual pain.
Fear of pain also resulted in increased muscle activity in the pelvic floor. However, this increase was noted in women with pain and women without sexual pain equally and was noted with exposure to sexually threatening film clips as well as threatening film clips without sexual content. The conclusion, then, from these results is that the pelvic floor plays a role in emotional processing and tightening, or overactivity is a protective response noted in all women regardless of sexual pain history.
The one difference that was noted was with women who had the experience of sexual abuse. For them, pelvic floor overactivity was noted when watching sexually threatening as well consensual sexual content. Women without sexual abuse history did not have increased pelvic floor activity when watching consensual sexual content.
In summary, evidence supports the hypothesis that women with sexually adverse experiences tend to have impaired genital response when in consensual sexual situations, however, women who do not have sexual abuse histories and but have sexual pain tend to have appropriate genital response. Both groups, however, have increased pelvic floor muscle activity in consensual sexual situations. This increase in pelvic floor muscle activity leads to muscle pain, reduced blood flow, reduced lubrication, increased friction between penis and vulvar skin and hence leads to pain.
This brings us to our next questions, how does the cohort that has had adverse sexual experiences present? How do women with history of sexual trauma process sexual experiences? How does the pelvic floor present or respond to consensual sexual situations when a woman has been abused in the past? Please tune in to the next blog for answers…
Blok BF, Holstege G. The neuronal control of micturition and its relation to the emotional motor system. Prog Brain Res. 1996; 107:113-26
Brauer M, Laan E, ter Kuile MM. Sexual arousal in women with superficial dyspareunia. Arch Sex Behav. 2006; 35:191-200
Brauer M, ter Kuile MM, Janssen S, Lann E. The effect of pain-related fear on sexual arousal in women with superficial dyspareunia. Eur J Pain: 2007; 11:788-98
Spano L, Lamont JA. Dyspareunia: a symptom of female sexual dysfunction. Can Nurse 1975;71:22-5
When I mentioned to a patient I was writing a blog on yoga for post-traumatic stress disorder (PTSD), she poured out her story to me. Her ex-husband had been abusive, first verbally and emotionally, and then came the day he shook her. Violently. She considered taking her own life in the dark days that followed. Yoga, particularly the meditation aspect, as well as other counseling, brought her to a better place over time. Decades later, she is happily married and has practiced yoga faithfully ever since. Sometimes a therapy’s anecdotal evidence is so powerful academic research is merely icing on the cake.
Walker and Pacik (2017) reported 3 cases of military veterans showing positive outcomes with controlled rhythmic yogic breathing on post-traumatic stress disorder. Yoga has been theorized to impact the body’s reaction to stress by helping to modulate important physiological systems, which, when compromised, allow PTSD to develop and thrive. This particular study focuses on 3 veterans with PTSD and their responses to Sudarshan Kriya (SKY), a type of pranayama (controlled yogic breathing). Over the course of 5 days, the participants engaged in 3-4 hours/day of light stretching/yoga, group talks about self-care and self-empowerment, and SKY. There are 4 components of breathwork in SKY: (1) Ujjayi (‘‘Victorious Breath’’); (2) Bhastrika (‘‘Bellows Breath’’); (3) Chanting Om three times with very prolonged expiration; and, (4) Sudarshan Kriya, (an advanced form of rhythmic, cyclical breathing).
This study by Walker and Pacik (2017) included 3 voluntary participants: a 75 and a 72 year old male veteran and a 57 year old female veteran, all whom were experiencing a varying cluster of PTSD symptoms for longer than 6 months. Pre- and post-course scores were evaluated from the PTSD Checklist (a 20-item self-reported checklist), the Military Version (PCL-M). All the participants reported decreased symptoms of PTSD after the 5 day training course. The PCL-M scores were reduced in all 3 participants, particularly in the avoidance and increased arousal categories. Even the participant with the most severe symptoms showed impressive improvement. These authors concluded Sudarshan Kriya (SKY) seemed to decrease the symptoms of PTSD in 3 military veterans.
Cushing et al., (2018) recently published online a study testing the impact of yoga on post-9/11 veterans diagnosed with PTSD. The participants were >18 years old and scored at least 30 on the PTSD Checklist-Military version (PCL-M). They participated in weekly 60-minute yoga sessions for 6 weeks including Vinyasa-style yoga and a trauma-sensitive, military-culture based approach taught by a yoga instructor and post-9/11 veteran. Pre- and post-intervention scores were obtained by 18 veterans. Their PTSD symptoms decreased, and statistical and clinical improvements in the PCL-M scores were noted. They also had improved mindfulness scores and decreased insomnia, depression, and anxiety. The authors concluded a trauma-sensitive yoga intervention may be effective for veterans with PTSD symptoms.
Domestic violence, sexual assault, and unimaginable military experiences can all result in PTSD. People in our profession and even more likely, the patients we treat, may live with these horrors in the deepest recesses of their minds. Yoga is gaining acceptance as an adjunctive therapy to improving the symptoms of PTSD. The Trauma Awareness for the Physical Therapist course may assist in shedding light on a dark subject.
Walker, J., & Pacik, D. (2017). Controlled Rhythmic Yogic Breathing as Complementary Treatment for Post-Traumatic Stress Disorder in Military Veterans: A Case Series. Medical Acupuncture, 29(4), 232–238.
Cushing, RE, Braun, KL, Alden C-Iayt, SW, Katz ,AR. (2018). Military-Tailored Yoga for Veterans with Post-traumatic Stress Disorder. Military Medicine. doi:org/10.1093/milmed/usx071
I work at University of Chicago and we are in the throes of preparing for a (big T) Trauma Center. But I am physical therapist who works with (little t) traumatized patients- as I treat only pelvic or oncology patients (and usually both).
From the online dictionary: Trauma is 1. A deeply distressing or disturbing experience (little t trauma) or 2. Physical injury (injury, damage, wound) yes- big T Trauma. In my experience, the Trauma creates the trauma and the body responds in characteristically uncharacteristic ways (more on this later).
People in distress/trauma-affected do not respond rationally or characteristically, so I have learned to respond to distress/trauma in a rational, ethical, legal and caring manner. Always. Every time. To the best of my ability, and without shame or blame.
Let’s talk briefly about Trauma Informed Approach
This is a (person), program, institution or system that:
The Tenets of Trauma Informed Approach
Trauma Specific Interventions
Types of trauma are varied but I usually treat survivors of emotional, verbal, sexual and medical trauma. I have even treated patients who felt traumatized by other pelvic floor physical therapists (again, no judgement). Since most of my clinical experience include sexual and medical trauma survivorship, I try to reframe these experiences as potential Post Traumatic Growth, especially when working with my oncology patients. For my pelvic patients who divulge sexual trauma, I don’t dictate or name anything. I allow the survivor to make the rules and definitions. Survivors of sexual trauma need extra care when treating pelvic floor dysfunction.
First, when treating survivors of sexual trauma: expect ‘characteristically uncharacteristic’ events to occur. These include the psychological/somatic effects of passing out, flashbacks, seizures, tremors, dissociation and other mechanisms of coping with the trauma. Have a plan ready for these patients.
Triaging the survivor to assess their needs, when trauma has been verbalized/disclosed:
After assisting the survivor in their journey towards healing, it is imperative that you take care of yourself. Making healthy boundaries (with patients and others), taking time to decompress, creating healthy ritualistic behaviors, mindfulness/relaxation and somatic release (like yoga, massage or working out) is crucial to successfully treating patients who have experienced trauma and who have shared that trauma experience with you.
Because I use gentle yoga for both my trauma survivors’ treatment and for my own self-care, my new course implements evidenced based trauma sensitive yoga. Additionally, modifications for manual therapy are explored. The class is designed to be informative and experiential while integrating the Trauma Informed Approaches of Safety, Trustworthiness and transparency, Peer support, Collaboration and mutuality, Empowerment, voice and choice and Cultural, historical and gender issues.
Join me in Trauma Awareness for the Pelvic Therapist, next available this March in Albany, NY.