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Trauma-Sensitive Yoga Interventions and Posttraumatic Stress and Depression

Outcomes Among Women: A Systematic Review and Analysis of Randomized
Control Trials

Article in International Journal of Yoga Therapy · February 2021

DOI: 10.17761/2021-D-20-00005

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International Journal of Yoga Therapy — No. 31 (2021)
Review
Trauma-Sensitive Yoga Interventions and Posttraumatic Stress and
Depression Outcomes Among Women: A Systematic Review and
Analysis of Randomized Control Trials
Ashleigh Kysar-Moon, PhD,1 Matthew Vasquez, PhD, LMSW,2 Tierra Luppen, LMSW3
1. Department of Sociology, Anthropology, & Criminology, University of Northern Iowa, Cedar Falls, Iowa.
2. Department of Social Work, University of Northern Iowa, Cedar Falls, Iowa.
3. Mental Health Therapist, YSS of Hamilton County, Webster City, Iowa.
Correspondence: ashleigh.kysar-moon@uni.edu
Abstract
Research shows that most people experience at least one
traumatic event in their lifetimes, and between 6% and 8%
of those with a history of trauma will develop posttraumat-
ic stress disorder (PTSD) and/or related mental health con-
ditions. Women face a greater threat of trauma exposure
and have a higher risk of PTSD and depression than men.
Trauma-Sensitive Yoga (TSY), a body-based adjunctive
therapy, has shown potential in several studies as an effec-
tive method for reducing PTSD and depression symptoms.
However, existing research and systematic reviews vary
widely in their methodological rigor and comparison sam-
ples. Thus, in this systematic review we examined the effec-
tiveness of TSY among women with a history of trauma and
depression who had participated in randomized control tri-
als with clear control and experimental groups. Findings in
fixed- and mixed-effects meta-analysis models suggest mar-
ginally significant to no effects of TSY on PTSD and
depression outcomes. Our systematic review highlights crit-
ical questions and significant gaps in the existing literature
about the rationale and best practices of TSY intervention
duration. Kysar-Moon et al. Int J Yoga Therapy 2021(31).
doi: 10.17761/2021-D-20-00005.
Keywords: Trauma-Sensitive Yoga, posttraumatic stress
disorder (PTSD), depression, women, assessment/evalua-
tion, meta-analysis
Introduction
About 89.7% of the population will experience at least one
traumatic event in their lifetimes.1 Of those exposed to trau-
ma, an estimated 5.6% to 8.3% of the general population
will develop posttraumatic stress disorder (PTSD), which is
a syndrome associated with intrusive symptoms such as
recurring and involuntary distressing memories (e.g., intru-
sive thoughts) and dissociative reactions (e.g., flashbacks),
heightened levels of arousal, numbing, mood dysregulation,
and distorted/negative changes in cognition associated with
the traumatic event.1 When examining PTSD prevalence
rates between men and women, findings consistently
demonstrate women reporting PTSD symptoms at twice
the rate of men.2–4 Theories explaining these discrepancies
vary. Some attribute the higher rates of PTSD in women to
their more frequent exposure to assaultive experiences, such
as rape, sexual and physical assault, muggings, shootings/
stabbings, and intimate partner violence, compared to
men.5–7 Others argue that the underlying causal mechanisms
explaining gender differences in PTSD rates have not been
adequately addressed in the research and require further
examination.8
Besides PTSD, one of the most common symptoms
that can arise following a traumatic event is depression.9 For
example, the U.S. National Comorbidity Study reported
that 78.4% of subjects with both PTSD and depression
experienced depressive symptoms after the manifestation of
their PTSD symptoms.10 Another study found that within a
12-month period in a sample of patients with PTSD, 85%
of men and 80% of women reported the presence of at least
one other psychiatric disorder, with depression being the
most common.11 High rates of comorbidity between PTSD
and depression, combined with higher overall rates of
PTSD in women, may account in part for why women
experience depression at a 2:1 risk ratio compared to men.12
With PTSD and depression sharing similar rates of comor-
bidity, some have argued for the two as being one and the
same and called for clinical interventions that can effective-
ly address both disorders.13,14
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Cognitive-behavioral and exposure-based approaches
have been empirically shown to reduce PTSD and depres-
sion symptoms.15–18 However, many have argued that the
studies supporting the effectiveness of these approaches suf-
fer from methodological issues such as high dropout rates19;
sampling criteria that exclude those with chronic, long-term
trauma or those with multiple comorbid symptoms20; and
effect sizes that have little or no meaningful significance in
clinical settings.21 In addition, van der Kolk and colleagues22
note that cognitive-behavioral and desensitization therapies
do not adequately address the broad spectrum of body-
based effects caused by PTSD, such as an overactive stress
response system, hyperarousal, and diminished interocep-
tive awareness (i.e., internal awareness of bodily sensations
and emotional states). These shortcomings may explain why
movement-based activities that focus on mindfulness and
emphasize mind-body participation, like yoga, have grown
in popularity and are increasingly being used to address a
wide range of symptoms and disorders, including PTSD
and depression.
Yoga is a comprehensive movement-based approach
that incorporates a system of breathing exercises, physical
poses, stretching, and meditation techniques. The attention
to the present moment and emphasis on controlled breath-
ing and physical movement are theorized to engender spe-
cific physiological changes in the body; these effects aid in
reducing the allostatic load caused by long-term stress, stim-
ulating the parasympathetic nervous system (which pro-
motes calm, lowers the heart rate, and restores homeostasis)
and increasing the activity of gamma-aminobutyric acid
(GABA), an inhibitory neurotransmitter that downregu-
lates the stress response system.23–25 Others have proposed
that the practice of mindfulness, which promotes exploring
one’s body using interoceptive awareness, allows yoga prac-
titioners to become better attuned to their emotional and
physical needs and more accepting of their bodies; this, in
turn, may enhance emotional regulation, improve mood,
and positively affect one’s outlook on life.26,27
The literature regarding the use of yoga as either
adjunctive or a monotherapy has consistently shown posi-
tive effects on reducing PTSD symptoms28–30 and depres-
sion.31,32 In many instances, studies that specifically exam-
ined the effects of yoga on PTSD inadvertently found sig-
nificant reductions in depression symptoms, which sup-
ports a growing notion that yoga intended to address PTSD
may have similar effects on depression.33 Although the
research regarding the effect of yoga on PTSD and depres-
sion is promising, methodological issues are frequently cited
as limitations to claiming generalizable results; these limita-
tions include small sample sizes, lack of clarity regarding
instructor credentials/experience, variations in the type of
asana and pranayama practices used, minor effect sizes,
International Journal of Yoga Therapy — No. 31 (2021)
missing information on dropout rates and exclusion criteria,
and few studies using randomized control trial (RCT)
designs.28,34
Another common but rarely discussed limitation is the
length of intervention durations. A majority of relatively
recently published studies examining the effects of yoga on
PTSD and other mental health disorders in women-only
samples used dosing schedules of once a week for 10–12
weeks.22,26,35–41 Most of these studies do not address the
rationale for this particular intervention duration (an excep-
tion is Danielly and Si l ve rt h o r n e , 36 discussed below ) .
Consequently, there is a lack of literature detailing the
effects of yoga on mental health beyond 3 months of prac-
tice. Considering that many people who practice yoga often
do so for longer than 3-month periods, additional research
on the long-term effects of yoga practice on mental health
is warranted.
Due to the perceived and reported benefits of yoga for
PTSD and other trauma symptoms, there has been a grow-
ing emphasis on modifying traditional yoga practice to
become more sensitive to the needs of those who have expe-
rienced trauma. Yoga approaches that incorporate trauma-
informed practices have emerged, such as Trauma-Sensitive
Yoga (TSY),42 Trauma-Informed Yoga (TIY),22,43 and
Trauma-Focused Yoga (TFY).36 Although there are some
variations in how trauma-informed concepts are imple-
mented across these styles of yoga, many share similar prac-
tices. For example, instructors may use language that gives
participants autonomy and choice, such as when to engage
in a specific movement or activity (e.g., “when you feel
ready,” “as much as you are able,” “try shifting your weight
to your left leg”). To minimize the potential for hyper-
arousal and retraumatization or triggering, instructor cor-
rections, which often require touch and are common in
many yoga studios, are discouraged. In addition, classes
may be single-gendered, with attendance capped at about
10 participants or less, all of which helps to promote a sense
of safety and a more personal and intimate experience. The
movements, breathwork, and overall aim of these approach-
es are to help practitioners become more aware and accept-
ing of their bodies. This contrasts with other types of yoga
in which the primary aim may be reaching specific levels of
flexibility or obtaining an optimal workout.
The research on yoga styles that employ trauma-
informed practices is promising but limited. One RCT
showed significant reductions in PTSD and other comorbid
symptoms in adult females with complex trauma, which
may be more difficult to treat.22,40 Feasibility studies looking
at the effect of TSY for those exposed to intimate partner
violence also show encouraging results.35 Price and col-
leagues38 found reduced PTSD and related symptoms in a
s i n g l e - t reatment group of women who participated in
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Systematic Review of Yoga Interventions and Posttraumatic Outcomes Among Women
a 20-week course of TS Y. Fu rt h e r m o re, Danielly and
Silverthorne36 found significant reductions in depression in
female inmates who participated in TFY. Finally, in a narra-
tive review on the effects of TSY on PTSD in women found
that TSY may be effective in reducing PTSD symptoms and
co-occurring symptomology such as depression and anxi-
ety.44 It should be noted that many of these studies and
reviews included feasibility studies, nonrandomized sam-
ples, and small sample sizes.
Although there has been a proliferation of studies
examining and espousing the positive effects of yoga, a
recent meta-analysis conducted by Cramer and
colleagues28(p. 6) that included only RCT designs examining
the effects of yoga on PTSD showed “low quality evidence
for statistically significant and potentially clinically relevant
effects of yoga on symptoms of PTSD.” The authors sug-
gested that methodological and statistical issues may
account for the lack of significant findings across interven-
tion and control groups. Moreover, the studies included
populations from around the world that are culturally dif-
ferent in comparison to those from the United States and
samples that ranged from exclusively male or female to
mixed-sex. Thus, some of the limited findings in previous
analyses could be due to comparisons made with dissimilar
samples. Another possibility is that the yoga interventions
being evaluated did not employ trauma-informed practices
and therefore may not have been able to adequately attend
to the needs of study participants who had experienced
trauma. These participants may not have felt safe enough to
experience the full effects of the interventions. It is reason-
able to assume that yoga practices that employ trauma-
informed concepts would better attend to the needs of trau-
ma survivors, potentially providing stronger effects on men-
tal health symptoms. The present study attempted to
address this assumption by presenting the results of a meta-
analysis that examined the effects of TSY on PTSD and
depression in women-only samples that use more rigorous
study designs such as RCTs. For ease and clarity, unless oth-
erwise specified all yoga practices that employ trauma-
informed concepts (i.e., TIY, TSY, and TFY) are hereinafter
referred to as TSY.
Methods
Procedure
Our analyses narrowed the scope to compare similar studies
using RCTs of women in the United States receiving TSY
interventions to determine whether a significant reduction
in symptoms was captured for PTSD and depressive out-
comes. Our rationale for using women-only samples was to
better control for effects from dissimilar samples. In exam-
ining women-only samples, we acknowledge that we limit
our scope to those who ascribe to a binary gender identity
and may exclude those who self-identify as nonbinary. Our
rationale for including a depression measure is based on the
high probability of depression developing after exposure to
trauma and/or the manifestation of PTSD symptoms.9–11
The inclusion of such a measure allows us to examine
whether TSY has an effect on a broader range of PTSD-
related symptomology. To be included in the present analy-
sis, studies met the following criteria:
1. RCT with distinct experimental and control
groups.
2. Subjects were adult women over the age of 18
years.
3. Subjects had a history of trauma or current PTSD
diagnosis.
4. Outcomes measured included PTSD and/or
depression.
5. Study conducted and completed in the United
States.
6. Intervention was described as “trauma-sensitive,”
“trauma-focused,” or “trauma-informed” yoga.
Studies were excluded if they: (1) lacked a control
group,38 (2) were designed as a feasibility35 or pilot study
only and not completed,45 (3) were a secondary publication
based on an RCT already included in the analysis,26 and/or
(4) were a long-term follow-up from the initial RCT.40
In August–October 2019, a computerized forward
search was conducted using the following electronic data-
bases: (1) EBSCO, (2) Google Scholar, (3) JSTOR, (4)
M E D L I N E/ Pu b Med, (5) Ps ychINFO, and (6) the
Cochrane Library.46 The following combination of terms
was used in the searches: (1) “trauma-sensitive yoga,” (2)
“trauma-informed yoga,” (3) “trauma-focused yoga,” (4)
“yoga AND health,” (5) “yoga AND PTSD,” (6) “yoga
AND mental health,” (7) “yoga AND anxiety,” and (8)
“yoga AND depression.”
Titles and abstracts were evaluated to determine each
study’s relevance to the present analysis. Other systematic
literature reviews and recent meta-analyses on similar topics
were also obtained to locate other potentially pertinent
studies.28,30,33,44,47,48 We did not seek out any unpublished
materials for the current analysis, as we were explicitly
examining the effectiveness of published interventions;
however, we acknowledge the risk of the “file drawer” prob-
lem (i.e., studies that fail to find significant results are typi-
cally not published) and draw attention to this particular
limitation of our review.46 A diagram of our search process
is outlined in Figure 1.
Analytic Plan
To assess the effectiveness of TSY for reducing PTSD and
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Figure 1. Literature Review Search Process
depressive symptoms among women with a history of trau-
ma, we used Stata 15 and the metan command for meta-
analysis.49–51 Metan was an ideal method for this study
because of the continuous nature of posttraumatic stress
and depressive symptoms measures and the comparison of
experimental and control groups. This command enabled
us to fit fixed- and random-effects models, correct for small-
sample bias with Hedges’ g, test the overall effect of the TSY
intervention, and conduct subgroup analysis by interven-
tion duration.52
Fixed-effects meta-analysis illustrates a common effect
across subgroups (i.e., experimental and control groups) by
estimating the overall mean difference. However, due to
variations in measurement instruments across studies, for
example CAPS22 and PSS-I34 to capture PTSD symptoms,
the differences in means and standard deviations (SD) are
standardized.51 We used Hedges’ standardization method,
which pools SD from both groups and adjusts for small
sample sizes in comparison to other pooling methods.53 The
pooled standard mean difference, 95% confidence interval
(CI), I 2 (the variation in the standardized mean difference
due to heterogeneity), and the overall effect (z score and p
value) are reported. Due to the lower statistical power of I 2
when only a few studies are included, p values ≤ 0.10 tend
to suggest significant heterogeneity.28,54
International Journal of Yoga Therapy — No. 31 (2021)
Random-effects models were also included in this
analysis because one of the research questions asks about the
effect of treatment duration. Although fixed-effects models
assume that the impact of treatment is consistent across
studies, random-effects models can test for differences
between studies that could be the result of treatment dura-
tion in addition to factors such as sampling error, demo-
graphic characteristics, and other study design factors.51
Excess heterogeneity between studies is also measured and
when occurring, random-effects models yield more conser-
vative estimates of TSY for PTSD and depressive outcomes.
The same information is reported for the random- and
fixed-effects models as well as the between-study variance
(τ2).
An advantage of estimating fixed and random effects
for TSY on PTSD and depressive outcomes is that this
approach may highlight the effects of smaller studies.55
Another strength of this meta-analysis is the inclusion of
intervention duration in the literature review and analyses.
Building on previous analyses such as that of Cramer and
colleagues,28 we conducted an exploratory analysis using the
metan command to examine intervention-duration sub-
groups to compare studies using 10 versus 12 weeks of TSY
treatment.50 We were able to compare the effect size of the
intervention based on duration and determine the statistical
significance of intervention by duration in contrast to the
overall effect. Although meta-regression is the more ideal
method for formal subgroup comparisons, we lacked a suf-
ficient number of studies for such methods.55
Separate analyses were conducted for PTSD and
depressive outcomes with (1) fixed-effects models, (2) ran-
dom-effects models, and (3) fixed- and random-effects
models stratified by intervention duration. Forest plots were
included with the fixed-effects models (Figs. 2 and 3).51
We had intended to examine the degree to which pub-
lication bias may have affected the results using a funnel
plot. However, as with other meta-analyses on TSY, we
lacked a sufficient number of cases to investigate funnel-
plot asymmetry.28
Results
The search, after all exclusion and inclusion criteria were
applied, yielded three studies; two had posttraumatic stress
symptom measures, and all three measured depression.
Table 1 includes summary information about each study,
and Table 2 provides an overview of the similarities and dif-
ferences in how trauma-informed practices were employed
across the yoga styles.
Each study was an RCT testing what the authors
described as “trauma-sensitive,”34 “trauma-informed,”22 or
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Systematic Review of Yoga Interventions and Posttraumatic Outcomes Among Women
Figure 2. Effect of TSY on Posttraumatic Stress Symptoms
This forest plot for the fixed-effects models depicts standardized mean
estimates and confidence intervals for each study, plotting squares whose
size is proportional to the weight that study contributes to the overall
effect, and a diamond that shows the overall computed confidence inter-
val. TSY = Trauma-Sensitive Yoga (see note in the Introduction).
Figure 3. Effects of TSY on Depression Symptoms
This forest plot for the fixed-effects models depicts standardized mean
estimates and confidence intervals for each study, plotting squares whose
size is proportional to the weight that study contributes to the overall
effect, and a diamond that shows the overall computed confidence inter-
val. TSY = Trauma-Sensitive Yoga (see note in the Introduction).
“t r a u m a - f o c u s e d” 36 yoga interventions among gro u p s
men. Two of the three studies used trauma-re l a t e d
d i a g n o stic criteria to determine eligibility for study partic-
ipation,22,34 whereas the other study considered all women at
the correctional facility as eligible participants given the
“impact of embodied trauma in prison populations.”36(p. 10) It
should be noted that although Danielly and Silverthorne36
did not measure trauma/PTSD symptoms, providing yoga
within an environment that is extremely stressful and
potentially traumatizing (i.e., prison) may serve to enhance
coping and not necessarily mitigate current trauma/PTSD
symptoms; if such a study had included an assessment of
trauma/PTSD symptoms, any lack of an effect may not
accurately reflect the benefits to the sample.
All three studies used a form of Hatha Yoga. However,
the intervention duration varied by study: One study used
6 weeks with two sessions per week or once-weekly sessions
for 12 weeks34; another met for 10 weeks, with weekly hour-
long sessions22; and the third study met for an unspecified
amount of time.36 The control groups were different across
all studies One control group participated in 10 weeks of a
women’s health education class,22 one group was a waitlist-
ed control for 10 weeks,36 and one group met once per week
for 12 weeks to complete questionnaires.34 Unique posttrau-
matic stress and depression outcomes were used across all
studies, justifying the need to standardize outcomes in the
analyses.
Effectiveness of TSY for PTSD
The unstandardized study characteristics for the effects of
TSY on PTSD are presented in Table 3. The fixed-effects
model yielded a marginally significant difference between
the TSY and control groups (standardized mean difference
[SMD] = –0.339, 95% CI [–0.732 to 0.054], p = 0.091)
and nonsignificant heterogeneity (I 2 = 42.6%, p = 0.187)
(Fig. 2). Random-effects models were also estimated to
determine if the smaller studies had a significant effect.55
Under these models, TSY no longer has any significant
effect on posttraumatic stress symptoms, consistent with
Cramer and colleagues’ findings.28
In this study, we asked why the TSY duration varied
widely across studies in the larger body of research. We lack
enough studies to thoroughly test the effects of intervention
duration; however, we offer preliminary evidence here to
start a larger conversation. Table 4 shows the hypothesis test
output (SMD = 0) following a stratified randomized meta-
analysis. The initial evidence suggested that in the study
with 10 weeks of TSY a statistically significant reduction in
symptoms occurred (p = 0.032). This evidence must be
interpreted with caution and not be used to make recom-
mendations on intervention length. Rather, this informa-
tion emphasizes the need to critically consider the dosing
necessary for clients to experience positive mental health
effects. Moreover, the study with 12 weeks’ duration had
some subjects attending once per week over that period,
whereas others participated in sessions twice per week for 6
weeks; again, these variations raise crucial questions with
regard to best practices.
Effectiveness of TSY for Depression
Table 5 shows the unstandardized study characteristics for
depressive symptoms by group. Figure 3 presents the effects
of TSY on depressive symptoms; neither the overall effects
(SMD = –0.233, 95% CI [–0.592 to 0.127], p = 0.205) nor
the heterogeneity (I 2 = 13.7%, p = 0.314) were statistically
significant. The random-effects model for TSY and depres-
sion was also not significant.
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 International Journal of Yoga Therapy — No. 31 (2021)

Table 1. Characteristics of Included Studies

Posttraumatic
Stress Depression
Participants Diagnostic Mean Treatment Control Outcome Outcome
Study and Setting n Instrument age (y) Group Group Measure Measure
van der Kolk Women aged 64 CAPS 42.90 10 wk of 1-h 10 wk of 1-h CAPS BDI-II
et al., 201422 18–58, recruited Trauma- women's health
from newspaper Informed Yoga education
and radio ads, classes with classes
research web- elements of
site, and Hatha Yoga
mental health
professionals
Mitchell et Military veteran 38 PSS-I 44.37 12 wk once/wk Assessment PCL-C CES-D
al., 201434 and civilian or 6 wk twice/wk control, 12 wk
women aged Trauma-Sensitive of once weekly
18–65, recruited Yoga classes meetings in
from VA medical with elements of groups to
center and Kripalu Yoga complete
Craigslist (a form of Hatha questionnaires
Yoga)
Danielly and Adult females 50 †
37.92 10 wk of 10-wk waitlist DASS
Silverthorne, aged 23–70 who trauma-focused
201736 were inmates at Hatha Yoga
South Carolina (class length not
correctional reported)
facilities, recruit-
ed by Prison
Yoga Project
personnel

BDI-II = Beck Depression Inventory-II; CAPS = Clinician-Administered PTSD Scale; CES-D = Center for Epidemiological Studies–Depression
Scale; DASS = Depression Anxiety Stress Scales; PCL-C = PTSD Checklist–Civilian; PSS-I = PTSD Symptom Scale–Interview; PTSD = posttrau-
matic stress disorder.
†
This study did not evaluate trauma prior to yoga classes beginning because it was assumed that trauma is part of the everyday lived experiences of
incarceration.

Table 6 reports the hypothesis test results (SMD = 0)
for the effects of intervention duration on depressive symp-
toms. The stratified findings were similar to the overall
effects: TSY does not have a significant impact on reducing
depression symptoms. In the two studies with 10-week
durations, the heterogeneity was not statistically significant
(I 2 = 10.8%, p = 0.29). The lack of significant findings may
be due to limited intervention duration or other unob-
s e rved factors. Indeed, Danielly and Si l ve rt h o r n e36(p. 10)
explained that,
The ten-week time frame was dictated by the prison in
line with their protocol for offering education classes.
The time period is not indicative of the best or most
appropriate time needed for a trauma-focused yoga
program to be most effective.
However, there is limited consensus in the literature for just
how much TSY is needed to be most effective, especially for
women with a history of trauma.
Discussion
The results of this meta-analysis found no discernible effect
of TSY on PTSD and depression. These findings are at odds
with the wealth of literature ascribing to yoga beneficial
effects on overall mental health.28–32 This disconnect raises
the issue of other potential factors affecting these outcomes.
For instance, methodologically, the existing body of RCTs
examining the effectiveness of TSY on mental health is
extremely limited. Even studies with a broader scope than
ours, such as that of Cramer and colleagues,28 found limit-
ed evidence to support a recommendation for TSY.
Consequently, additional studies using more rigorous (i.e.,
RCT) designs may be needed to demonstrate more accurate
effects.
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Systematic Review of Yoga Interventions and Posttraumatic Outcomes Among Women

Table 2. Trauma-Informed Practices Across Yoga Styles†

Study Type of Yoga Characteristics
van der Kolk et Trauma-Informed Based on Hatha Yoga, with elements of breathing, postures, and meditation
al.22 Created by yoga professionals with master's and doctoral degrees in psychology
Used simple language (no metaphors)
Focused on self-inquiry, with language such as “notice”
Focused on invitational language (e.g., “when you're ready,” “if you like”)
Participants were encouraged to have bodily control and change/adjust postures as needed
Mitchell et al.34 Trauma-Sensitive Based on Kripalu/Hatha Yoga
Created by the researcher and trained yoga instructor
Instructed by one yoga instructor
Difficulty of poses increased over time
Participants were offered opportunities to make modifications to poses and take breaks as
needed
Focus was on inviting participants to try poses but never making them feel forced to do
something uncomfortable
Safety and nonjudgment were emphasized
Mindfulness, consisting of watching and not labeling/judging feelings and letting them pass,
was incorporated
PTSD symptoms were not discussed in sessions
Danielly and Trauma-Focused Based on Hatha Yoga
Silverthorne36 Created by the Prison Yoga Project
Instructed by trained volunteers
Instructors did not use commanding language or certain words to avoid triggering
Gently encouraged participants to pay attention to what felt good and what did not
Participants were empowered to make choices in terms of their own bodies
†
All study interventions
• were based on Hatha Yoga;
• used invitational rather than commanding language;
• emphasized bodily control (making adjustments/modifications to poses, choosing which poses to do or not do); and
• promoted self-awareness of the body.
PTSD = posttraumatic stress disorder.

Table 3. Posttest Effects of TSY on Posttraumatic Stress Symptoms

Experimental Group Control Group Duration (wk)
Study Mean SD n χD Mean SD n χD
van der Kolk et al.22 49.48 25.16 32 24.46 63.49 25.48 32 13.17 10
Mitchell et al.34 39.07 16.01 20 12.87 39.09 12.64 18 14.35 12
TSY = Trauma-Sensitive Yoga (see note in the Introduction); SD = standard deviation.

Table 4. Effect of TSY Duration on Posttraumatic Stress Another factor could be the limited intervention dura-
Symptoms tions (e.g., 10–12 wk) in the examined studies, which may
Duration z p Value
have substantially contributed to the lack of significant
10 wk 2.14 0.032 effects on both trauma and depression scales. It has been
12 wk 0.00 0.997 theorized that yoga practice can help to mitigate the effects
Overall 1.15 0.249 of PTSD and depression by lowering stress, pushing the
TSY = Trauma-Sensitive Yoga (see note in the Introduction). stress response system into more parasympathetic (i.e.,
calmer) states, and helping to reconnect people with and be
more accepting of their bodies. There is, however, no con-
sensus on how much yoga practice is required for these
effects to emerge. Confounding this issue further is the fact
that not all trauma is created equal. Trauma-specific assess-
ment tools may only measure certain symptoms, and they
may not capture more severe, harder-to-treat, or complex
forms of trauma (i.e., long-term, chronic sexual, and/or
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Table 5. Posttest Effects of TSY on Depression Symptoms
Experimental Group
Study Mean SD n χD
van der Kolk et al.22 13.92 9.91 32 6.97
Mitchell et al.34 22.50 15.82 20 7.08
Danielly and Silverthorne36 25.87 8.30 15 6.26
TSY = Trauma-Sensitive Yoga (see note in the Introduction); SD = standard deviation.
Table 6. Effect of TSY Duration on Depression Symptoms
Duration z p Value
10 wk 1.45 0.148
12 wk 0.19 0.851
Overall 1.08 0.282
TSY = Trauma-Sensitive Yoga (see note in the Introduction).
childhood trauma). These types of trauma may create more
deleterious physiological effects on the stress response and
self-sensing systems of the body and potentially lead to
more severe and/or longer-lasting depressive episodes.
Consequently, longer exposure to yoga practice would be
required for clinically meaningful effects to emerge. As a
result, the included studies may not have been long enough
to demonstrate the true effects of long-term yoga use on
PTSD and depression.
Another issue related to limited intervention duration
may be potential effects of enhanced interoceptive aware-
ness and its effect on mental health outcomes. As previous-
ly mentioned, yoga is believed to help practitioners to
become better aware of their internal bodily sensations,
which can promote self-regulation skills. However, it is
problematic to assume that enhanced internal awareness
directly relates to improved mental health, especially in the
short term. Some have argued that increased mindfulness
can potentially lead to overengagement of experiences,
which could result in people becoming consumed or over-
taken by thoughts, memories, and/or internal sensations.56
Others have found that enhanced interoceptive awareness
in those with chronic pain can lead to heightened anxiety,
leading some to suggest that guidance is necessary to effec-
tively navigate internal sensations, especially if they are neg-
ative or painful.57,58 Those with histories of trauma and
depression who practice yoga may experience more visceral
reactions to remembering past traumatic events and/or
more fully experience depressive episodes. From an evalua-
tive perspective, this could result in minimal or no changes
on PTSD and depression measures. To date, this potential
effect has not been adequately addressed in the literature.
Further research on the effects of yoga and interoceptive
awareness across varying intervention lengths is therefore
warranted.
International Journal of Yoga Therapy — No. 31 (2021)
Control Group Duration (wk)
Mean SD n χD
19.47 11.91 32 4.59 10
21.64 11.21 18 9.19 12
25.43 6.63 7 0.00 10
A limitation of the present meta-analysis is that we
lacked a sufficient number of studies to test for risk of pub-
lication bias using funnel-plot asymmetry. Such tests
require a minimum of 10 studies for accuracy. We also
acknowledge the limitations with regard to the analyses on
intervention duration. Considerably more studies are need-
ed to account for meaningful differences in the effectiveness
of TSY for mental health outcomes based on the duration
of yoga practice. However, this systematic review is among
the first to our knowledge to raise the issue of heterogeneity
in intervention duration across RCTs and calls into ques-
tion whether commonly used periods of 10 to 12 weeks are
sufficient to observe change in PTSD and depression out-
comes among women with a history of trauma.
Conclusions
With women experiencing PTSD and depression at approx-
imately twice the rate of men, interventions that can effec-
tively address both disorders in a safe, trauma-sensitive
manner are needed. Yoga approaches that employ trauma-
informed practices appear to be promising interventions
that take into consideration the specific needs of those who
have been exposed to adverse and traumatic experiences.
These approaches also promote body awareness and accept-
ance, self-efficacy, and autonomy, all of which are frequent-
ly damaged or erased by trauma. Although this study’s find-
ings show no discernible effects, the authors caution readers
from viewing these results as a declaration of the effective-
ness (or lack thereof ) of TSY. Rather, as previously men-
tioned, we hope these findings spark further discussion on
how to design future studies to better capture the true
effects of yoga on mental health symptoms (e.g., increase
study duration and explore the effect of enhanced intercep-
tion) and encourage additional study in this area.
Acknowledgment
The authors would like to thank Katelyn Hoffman for her
help identifying relevant sources for this review and meta-
analysis.
Conflict-of-Interest Statement
The authors declare that they have no conflicts to report.
www.IAYT.org
Systematic Review of Yoga Interventions and Posttraumatic Outcomes Among Women
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