Digital Repository Doctoral Projects Spring 2023 Implementation of a Trauma-Informed Yoga Program Trish Gibbs Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Gibbs, T. (2023). Implementation of a trauma-informed yoga program. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. WSU REPOSITORY MSN/DNP Implementation of a Trauma-Informed Yoga Program Project Title by Trish Gibbs, DNP-Executive Leadership, RN, CNE, RYT-500 Student’s Name A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 28, 2023 Date April 28, 2023 Student Name, Credentials (electronic signature) April 28, 2023 Diane Leggett-Fife, PhD, RN DNP Project Faculty Name, Credentials Graduation Date (electronic signature) April 28, 2023 Melissa NeVille Norton (electronic signature) DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. Date IMPLEMENTATION OF A TRAUMA-INFORMED 2 Acknowledgments I offer my sincerest appreciation to The Annie Taylor Dee School of Nursing, The New Hope Crisis Center, my esteemed professors, and my DNP faculty lead, Dr. Fife. Their guidance, collaboration, and feedback were critical to completing this project. It’s important to note that I could not have undertaken this journey without the D. Wade Mack Foundation and the Annie Taylor Dee School of Nursing Faculty Organization, whose generous support helped finance my educational journey and project research. I am also grateful to my colleagues and cohort members for their comradery and moral support throughout this experience. In closing, words cannot express my gratitude for the endless commitment of my “Reindeer Cyclone” (you know who you are). This endeavor would never have been possible without them. Finally, and most importantly, thank you to the survivors. I see you. I hear you. I believe you. IMPLEMENTATION OF A TRAUMA-INFORMED 3 Table of Contents Background and Problem Statement 7 Diversity of Population and Project Site 8 Significance for Practice Reflective of Role-Specific Leadership 9 Literature Review 10 Search Methods 10 Synthesis of the Literature 11 Trauma 11 Adverse Effects of Trauma 11 Barriers Related to Traditional Treatment 12 Benefits of Trauma-Informed Yoga 14 Coping 14 Solution 17 Discussion 18 Framework Description 19 Framework Application to Project 20 Project Plan 20 Project Design 21 Needs Assessment/Gap Analysis of Project Site and Population 22 Cost Analysis and Sustainability of the Project 23 Project Outcomes 23 Consent Procedures and Ethical Considerations 24 Instrument(s) to Measure Intervention Effectiveness 25 IMPLEMENTATION OF A TRAUMA-INFORMED 4 Project Implementation 26 Project Intervention 27 Deliverables 27 Project Timeline 28 Project Evaluation 29 Data Maintenance/Security 29 Data Collection and Analysis 29 Findings 32 Strengths 33 Weaknesses 34 Discussion 35 Translation of Evidence into Practice 35 Implications for Practice and Future Scholarship 36 Sustainability 38 Dissemination 39 Conclusion 39 References 41 Appendix A 47 Appendix B 48 Appendix C 53 Appendix D 54 IMPLEMENTATION OF A TRAUMA-INFORMED 5 Appendix E 55 Appendix F 69 IMPLEMENTATION OF A TRAUMA-INFORMED 6 Abstract Trauma is exposure to an event or experiences perceived as a significant safety threat. Current treatments have high attrition rates, may not be suitable or effective for all survivors, are avoided by some survivors due to a requirement to disclose specifics related to their trauma, or fail to address the mind-body relationship associated with trauma. Purpose: This project explored the efficacy of Trauma-Informed Yoga (TIY) as an adjunctive or alternative treatment to traditional trauma interventions to increase interoceptive awareness, process somatic symptoms, reduce trauma symptomology, and improve quality of life. Methodology: The evidence-based 6-week TIY program was implemented at a local shelter and survivor advocacy center. Baseline assessments were completed before the start of the TIY program and again after each class attended. Results: Self-reported quality of life and presence of trauma symptoms were measured using quantitative data from an anonymous Qualtrics survey that included the Quality-of-Life Survey (QOLS) and Trauma Screening Questionnaire (TSQ). Survey results indicated reduced trauma symptoms and increased quality of life scores supporting using the TIY program to improve outcomes for trauma survivors. Implications: TIY programs appear to improve the survivor's ability to remain in the window of tolerance between hyper and hypo arousal through downregulating practices that help restore a sense of power and control while re-establishing a sense of safety within the body. This is critical to bridging a gap in treatment, combating mind-body dichotomies existing within traditional treatment, and eliminating significant barriers survivors face when seeking treatment. Keywords: Trauma, survivors, sexual assault, interpersonal violence, trauma-informed yoga IMPLEMENTATION OF A TRAUMA-INFORMED 7 Implementation of a Trauma-Informed Yoga Program The National Coalition Against Domestic Violence [NCADV] (2021) reported that 1 in 3 women experience domestic violence, also known as intimate partner or interpersonal violence, during their lifetime. This abuse is defined as “the willful intimidation, physical assault, battery, sexual assault, and/or abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another” (NCADV, 2021. p. 1). This abuse can include threats, physical violence, sexual violence, and financial, emotional, or psychological abuse. In addition, recent evidence supports a global rise in domestic violence since the onset of the COVID-19 pandemic (Ovissi, 2020). The resulting emotional and physical trauma from these events can negatively impact the survivor and result in long-term impairments. Research indicates that trauma-informed yoga (TIY) or trauma-sensitive yoga (TSY) has the potential to improve quality of life, increase mind-body connection, decrease the adverse effects of trauma, and empower the survivor with a long-term resource for healing (Ong et al., 2019; Stevens & McLeod, 2019; West et al., 2017). This paper explores implementing a TIY program as an adjunctive treatment for trauma survivors at New Hope Crisis Center, a shelter and traumasurvivor resource center. Background and Problem Statement Trauma increases an individual’s risk of medical issues, substance abuse, financial burden, poor mental health, and long-term physical ailments (DiMauro & Renshaw, 2021). If left untreated, or if traditional treatments are ineffective, the negative impact of trauma can significantly decrease the survivors' quality of life and overall social function (DiMauro & Renshaw, 2021). Further, trauma's impact when held in the body must be addressed by providing guidance that increases the individual's ability to mindfully regulate internal states and IMPLEMENTATION OF A TRAUMA-INFORMED 8 physiological responses (West et al., 2017). To allow these survivors to return to a sense of normality, they must regain a sense of empowerment and feel safe in their bodies (Nolan, 2016). Providing survivors with a coping skill that aids them in regaining a sense of safety within their bodies is essential in supporting the individual’s emotional regulation and somatic experiencing. Clinicians can address this need by implementing a TIY program as an intervention for adult female trauma survivors. Mindful-based interventions attempt to bridge the gaps identified within traditional trauma treatments (Ong et al., 2019). Described by Ong et al. (2019) as a structured bodyoriented practice that promotes reconnection with the body, TIY is a body-based intervention that provides survivors with a tool that helps make the somatic connections needed to facilitate healing. The intervention is grounded in specific principles, including establishing a safe environment, invitatory language, offering choices to promote empowerment, and providing verbal modifications instead of hands-on adjustments. Mindfulness, deep breathing, and basic poses, not prescriptive postures, are utilized to create a safe space, empower the survivor and allow them to establish a mind-body connection (Justice et al., 2018; Ong, 2021). In contrast, traditional yoga, where breath retention and poses that may stimulate the sympathetic nervous system are used, may act as a trigger related to the individual's trauma and are therefore contraindicated (Cook-Cottone et al., 2017; Justice et al., 2018; Ong, 2021). Diversity of Population and Project Site The Family Violence Prevention and Services Program statistics reveal that 2,425 trauma survivors used Utah’s shelter services from October 2015 to September 2016 (New Hope Crisis Center, 2016). The chosen site for the TIY program implementation is the New Hope Crisis Center, a shelter and trauma survivor resource center located in rural Brigham City, Utah. IMPLEMENTATION OF A TRAUMA-INFORMED 9 The center provides shelter, counseling, crisis support, and group therapy for survivors of child abuse, interpersonal violence, and sexual assault (New Hope Crisis Center, 2016). In addition, the crisis center provides advocacy, legal assistance, educational classes, and community outreach programs that support and encourage the survivors in their journey of healing (New Hope Crisis Center, 2016). Currently, no body-based therapeutic interventions at this facility focus on somatic awareness and treating the adverse effects of trauma (New Hope Crisis Center, 2016). Based on demographic information, a TIY program at New Hope Crisis Center for adult female trauma survivors would reach a diverse group of individuals ranging in age, ethnicity, socioeconomic status, and education level (New Hope Crisis Center, 2016). Significance for Practice Reflective of Role-Specific Leadership The potential outcomes of implementing a TIY program support the DNP leadership role by developing an innovative change in current practice. By filling an existing gap in practice and applying evidence-based research, the program improves the ability of patients to access quality care based on recent research. As change agents, nurse leaders actively contribute to bridging the gap between researchers and practice (Warshawsky, 2019). Furthermore, this program addresses a lack of community resources and provides access to a cost-free, easily accessible intervention that decreases the barriers some patients face with traditional treatment. Additionally, it offers an adjunctive treatment that can be used concurrently with conventional trauma treatment modalities to improve patient outcomes and decrease the long-term adverse effects of trauma (Stevens & McLeod, 2019). The need for additional resources to respond to the increase in interpersonal violence reported during the ongoing COVID-19 pandemic is essential (Ovissi, 2020), allowing the implementation of this program as an impactful resource to empower survivors. Finally, this program provides a baseline for future research and promotes IMPLEMENTATION OF A TRAUMA-INFORMED 10 collaboration with other clinicians to innovate future practice by implementing and building on new knowledge (Warshawsky, 2019). Literature Review Trauma negatively impacts the survivor and can result in long-term impairments such as PTSD symptomatology (Van der Kolk et al., 2014). Research supports the use of body-based interventions to improve the outcomes of trauma survivors (DiMauro & Renshaw, 2021; Van der Kolk et al., 2014). This literature review explores the research evidence, common themes, and gaps associated with the body-based intervention, TIY, as an adjunctive treatment for interpersonal violence and sexual assault survivors. While barriers to implementation may exist, research indicates that TIY can improve quality of life, increase mind-body connection, decrease the adverse effects of trauma, and empower the survivor with a long-term coping mechanism that assists with somatic body awareness (Stevens & McLeod, 2019). Search Methods The search was conducted by consulting EBSCOhost, Google Scholar, PubMed, and CINAHL from 2016 to 2021. Limits were set to include the English language. Keywords used for the search included Trauma, Trauma-Informed Yoga, Trauma-Sensitive Yoga, Interpersonal violence, Sexual assault, Post-Traumatic Stress Disorder, and trauma survivors. Seventeen articles were reviewed. The review inclusion criteria consisted of research that included study participants at least 18 years of age with a history of trauma and body-based trauma intervention. Qualitative, quantitative, mixed-method, systematic reviews, or meta-analysis designs were included. Exclusion criteria for the literature review included participants with no history of interpersonal violence or sexual assault, grey literature, and articles greater than five years old. IMPLEMENTATION OF A TRAUMA-INFORMED 11 Synthesis of the Literature Trauma According to Ong (2021), sixty-one percent of men and fifty-one percent of women have experienced at least one traumatic event in their lifetime, which they define as exposure to an event or experiences perceived as a significant safety threat. When experiencing trauma, the sympathetic nervous system’s stress response activates as a protective, physiological response. Whether the trauma occurs as a single event or is an ongoing occurrence, the physical responses can overwhelm this system. This physical response to trauma can result in prolonged hyperarousal or dissociation, where the individual cannot self-regulate and regain homeostasis (Justice et al., 2018). One result of this inability to restore homeostasis is when the individual’s coping capacity is overwhelmed, resulting in long-term adverse effects (American Psychiatric Association, 2017). The high incidence of trauma exposure in the United States increases the need for clinician response to address survivor’s risk of developing anxiety, depression, and Post Traumatic Stress Disorder (PTSD), with approximately 8% of trauma survivors receiving a diagnosis of PTSD (American Psychological Association, 2017; DiMauro & Renshaw, 2021; Nguyen-Feng et al., 2019b; Van Der Kolk et al., 2014). Adverse Effects of Trauma Trauma results in a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which plays an essential role in modulating stress in the body. This dysregulation results in common symptoms among trauma survivors, such as impaired cognitive function and disturbed sleep patterns (Cushing et al., 2018; Nguyen-Feng et al., 2020; Zaccari et al., 2020). One result of this dysregulation can be a decrease in the individual’s overall quality of life. This IMPLEMENTATION OF A TRAUMA-INFORMED 12 dysregulation leaves the survivor debilitated and unable to complete activities of living which restrains their thought processes and ability to interact (Nolan, 2016; Zaccari et al., 2020). In incidences of chronic, ongoing trauma, as seen in a 10-week qualitative study of 31 adult female survivors, emotional dysregulation, dissociation, and somatization are positively impacted by a trauma-sensitive intervention (West et al., 2016). Conversely, in a systematic review and quantitative analysis assessing the efficacy of yoga interventions ranging from 2 to 16 weeks, the strength of evidence to support a decrease in trauma symptoms was lacking (Nguyen-Feng, 2019b). Ultimately, the impact of the trauma and its associated cognitive and physical effects may result in the potential loss of income and an inability to maintain employment, with survivors also being impacted by increased healthcare costs (Nolan, 2016). These adverse effects of trauma also raise a survivor’s risk for self-harm and suicidal ideation (Nolan, 2016). Further, Taylor et al. (2020) found that trauma survivors are at an increased risk for developing eating disorders, mood disorders, and other mental illnesses. Barriers Related to Traditional Treatment In addition to surviving a traumatic event, waitlists for specialized treatment, the stigma associated with mental health disorders, and barriers to survivor disclosure create another obstacle that often prevents individuals from seeking treatment (Justice et al., 2018; Stevens & McLeod, 2019). Traditional therapeutic interventions used to treat trauma, such as Eye Movement Desensitization and Reprocessing (EMDR), Cognitive Behavioral Therapy, and Exposure Therapy, focus on re-experiencing and verbalizing past emotions (Nicotera & Connolly, 2020; Ong, 2021). Further, the potential for symptom exacerbation during traditional therapies makes trauma a complex issue to treat. By exposing survivors to experiences during IMPLEMENTATION OF A TRAUMA-INFORMED 13 treatment that may trigger traumatic memories, physiological and psychological symptoms may reoccur (Nicotera & Connolly, 2020). Traditional therapies may be less effective for individuals who struggle to communicate their experiences due to the body's coping mechanism of deactivating the area of the brain that supports communicable language (Nicotera & Connolly, 2020). According to Ong (2021), although considered the cornerstone of trauma treatment, therapy may not be suitable for all trauma survivors, with dropout rates of up to 54% and no improvement in symptomology of up to 100%. Additionally, Zaccari et al. (2020) found that 60-72% of survivors still retain symptom significance that constitutes retention of a PTSD diagnosis (Zaccari et al., 2020). Conversely, according to Nicotera and Connolly (2020), 44-54% of individuals demonstrate clinical improvement after receiving traditional treatment and, while no longer meeting criteria for a diagnosis of PTSD, still experience significant trauma symptoms that impact their quality of life. Worsening of symptoms or non-responsiveness to traditional treatments, where the survivor experiences triggers that exacerbate symptoms or do not experience any symptom relief, may increase attrition with traditional therapy strategies (Nicotera & Connolly, 2020; Nolan, 2016; Ong et al., 2019; Ong, 2021; Taylor et al., 2020). These experiences may lead to long-term complications such as new mental health diagnoses, increased dissociation and avoidance behaviors, substance abuse, an inability to maintain employment, increased financial burden, relationship issues, poor physical health, self-harm, and suicide (Nicotera & Connolly, 2020; Nolan, 2016; Ong et al., 2019; Ong, 2021; Taylor et al., 2020). Conversely, in a 12-week study of female survivors of intimate partner violence, the use of TIY as an adjunctive treatment to traditional therapy, participants reported decreased anxiety, depression, and PTSD symptoms (Clark et al., 2014). IMPLEMENTATION OF A TRAUMA-INFORMED 14 Benefits of Trauma-Informed Yoga Coping Coping is the survivor's attempt to manage the physical and psychological needs produced by a stressful event, such as trauma, that overwhelms the survivor’s resources (Ullman & Peter-Hagene, 2014). Positive coping strategies such as mind-body interventions that promote mindfulness effectively increase awareness, improve emotional regulation, and support survivors in processing traumatic memories (Nicotera & Connolly, 2020). Trauma survivors have an increased need for positive coping strategies, such as mind-body interventions seen within TIY, as these can help address the residual effects of unresolved trauma (Nguyen-Feng et al., 2019a; Nguyen- Feng et al., 2020). A common coping strategy used within TIY is grounding techniques such as physical movement, deep breathing, and focusing on observations associated with the five senses. Grounding improves the regulation of the fear response and increases the survivor's ability to regulate the intense emotions associated with traumatic memories (Nguyen-Feng et al., 2019a; Nicotera & Connolly, 2020; Nolan, 2016). These strategies help reorient the survivor to the present moment and move out of hyperarousal into a mindful state of awareness (Nguyen-Feng et al., 2019a). Grounding techniques help the survivor to manage the sympathetic nervous system’s response to trauma, remain in their window of tolerance between hypoarousal and hyperarousal, and reorient to the safety of the present moment during intense fear or episodes of disassociation (Nguyen-Feng et al., 2019a; Ong et al., 2019). Working with grounding techniques addresses the need for a mindfulness practice that assists the survivor in focusing on being receptive and present in the body while observing what occurs physically and emotionally (Nguyen-Feng et al., IMPLEMENTATION OF A TRAUMA-INFORMED 15 2019a; Ong et al., 2019). The ability to remain present in the moment improves somatic awareness, which increases the capacity for the survivor to reconnect with the body, cultivate self-awareness, enhance emotional regulation, and increase distress tolerance (Nguyen-Feng et al., 2019a; Nicotera & Connolly, 2020; Ong et al., 2019; Ong, 2021; West et al., 2016). By increasing the mind-body connection, the survivor may use less maladaptive avoidant coping strategies, increase physical self-awareness, and improve emotional regulation. One of the outcomes of mindfulness can be found in aiding the survivor in developing and integrating the coping strategies that are necessary to safely access traumatic memories stored in the body and process them cognitively, thereby decreasing the trauma symptoms (Nicotera & Connolly, 2020; Ong et al., 2019). In a peer review of quantitative, quasi-experimental, random-controlled, and qualitative studies, Nolan (2016) found that relaxation strategies that support a mind-body connection, such as restorative yoga poses, meditation, chanting mantras, and breath regulation, may stimulate the parasympathetic nervous system, and allow the survivor to shift out of the high-stress trauma response of “fight, flight, or freeze,” and into a state of equilibrium. By reestablishing homeostasis, the survivor may experience improved sleep, decreased stress reactivity, and lower heart rate variability (Nolan, 2016). Additionally, mind-body interventions may mitigate trauma’s adverse effects on survivors' self-worth and overall coping ability (Nguyen-Feng et al., 2019a). Providing survivors with coping skills that acknowledge emotional regulation and somatic experiencing to address trauma's impact when being held in the body is vital in mindfully regulating internal states and physiological responses (West et al., 2016). Comparatively, Ong et al. (2019) found that this approach addresses trauma's multifaceted IMPLEMENTATION OF A TRAUMA-INFORMED 16 effects on psychological, physiological, and social aspects of the individual’s health (Ong et al., 2019). It provides the survivor with readily available coping mechanisms to regulate arousal and regain homeostasis (Ong et al., 2019). Mindfulness Mindfulness focuses on the present moment from a place of nonjudgement while being open to observing thoughts, emotions, and somatic responses (Nicotera & Connolly, 2020). The positive impact of mindfulness on the survivor can counter avoidance behavior that acts as a barrier to treatment (Nicotera & Connolly, 2020). Since trauma memory impacts the individual physically, mentally, emotionally, and socially, a “bottom-up” approach focuses on grounding the survivor in the present, which increases mindfulness and helps establish a sense of selfawareness (Ong, 2021). This mindful body awareness may be a necessary first step to improving cognitive-based interventions' efficacy in some individuals (Ong, 2021). However, mindfulnessbased interventions that consisted of 8 weeks or less were less effective than longer interventions (Taylor et al., 2020). Zaccari et al. (2020) supported this trauma-sensitive approach by implementing a TIY intervention to treat PTSD. This intervention significantly improved response inhibition, PTSD symptoms, depressive symptoms, and quality of life. Empowerment Taylor et al. (2020) suggest that mindfulness-based interventions, such as TIY, are costeffective, safe interventions that clinicians can implement as an adjunct treatment for trauma survivors. Through TIY, survivors may experience a sense of empowerment through enhanced self-confidence, improved social function, decreased feelings of shame, and increased hopefulness (Ong, 2021). Ong et al. (2019; 2021) found that TIY was an effective intervention to IMPLEMENTATION OF A TRAUMA-INFORMED 17 decrease the severity of trauma symptoms, with survivors reporting improved sleep, increased physical strength, and enhanced self-regulation. It is further identified that the positive effect of the yoga intervention can be sustained over time (Nolan, 2016; Ong, 2021). After attending a 10-week TIY program, survivor responses revealed five significant themes: feelings of self-love, increased interoceptive awareness, acceptance, centeredness, and empowerment (Ong, 2021). These themes support survivors in integrating their trauma, improving tolerance to change, developing a stronger connection to self, and an increased ability to engage in physical and psychological intimacy with partners (Ong, 2021). This empowerment positively impacts the survivor by improving self-confidence, increasing motivation to navigate day-to-day life, and helping them embrace life after trauma (Ong, 2021). In addition, TIY creates an environment that improves self-concept and increases the individual's ability to cope (Nguyen-Feng et al., 2019a). Solution Yoga, a mindfulness-based practice, has been used for centuries to promote grounding and relaxation through meditation, breathwork, and physical postures (Nolan, 2016). Modifying this century-old practice to meet the needs and be sensitive to trauma survivors creates a shared space where participants feel a sense of belonging, acceptance, safety, and structure (Stevens & McLeod, 2019). Facilitating and creating a safe environment is a vital component of treatment for trauma survivors. Respecting personal boundaries, minimal disruptions, survivor orientation to the space, ensuring appropriate lighting and temperature, and eliminating power differentials create a space conducive to healing that avoids potentially triggering the survivor (Justice et al., 2018; Ong et al., 2019; Ong, 2021). IMPLEMENTATION OF A TRAUMA-INFORMED 18 Within an environment of safety, a facilitator provides consistency and a nonjudgmental approach through the TIY intervention, which decreases hyperarousal, supports physical and psychological safety, and promotes healing (Ong, 2021). Combining social interaction in a safe environment within the structured mind-body intervention can add another dimension to trauma healing by counteracting avoidance behavior and decreasing the need for isolation (Stevens & McLeod, 2019). Discussion The literature on TIY as an adjunctive treatment commonly displays the following limitations: poor compliance, small sample sizes/limited sample, possible self-reporting bias, and short duration of the study (Cushing et al., 2018; Gladden et al., 2022; Justice et al., 2018; Nguyen-Feng et al., 2019b; West et al., 2017; Zaccari et al., 2020). The most common limitation was small sample sizes which decreased validity and reliability. These findings support the need for more studies to support the use of TIY. Additionally, the research on TIY is still in the nascent stages, and more robust studies are needed to determine the overall efficacy of using TIY as an adjunctive intervention (Nguyen-Feng et al., 2019a; Ong, 2021). There is also a need for long-term follow-up studies to determine if the positive effects of TIY are sustained over time (Ong, 2021; Van der Kolk et al., 2014). The research suggests that TIY can empower, improve the quality of life and promote healing in individuals who have suffered trauma while empowering survivors with mindfulness, grounding, and relaxation (Nolan, 2016; Ullman & Peter-Hagene, 2014). In addition to providing an opportunity for future research on its efficacy, an evidence-based mind-body intervention as an adjunctive treatment would provide an additional resource to promote healing and improve long-term outcomes in trauma survivors (West et al., 2017; Ong et al., 2019). IMPLEMENTATION OF A TRAUMA-INFORMED 19 Framework Description This quality improvement project utilizes the G.R.A.C.E. Model as a framework with the Health Belief Model Theory (HBM) to guide its development, efficacy, and evaluation. The HBM is an assessment tool that eliminates barriers and amplifies motivators toward positive change. In conjunction with the G.R.A.C.E. framework, the HBM aids the survivor in fully immersing themselves in the themes of the G.R.A.C.E. model. The acronym G.R.A.C.E. stands for the six themes: grounding, reconnection/relatedness, awareness/acceptance, compassion, and empowerment (Gladden et al., 2022). Developed by Raechel Morrow BSW, E-RYT, and based on Emerson’s trauma yoga guidelines (Emerson et al., 2009), this model consists of a 6-week TIY series with a specific theme focus for each session. The combination of program themes aid in addressing trauma's damaging impact on the body and reestablishing feelings of safety, somatic awareness, and empowerment. The series involves validating the need for trauma survivors to reconnect with the body, experience interoception in a safe space, recognize embodiment cues, and regain control over trauma symptoms (Gladden et al., 2022). Research utilizing this model has reported improvement in self-care, decreased feelings of stress, feelings of empowerment, increased emotional awareness, and reduced reactivity (Gladden et al., 2022). The intervention will begin with the first session, which focuses on grounding. The purpose of grounding is to help cue the body to shift from the sympathetic nervous system into the parasympathetic. The focus shifts to reconnection in the second session, which supports the survivor’s ability to remain in the present moment. Next, the third session stresses the importance of feeling the sensations in the body and bringing awareness and acceptance to them. Compassion is the theme of the fourth session. During this session, meditation and positive affirmations help the individual improve their ability for self-compassion. The fifth session IMPLEMENTATION OF A TRAUMA-INFORMED 20 theme is empowerment, a common theme throughout trauma research literature. The instructor promotes empowerment by offering choice and supportive cues throughout the class. Participants choose the best option for their body and what feels right to them at any moment. Finally, the sixth session integrates the previous sessions (Gladden et al., 2022). The HBM will be used throughout the intervention to understand better trauma survivors' hesitancy to seek and comply with treatment. This conceptual framework will be a beneficial tool in identifying perceived benefits, barriers, and cues to action in participants (The Health Belief Model, 2019). The model will also be a reference when meeting with stakeholders and evaluating the program for revision and improvement. Framework Application to Project Although a new framework requiring further research, the G.R.A.C.E Model has shown promise in recent studies (Gladden et al., 2022; West et al., 2017). Noting the model’s basis in Emerson’s Trauma-Sensitive Guidelines grounded in trauma treatment in collaboration with Van der Kolk is encouraging. The G.R.A.C.E. Model’s emphasis on mindful movement, interoceptive awareness, and six themes that focus on counteracting the adverse effects of trauma has been shown to improve self-regulation and increase the individual’s overall ability to experience emotions and sensations in the body safely (West et al., 2017). Additionally, the themes of the model have the potential to provide benefits both on and off the yoga mat for trauma survivors. Such benefits may include but are not limited to an improved quality of life, a regained sense of ownership over their bodies, and a sense of peace in the present moment (West et al., 2017). Project Plan Trauma, whether physical or emotional, can result in long-term impairments for the affected individual (Clark et al., 2014; Gladden et al., 2022). Therefore, a promising intervention IMPLEMENTATION OF A TRAUMA-INFORMED 21 to decrease trauma symptomology and improve quality of life is TIY (Cook-Cottone et al., 2017; Justice et al., 2018; Nicotera & Connolly, 2020). The following section outlines the plan for implementing a Trauma-Informed Yoga Program at New Hope Crisis Center for survivors of interpersonal violence and sexual assault. In addition, the project design, needs assessment, cost analysis, sustainability, program outcomes, ethical considerations, and project evaluation are addressed. Project Design The TIY project consisted of a 6-week TIY program that will continue to be delivered at regular intervals throughout the year at New Hope Crisis Center. Informed consent and preintervention survey data were collected before implementation. The program started with a formal presentation to participants, which prepared them for the program, explained the purpose of the TIY intervention in relation to trauma treatment, and discussed how the intervention might impact some of the adverse side effects (ASE) of the trauma they were experiencing. The presentation was integrated into the pre-intervention process. Participants retained the right to withdraw from the program at any time. The TIY sessions occurred directly following a voluntary group therapy session with a Licensed Mental Health Counselor (LMHC) to help prepare them for the session. Survivors participated in the TIY session each week for six weeks, with each session addressing another theme based on the G.R.A.C.E. Model Framework supported by Emerson’s Trauma-Informed Yoga guidelines (Emerson et al., 2009; Emerson & Hopper, 2011; Gladden et al., 2022; Van der Kolk et al., 2014). After each TIY session attended, survivors completed anonymous, voluntary Qualtrics post-surveys. IMPLEMENTATION OF A TRAUMA-INFORMED 22 Needs Assessment/Gap Analysis of Project Site and Population The prevalence of trauma and its devastating impact on the survivor's QOL speaks to the significance of trauma and the need to apply evidence-based resources in treatment. Effective treatment must ensure that survivors feel safe in their bodies for healing to occur (Nolan, 2016). The problem is the failure to effectively treat trauma leading to long-term ASE that negatively impacts survivors QOL. In survivors of interpersonal violence and sexual assault, avoidance behaviors, dissociation, PTSD, exacerbation of symptoms with cognitive-based interventions, fear of disclosure, intellectualization, and a need for somatic connections missing in traditional treatment modalities creates a need for an intervention, such as TIY, to bridge the gap in trauma treatment (Justice et al., 2018; Stevens & McLeod, 2019). Trauma does not discriminate regarding gender; however, this project focuses on female survivors due to the concern that female survivors may be triggered by males being present during the intervention since, statistically, males are the most common perpetrators of violence against women. The program was implemented at New Hope Crisis Center, a shelter and trauma survivor resource center in rural Brigham City, Utah. Before implementation, this facility lacked body-based programs to treat trauma and welcomed any resources that would support the healing journey of their clients. Based on demographic information, New Hope Crisis Center’s survivor population included diverse individuals ranging in age, ethnicity, socioeconomic status, and education level (New Hope Crisis Center, 2017). This diversity provided an opportunity to address multiple social determinants of health and eliminate potential barriers to treatment for this vulnerable population. As a result, stakeholders, including New Hope Executive Director, LMHTs, New Hope Staff, the survivors, and the DNP student/Registered Yoga Instructor, worked IMPLEMENTATION OF A TRAUMA-INFORMED 23 collaboratively to implement and revise the program to best meet the needs of this diverse group of survivors, increase accessibility and inclusivity, decrease barriers, create awareness through social media, and remain in line with New Hope’s commitment to advocacy. This program addressed a current lack of community resources. It provided access to a cost-free, easily accessible intervention in a safe environment that decreased survivors’ barriers to traditional treatment. Cost Analysis and Sustainability of the Project This project needed to be cost-effective. New Hope Crisis Center has limited funding, best utilized to address the growing number of survivors seeking shelter and their acute safety needs. A budget outline was created (see Appendix A), and a grant was obtained for implementation expenses such as yoga mats, blocks, bolsters, and journals. The funds were also allocated to ongoing costs related to the equipment upkeep. For cost containment, it was also a priority that all TIY instructors delivering the program did so on a volunteer basis. A lack of trained TIY instructors may impact long-term sustainability. Training additional TIY instructors to continue the 6-week program for survivors is necessary. Recruiting other TIY yoga instructors interested in a volunteer opportunity and willing to learn the program is ongoing. Project Outcomes Judith Hermann, a renowned trauma theorist, defines the guiding principle of trauma recovery as “restoring a sense of power and control to the survivor” (Emerson & Hooper, 2011, p. 23). This project aims to help restore that essential sense of power and control, as described by Judith Hermann, to help survivors effectively heal from trauma, decrease trauma symptoms, and experience improvement in their QOL. Additional goals included developing and implementing IMPLEMENTATION OF A TRAUMA-INFORMED 24 a free, sustainable EBP resource available as an adjunctive treatment. Furthermore, it was important that the resource also addressed social determinants of health barriers for the vulnerable population of survivors of abuse regarding access to quality trauma care. It was also critical that the program did not require survivor disclosure of the specifics related to their trauma which has been identified as a significant barrier to seeking treatment and increasing survivor attrition rates (Ullman & Peter-Hagene, 2014). These outcomes would increase the number of individuals receiving treatment and potentially increase the efficacy of treatment. Additionally, the program functions as an adjunctive therapy that can be used concurrently with conventional trauma treatment modalities to augment treatment, improve patient outcomes, and decrease the long-term adverse effects of trauma (Stevens & McLeod, 2019). Consent Procedures and Ethical Considerations A key component of TIY is offering choices and empowering survivors to regain control and ownership over their bodies (Emerson & Hooper, 2011; West et al., 2017). The project was developed and coordinated under the direction and consideration of a local university, with the institutional review board (IRB) providing ethical approval that addressed vulnerable population considerations and the potential for trauma triggers. Additionally, the survivors were further protected from any supplementary trauma by retaining anonymity related to personal experiences. The introduction of the TIY program supported the organizational ethics of New Hope Crisis Center. With the aim of TIY to provide survivor-centered advocacy through empowering survivors and assisting them to develop coping skills that would aid them in rebuilding a secure IMPLEMENTATION OF A TRAUMA-INFORMED 25 future the intervention remained in-line with the crisis center’s primary focus (New Hope Crisis Center, 2016). Instrument(s) to Measure Intervention Effectiveness The project was evaluated using pre- and post-intervention voluntary, anonymous, Qualtrics surveys that rated the survivors’ self-assessed Quality of Life and trauma symptoms (see Appendix B). The pre-intervention survey also included an informed consent statement and liability waiver. The tools used for evaluation included the Quality-of-Life Survey (QOLS), a 15item tool that measures material and physical well-being, social, community, and civic activities, relationships with others, personal development, fulfillment, and recreation. This tool focuses on diversity and individual patient perception. “The QOLS is a valid instrument for measuring the quality of life across patient groups and cultures and is conceptually distinct from health status or other causal indicators of quality of life” (Burckhardt & Anderson, 2003, p. 1). This tool has been used in studies involving adult participants suffering from trauma symptomology such as PTSD (Burckhardt & Anderson, 2003). The second tool used for evaluation included the Trauma Screening Questionnaire (TSQ), which consists of 10 items that measure trauma symptoms within the last week. This tool was modified from the larger Post Traumatic Stress Symptom Scale (PSS-SR) tool and has demonstrated similar specificity and sensitivity. Respondents indicate whether they have or have not experienced each symptom at least twice in the past week (Burckhardt & Anderson, 2003). Data from instructor in-person observations during TIY delivery was also included. Finally, the aggregated data was analyzed and disseminated. This data serves as a baseline for future QI and research. Additionally, formative and summative feedback from stakeholders will be encouraged and used to guide project implementation and revision as needed. IMPLEMENTATION OF A TRAUMA-INFORMED 26 Project Implementation The TIY project was implemented at New Hope Crisis Center in Brigham City, Utah. The program consisted of six (6) sessions following a scheduled group therapy session. As part of the informed consent process, information was provided regarding TIY’s potential benefits and risks, and participation was voluntary. Survivors were encouraged to address any questions or concerns regarding using this resource as an adjunctive treatment to their current treatment with their individual counselor or medical provider. At the beginning of each session, the instructor greeted students, invited them to select a seat on a mat of their choice, and encouraged them to take some time to settle into the space. Survivors were reminded of the TIY protocols, the power of choice, the safety of the space, the potential for enhanced somatic awareness, how to navigate potential triggers, and the resting position they could return to at any point during the session. Each session lasted 60 minutes and included breathing exercises, positive affirmations based on the week's theme, gentle movement, and posture options that could be modified per the survivor's preference and need. Survivor participation and successfully recruiting registered yoga teacher volunteers with trauma-informed training will be essential to the project's sustainability. Recruitment and screening will begin after evaluating the data from the initial project implementation and making the necessary revisions. Recruitment will occur through New Hope's social media. Interested volunteers will submit a CV and then complete an interview with the New Hope Director and the TIY instructor who created the program. After the credentials are verified and the interview is completed, they will begin training. After the trainee demonstrates competency to the TIY instructor, the student can implement the program with survivors. The TIY instructor will be IMPLEMENTATION OF A TRAUMA-INFORMED 27 present for the implementation of the new instructor's first six-week program and will intervene if needed. In addition, community support and grant funding will increase the likelihood of longterm sustainability. The goal is to continue to offer the 6-week program at regular intervals throughout the year at New Hope Crisis Center and gradually expand the program to similar facilities within the state once it has been established. Project Intervention Interventions used for project implementation included the initial proposal to stakeholders at New Hope which included collaborative discussion on survivor needs, education on the TIY intervention, identifying short and long-term goals of the project, and exploration of possible barriers and solutions to implementation. These conversations were predominately with New Hope’s executive director; however, valuable feedback was also received from the crisis center staff members. Additionally, coordination between scheduled group therapy and the timing of the TIY intervention was completed to promote a positive experience for participants and ensure resources were available to address potential triggers if needed. The initial project plan and approval were followed by the development of deliverables, including an educational PowerPoint, evaluation tools, advertising, and the TIY 6-week program curriculum. These tools were presented to the New Hope director for feedback and approval. Then, official IRB approval was obtained, and grant applications were submitted to get financial support for project implementation. Deliverables After IRB approval and funding were obtained, advertising for the 6-week TIY program was posted on New Hope Crisis Center's social media (see Appendix C) and highlighted IMPLEMENTATION OF A TRAUMA-INFORMED 28 specifics of the program. It was important that advertising addressed that the program was specific to survivors of interpersonal violence and sexual assault. Interested participants contacted New Hope to sign-up. New Hope staff then forwarded participants an informational email with a QR code that linked the pre-intervention Qualtrics survey (see Appendix B) and access to the TIY instructor-guided educational PowerPoint (Appendix D). The survey also included informed consent and a legal waiver that each participant was required to sign if they chose to participate in the program. In preparation for project implementation, the room was prepared to meet TIY protocol guidelines, and equipment was purchased or donated. Equipment included yoga mats, blocks, bolsters, journals, blankets, and cleaning supplies. Mats were set up in a U shape, providing survivors with clear visuals of entries, exits, and the instructor. The room was well-lit, and journals were placed on each mat for easy access. The room needed to allow for personal space that did not require participants to have fellow survivors behind them. After verification of consent and legal waiver completion, the program began with the first session based on the TIY program curriculum explicitly developed for the project by the DNP student (see Appendix E). The program is based on Emerson’s TIY protocol, Van der Kolk’s trauma research, and the G.R.A.C.E. framework (Emerson et al., 2009; Emerson & Hopper, 2011; Gladden et al., 2022; Van der Kolk et al., 2014). After each class attended, the participant would scan a QR code and complete the post-survey. The program continued for a consecutive 6-week period per the class plans. Project Timeline The project timeline (see Appendix F) covers initial meetings with stakeholders, gap analysis, completion of literature review, and IRB approval. The timeline also addresses the IMPLEMENTATION OF A TRAUMA-INFORMED 29 development of deliverables, scheduling, advertising, implementation of the 6-week program, evaluation, and project data dissemination. Project Evaluation The data was collected from December 2022 to January 2023 as part of the initial sixweek TIY program implementation through pre and post-intervention surveys. These surveys evaluated the program's effectiveness in decreasing trauma symptomology and improving the quality of life for trauma survivors. The project outcomes were met by participants indicating a decrease in trauma symptoms and an increase in their quality-of-life post-intervention. The aggregated data was analyzed, findings discussed, and the overall impact on trauma survivor outcomes evaluated. Data Maintenance/Security Pre and post-surveys were accessed via a QR code linked directly with Qualtrics. Access to the survey results was limited to only the researcher and secured in a cloud-based databank which required a two-party authentication and was further isolated within the databank. Participants developed their usernames by selecting three letters and two numbers. By allowing the participant to create their username, it was possible to ensure anonymity as the username acted as a de-identifier, and only the respondent was aware of their name. Data Collection and Analysis Data collection began before the first yoga session. Participants were required to complete a pre-survey that provided a baseline from which it would be possible to understand the impact the yoga session may or may not have on the survivors. The pre and post-survey followed the Trauma Screening Questionnaire (TSQ) (Brewin et al., 2002), which consisted of questions that asked the participant to identify yes or no responses regarding the current presence of trauma IMPLEMENTATION OF A TRAUMA-INFORMED 30 symptoms. To complement the screening questionnaire, the survey included a Likert Scale from 1 (terrible) to 7 (delighted) to measure the patient’s self-reported Quality of Life (QOL), which was based on the Quality-of-Life Scale (QOLS) (Burckhardt & Anderson, 2003). All quantitative data were collected using a Qualtrics Survey Tool. Following the completion of each yoga session, participants were encouraged to complete the post-survey, which was the same as the pre-survey, within 24 hours. Participants that attended more than one yoga session were not required to repeat the baseline survey and were instructed to identify which yoga session they had completed. The TSQ was scored with yes responses scoring one (1) and no responses scoring zero (0). Participants that scored six (6) or higher were at risk of having or attaining post-traumatic stress disorder (PTSD). The QOLS was scored by adding up the scores for each question, with a scale of 1-7, yielding a total score of up to 112 (Burckhard & Anderson, 2003). Students that scored high were identified as having a high quality of life. Likewise, participants that scored low struggled with their quality of life, with the average health population scoring around 90 (Burckhard & Anderson, 2003). The data results were analyzed within Qualtrics, and the statistical measurements of central tendency were obtained related to each participant and cumulatively across the survivor sample. The analysis allowed for the evaluation of the mean and standard deviation. The statistical results were compared, contrasted, and summarized in Figure 1 and Figure 2, respectively. IMPLEMENTATION OF A TRAUMA-INFORMED 31 Figure 1 Scores on Pre and Post-Trauma Screening Questionnaires (TSQ) 10 9 8 7 Pre 6 Mean 5 Post 4 Group Mean Pre 3 Group Mean Post 2 SD 1 0 A B C D E F Note: n=27. Participants (N=6. Identified as A-G) indicated Yes or No regarding the presence of 10 personal reactions associated with trauma using the Trauma Screening Questionnaire (TSQ). Figure 2 Scores on Pre and Post-Quality-of-Life Questionnaires (QOLS) 120 100 QOL Pre 80 QOL Mean 60 QOL Post Group Mean Pre 40 Group Mean Post SD 20 0 A B C D E F Note: n=27 Participants (N=6. Identified as A-G) rated their satisfaction with 16 quality of life indicators on a scale of 1=Terrible to 7=Delighted using the Quality-of-Life Survey (QOLS). IMPLEMENTATION OF A TRAUMA-INFORMED 32 Findings Healing from trauma is a unique, nonlinear journey that survivors face. Triggers and responses will differ. Creating an environment similar to the traditional structure seen in group therapy or one-on-one sessions may block the survivor, causing them to withdraw. Seeking to assess if alternatives to the traditional structure would be viable created an opportunity to investigate a different form of intervention. The project's intended outcome was to ascertain whether the TIY resource could help facilitate this healing and decrease barriers for survivors. Results from the survey indicated that trauma symptomology remained at baseline levels or decreased for each participant after the intervention. These findings, though from a small group of participants, provided an awareness that TIY could be used to aid survivors in controlling and regulating their trauma symptoms. Further, in supporting the symptomology changes, the research found that the cumulative TSQ mean score decreased from 5.83 to 3 post-intervention, identifying that participation in TIY increased the quality of life for participants by reducing the traumatic response. The quality-oflife (QOL) scores supported this insight, which either remained at baseline or increased after the intervention, with the cumulative mean increasing from 83.7 to 93.67. QOL, as defined over two decades ago, coordinated subjective functioning with personal expectations that were meaningful to the individual and recognizable to most people (Revicki et al., 2000; Revicki et al., 2014). For survivors, the ability to increase their perception of a ‘better life’ and better control their symptoms could provide an answer to the changes in the results and an indication of the effectiveness of TIY. TIY, as identified earlier, is designed to provide a safe space that affords survivors the techniques and strategies to respond rather than be overwhelmed by the circumstance and IMPLEMENTATION OF A TRAUMA-INFORMED 33 symptoms that arise (Cook-Cottone et al., 2017; Justice et al., 2018). TIY classes were structured to allow for development through awareness over a sequence of classes. A total of six (6) classes were offered as part of the TIY program, with a recommendation that survivors complete classes in a sequenced structure. In reviewing the data, it was found that a correlation could be drawn between those participants who attended four or more sessions. Tibbits et al. (2021) found that after one TIY class, participants had an increased awareness of their breathing, movements, and internal sensations with a decrease in negative emotional responses and pain. Additionally, when participants attended more than one TIY class, Tibbits et al. (2021) discovered that selfregulation increased with reports of better sleeping, social interactions, and a sense of well-being and calmness. Comparatively, findings from both the TSQ and QOL scores demonstrated significant improvements from baseline in participants who attended four or more out of the six sessions. Strengths One strength of this project was the use of a local crisis center. This local center had established group meetings directly aimed at trauma, focusing on domestic and sexual assault survivors. In the context of this project, purposive sampling refers to the recruitment of participants who can provide a depth of relevant insight into a research area. Through coordination with this center, it was possible to engage participants in the research by establishing the yoga sessions after survivor group meetings. Using validated and reliable tools, such as the TSQ and the QOLS tools, provided another strength to the research. Each tool has been separately validated so practitioners can validate the risks and effectiveness of offered treatment plans. The ongoing use of these tools directly affected the insights gained through this project, which further validated the measurement of IMPLEMENTATION OF A TRAUMA-INFORMED 34 quality of life and trauma symptomology. Weaknesses One major weakness of the project was the potential for low participation from the crisis center. During the winter months (November-March), it was noted that there were historically low attendance rates at group therapy. These numbers were historically even lower during the holidays between December and January. The director of the crisis center noted a general lack of participation among survivors of sexual assault, supported by the research which identified behaviors of avoidance and isolation that commonly occur among survivors of sexual violence (Nicotera & Connolly, 2020; Stevens & McLeod, 2019). An additional weakness was that some participants attended TIY sessions sporadically or only attended one class. While still beneficial, attendance at all six sessions might have provided a more complete picture of the program’s impact. Also, not all participants completed the post-survey, which decreased the reliability of data, further limiting the generalizability and the provision of feedback to effectively revise specific class sessions that would better meet survivor needs. Further limitations include some survivors' inability to access and navigate the survey. Participants often identified that they were unsure which survey they needed to complete, requiring prompting from the instructor and confirmation as to which class had been completed. Surveys being completed up to 24 hours after the class could contribute to missed surveys or the completion of the wrong survey. Missed surveys were seen when three post-surveys were completed outside the 24-hour window after the intervention. Additionally, one participant completed a baseline but failed to complete a post-survey, so that data was omitted from the data analysis. Ultimately, the number of participants was seven for all the classes combined. This small IMPLEMENTATION OF A TRAUMA-INFORMED 35 number of participants, some of whose trauma was identified as outside the interpersonal violence or sexual assault realm, could further limit the understanding and impact of TIY specific to this population demographic. TIY research is nascent, and this area would benefit from additional research with larger sample sizes and a mixed-method approach to include survivor voices regarding their personal experience with the TIY program. Discussion The ability to live a life that feels safe and free, with recognition and understanding of triggers and symptoms, can be considered an essential part of a person’s quality of life. Through TIY, survivors can become more centered and develop a calming effect that allows time to think. This process leaves them feeling renewed, replenished, and centered (West et al., 2017). As Nolan (2016) identified, survivors must develop a sense of empowerment that will allow them to feel safe within their bodies and develop a sense of normality. In addressing the needs of veterans that had survived sexual trauma, Braun et al. (2021) found that stress responses went down, that mindful meditation was used in everyday life, and that survivors were able to practice self-compassion. The results indicate that TIY can increase quality of life while decreasing survivors' trauma symptoms. Translation of Evidence into Practice The purpose of this project has been to acquire insight into the effectiveness of TIY in helping survivors of trauma. Sweeney et al. (2016) identified that mental health and trauma are closely interlinked, with survivors of trauma accessing support twice as frequently as the general population. Trauma-Informed Access (TIA), as argued by Sweeney et al. (2016), would allow survivors to focus on hope and empowerment and provide access to resources that aim to support rather than potentially retraumatize. In exploring interventions that can help survivors, May et al. IMPLEMENTATION OF A TRAUMA-INFORMED 36 (2022) found that traditional or standardized trauma therapy focused on the survivors' stories and providing medical explanations for symptoms. These therapy techniques often missed the individual, where explicit permission and acknowledgment of the trauma including associated physiological responses could be given. When permission was given to remember and process trauma held in the body, participants were less occupied with recall. Instead, they could focus on coping strategies that would be both helpful and compassionate (May et al., 2022). Literature (Ong et al., 2019; Stevens & McLeod, 2019; West et al., 2017) has identified that through engagement with TIY, survivors could develop an increased awareness of themselves and their psychological, psychological and physiological responses to new stimulations. With the increased awareness comes an awareness of their body within the space and a connection with how invitational movement offers control. These key components allow the survivor an opportunity to practice grounding, notice sensations that occurred within the body, and remain in the present moment (Emerson et al., 2009; Emerson & Hooper, 2011; Gladden et al., 2022; Nicotera & Connolly, 2020; West et al., 2017). As survivors were able to participate and transition through the six classes, their self-awareness and somatic experiences increased, as noted in the decrease in trauma symptomology and an increase in their perception of quality of life. Implications for Practice and Future Scholarship To increase awareness and acknowledge trauma and its sequelae as a healthcare crisis requiring a trauma-informed approach, clinicians must address issues beyond the mental health arena. To address the survivors’ reexperiencing states that often occur in traditional treatment and the associated negative peritraumatic symptoms that affect survivors' quality of life requires advocacy. Advocacy includes applying recent evidence to provide survivors with an inclusive IMPLEMENTATION OF A TRAUMA-INFORMED 37 embodied treatment on a physical and somatic level that targets the cascade of dysregulation that commonly occurs after trauma exposure that is missing from traditional interventions (Seng et al., 2019) As previously mentioned, the research regarding TIY is nascent, and more rigorous mixed-method studies, including larger samples, would be beneficial (Nicotera & Connolly, 2020; Ong, 2021). It is necessary to use existing research to raise awareness of the potential impact of body-based quality-improvement interventions, such as TIY, in combating the aftermath of trauma. Highlighting TIY’s efficacy in decreasing symptoms of the fight, flight, freeze, and faint response within survivors is vital in establishing the self-regulation necessary to manage reactive symptoms. The knowledge gained will improve understanding of body-based interventions and increase survivor accessibility. Additional scholarship addressing TIY may aid in augmenting the existing knowledge regarding body-based trauma interventions and increase access to this treatment for survivors. Improved access, usage, and research regarding TIY will help to strengthen survivor adaptation and allow for a better understanding of survivors' personal experience shifting from fight, flight, or freeze to one of "flow" or self-regulation (Seng et al., 2019). Building on past TIY research that counters the core experiences of psychological trauma, such as disempowerment and disconnection (Emerson et al., 2009; Gladden et al., 2022; Herman, 1998; Van der Kolk et al., 2014; West et al., 2017), increases understanding of a new approach to trauma treatment. Key concepts from polyvagal theory (Porges,1995), Van der Kolk et al.'s (2014) trauma research, and somatic experiencing (Levine et al., 2018) combined with Emerson's TIY guidelines (2009) and Gladden's 6-week TIY framework (2022) acknowledge the interconnection of physiological, emotional, psychological, and social components of IMPLEMENTATION OF A TRAUMA-INFORMED 38 posttraumatic health (Nguyen-Feng et al., 2019a; Ong, 2021). Survivors can complete the stress response cycle by noticing and allowing stored survival energy or somatic markers. Through the process of releasing accumulated over-activation of the sympathetic stress response, TIY provides a safe space that is a supportive environment to navigate sensations, process them, and help mitigate continued adverse reactions in response to reoccurring trauma triggers (Justice et al., 2018; Levine, 2018). Combining the aspects of body-based interventions with traditional therapy may help combat the mind-body dichotomies existing within an outdated model that segregates mental and physical health (Seng et al., 2019). However, future research is necessary to explore implementation across a more comprehensive array of settings to provide greater access for survivors. Additionally, offering dual training for clinicians, such as mental health workers and first-line responders, would allow them to provide the TIY programs in their professional roles. Finally, the TIY would be used as adjunctive treatment, including examining various academic settings, high-risk groups, hospitals, women's resources centers, homeless shelters, and other community-based agencies. Sustainability Acceptance and support from key stakeholders could increase the sustainability of the TIY program. The positive findings from this project of decreased trauma symptomology and improved quality of life are motivating factors to continue to provide the program at regular intervals at New Hope Crisis Center. Collaboration with other sites to identify the best time to implement the 6-week programs would increase attendance and access to survivors. Additionally, to aid in the sustainability of TIY, the recruitment and training of additional TIY instructors would allow for less burden on a single instructor. IMPLEMENTATION OF A TRAUMA-INFORMED 39 Dissemination Dissemination includes educational presentations to community partners to gain increased interest in providing the TIY resource to a larger population of survivors and expanding program reach beyond the New Hope Crisis Center to other community partners. Plans regarding dissemination include incorporating the results of this project into a broader study which will aid in building on existing research and increasing the validity and generalizability of study findings. Additional plans include presenting at a national conference, sharing findings at professional organization meetings, and disseminating study findings through New Hope Crisis Center's social media. Finally, study results will be submitted for publication consideration. Conclusion The use of bottom-up, body-based interventions such as TIY is still a relatively new intervention implemented in trauma treatment which requires additional research, long-term follow-up, exploration, and reflection (Nolan, 2016; Stevens & McLeod, 2019; Taylor et al., 2020). Evidence, however, identifies a clear gap between traditional treatments and the provision of holistic trauma. This gap was highlighted in the preliminary efficacy of TIY treatment to positively impact survivors' quality of life, decrease trauma symptomology, and address that gap. Additionally, TIY provided an alternative or adjunctive treatment that eliminated the need for disclosure, avoided the potential for re-traumatization, and provided an intervention appropriate for a survivor who might find traditional treatment inaccessible or ineffective (Justice et al., 2018; Nicotera & Connolly, 2020; Ong, 2021). Providing this evidence-based intervention to survivors bridges a gap between old treatment modalities and new research IMPLEMENTATION OF A TRAUMA-INFORMED regarding somatic experiencing that may offer many still suffering the hope that healing is possible (Ong et al., 2019; West et al., 2017). 40 IMPLEMENTATION OF A TRAUMA-INFORMED 41 References American Psychological Association. (2017, February 24). Clinical practice guideline for the treatment of PTSD. 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Journal of Psychological Trauma: Theory, Research, Practice, and Policy, 12(8), 913-917. http://dx.doi.org/10.1037/tra0000909 IMPLEMENTATION OF A TRAUMA-INFORMED Appendix A Budget Outline Project Budget Implementation Expenses Items Cost per Unit Number Staff Training n/a n/a Training Materials (Electronic training n/a n/a $62.50 8.00 Miscellaneous such as equipment you would need to have to start Total $ 62.50 $ Total Cost n/a $0.00 $500.00 8.00 $500.00 Ongoing Expenses Items Cost per Unit Number n/a n/a Rent Total Cost n/a Equipment (Upkeep/replacement) $ 50.00 $1.00 $50.00 Total $ 50.00 $1.00 $50.00 Funding Items Grant (yoga mats, bolsters) Amount $ 300.00 Grant/Donations (blocks, journaling s$ 200.00 Total 500.00 $ 47 IMPLEMENTATION OF A TRAUMA-INFORMED Appendix B 48 IMPLEMENTATION OF A TRAUMA-INFORMED 49 IMPLEMENTATION OF A TRAUMA-INFORMED 50 IMPLEMENTATION OF A TRAUMA-INFORMED 51 IMPLEMENTATION OF A TRAUMA-INFORMED 52 IMPLEMENTATION OF A TRAUMA-INFORMED Appendix C Deliverables: Advertising 53 IMPLEMENTATION OF A TRAUMA-INFORMED 54 Appendix D Deliverables: PowerPoint Presentation 10/17/22 Trauma-Informed Yoga Trauma DNP Project New Hope Crisis Center Trish Small MSN, RN, CNE, RYT-500 "The guiding principle of recovery is restoring a sense of power and control to the survivor" -Judith Herman (Emerson, 2011, p.23). It is essential for trauma survivors to feel safe in their bodies, regain a sense of empowerment, and experience improved quality of life (Nolan, 2016). The long-term adverse effect trauma has on survivors may be a barrier to healing and significantly decrease quality of life (QOL). In adult female trauma survivors at New Hope Crisis Center, does the implementation of a 6-week TIY program, compared to traditional treatment alone, improve quality of life and decrease trauma symptomology? 1 2 What exactly is Trauma-Informed Yoga? Effects of Trauma • TIY • Trauma Symptoms – Physiological – Psychological • Sympathetic Nervous System Response – Adapted from traditional yoga – Safe Space – Mind-body connection – You are in control! – Natural self-protective response to threat – Inability to complete the cycle=stored trauma • G.R.A.C.E. Model – – – – – • Interoceptive Awareness – Process stored trauma 3 Grounding Reconnection/Relatedness Awareness/Acceptance Compassion Empowerment 4 What to expect during the 6-week program 6-week TIY program based on the G.R.A.C.E. Model No hands-on adjustments, invitational language (you are ALWAYS in control), TIY intervention will be scheduled after a voluntary group therapy session Licensed therapist available to address potential triggers Questions? Anonymous pre and post program surveys to measure the effectiveness of the program 5 6 1 IMPLEMENTATION OF A TRAUMA-INFORMED 55 Appendix E DNP Trauma-Informed Yoga Program Class Plan-Week 1 G.R.A.C.E. Model: Grounding Welcome 6:00 pm-6:05 pm *Instructors may change the class plan at their discretion as needed. All changes will align with TIY standards. -Instrumental music (optional) -Check room temp -acknowledge unexpected “noises” (name them) -gender-neutral greetings e.g. “Friends” -pre/post-cleaning of space & equipment -Invitational language reminders: “When you feel ready...” “If you like...” “If it is calling to you...” “When it feels right to you...” “Invite/Explore/noticing/allowing.” Note: Sanskrit terms provided on lesson plan. However, these terms are used selectively d/t potential to overwhelm students. 6:05 pm-7:00 pm OPENING / CENTERING - 5 MIN Introduction of theme: GROUNDING • Create safety in the body and cue the parasympathetic nervous system to engage • Offering to set personal intention for the class (e.g., I am present, I am listening to my body, I am strong) • Invitation to come to a standing position: • Tadasana -Mountain (Grounding posture) WARM-UP - 10 MIN • Sun salutations x2 • Surya Namaskar-Sun salutation A x2 • Tadasana/Mountain Pose TARGETED WARM-UP // PEAK (OPTIONAL) - 15 MIN • Utthita Tadasana- Five-pointed star (step to right/look to right) • Virabhadrasana I (Warrior I - R side) x 4 breaths Meet in a seated position, encourage to keep eyes open to help remain present in the moment and increase sense of safety. Checkin with the breath. Offer a reminder of the importance of survivors making choices for themselves regarding their needs above adhering to the structure of the class Introduction of rest posture options and offer invitation to return to this place when needed at any time during the class Setup: Mats Bolsters Blanket Blocks Journals Instructor Notes/Verbiage Cues: IMPLEMENTATION OF A TRAUMA-INFORMED Utthita Tadasana- Five-pointed star Virabhadrasana I (Warrior I - L side) x 4 breaths Tadasana - re-grounding x 4-6 breaths Uttanasana-Forward fold to Bharmanasana-tabletop to seated FLOOR / COOL DOWN - 15 MIN • Bharmanasana-tabletop • Bitilasana Marjaryasana-Cat/Cow stretches • Modification: seated cat/cow • Balasana (child’s pose “resting pose”) • Modification: Vajrasana-Thunderbolt • Bharmanasana-Tabletop • Dandasana (staff pose) x 4 breaths • Ardha Matsyendrasana (Seated spinal twist) • Janu Sirsasana (head to knee forward bend - L/R) • Supta Matsyendrasana II-Reclined twist (L/R) • Check-in with breath. Transition to Savasana • Multiple resting postures offered. Students encouraged to assume any position of comfort that feels right in their body. CLOSING - 10 MIN • Savasana (4-5 mins) lights remain on. Closing meditation. • Comfortable seated pose of choice (easy pose, closing intention setting, gratitude. Option to journal) • • • • 56 IMPLEMENTATION OF A TRAUMA-INFORMED 57 DNP Trauma-Informed Yoga Program Lesson Plan-Week 2 G.R.A.C.E. Model: Reconnection/Relatedness Welcome 6:00 pm-6:05 pm *Instructors may change the class plan at their discretion as needed. All changes will align with TIY standards. -Instrumental music (optional) -Check room temp -acknowledge unexpected “noises” (name them) -gender-neutral greetings e.g. “Friends” -pre/post-cleaning of space & equipment -Invitational language reminders: “When you feel ready...” “If you like...” “If it is calling to you...” “When it feels right to you...” “Invite/Explore/noticing/allowing.” Note: Sanskrit terms provided on lesson plan. However, these terms are used selectively d/t potential to overwhelm students. 6:05 pm-7:00 pm OPENING / CENTERING - 5 MIN Introduction of theme: Reconnection/Relatedness • Embodiment cues that bring participants continuously back to the present moment’s sensations. • Opportunity to genuinely relate to the instructor (mirroring attachment: mindful integrated movement/group practice) • Offering to set personal intention for the class (e.g., I am safe, I am loved, I am home, I remember that it is okay to ask for help and receive support, I am present in my body) • Invitation to remain in seated position of comfort: • Start to connect with the body through small movements (e.g., wiggle fingers/toes, circle wrists, maybe explore interlacing arms overhead stretch) WARM-UP - 15 MIN • Core connection/engagement Meet in a seated position, encourage to keep eyes open to help remain present in the moment and increase sense of safety. Check-in with the breath. Offer a reminder of the importance of survivors making choices for themselves regarding their needs above adhering to the structure of the class Reminder of rest posture options and offer invitation to return to this place when needed at any time during the class “You have already done the hardest work of arriving to class. You might take a moment to express gratitude for how you show up for you.” Setup: Mats Bolsters Blanket Blocks Journals Instructor Notes/Verbiage Cues: IMPLEMENTATION OF A TRAUMA-INFORMED Ardha Matsyendrasana-Seated twists Neck rolls Shoulder rolls 5-step Self-Holding Breathing technique (Yamasake, 2022. P.156). • Vairasana-Thunderbolt • Modification: any comfortable seated shape • Transition to Parihjasana-gate pose (L and R) Exploring sensations inside the body, lengthening, expansive “There is no need to shrink or hide.” • Vairasana-Thunderbolt TARGETED WARM-UP // PEAK (OPTIONAL) - 15 MIN • Adho Mukha Svanasana-Press up to Downward facing dog • Option: straight to standing • Uttanasana-Forward fold with a slight bend in the knees and slowly roll to standing • Tadasana-Mountain (re-grounding) • Big Arm circles (forward/back) • Surya Namaskar-Sun salutation A x4 • Utkatasana-Chair pose (sweep arms back, release fear, self-doubt, shame) x2 • Tadasana-Starfish • Virabhadrasana 1-Warrior 1 (palms push out) (R&L) • Tadasana to Utthita Tadasana- Five-pointed star • Virabhadrasana 2-Warrior 2 (R) • Viparita Virabhadrasana-Reverse Warrior (R) • Tadasana to Utthita Tadasana-Five-pointed star • Virabhadrasana 2-Warrior 2 (L) • Viparita Virabhadrasana-Reverse Warrior (L) FLOOR / COOL DOWN - 10 MI • Tadasana • Inhale arms overhead • Exhale Uttanasana-forward fold • Bharmanasana-Tabletop • Marjaiasana/Bitilasana-Cats & Cows • Balasana-Child’s pose CLOSING - 10 MIN • Savasana (4-5 mins) lights remain on. Multiple resting postures offered. Closing meditation. Students encouraged to assume any position of comfort that feels right in their body. • Comfortable seated pose of choice (easy pose, closing intention setting, gratitude. Option to journal) 58 • • • • Yamasaki, Z.A. (2022). TraumaInformed Yoga for survivors of sexual assault W.W. Norton & Company. IMPLEMENTATION OF A TRAUMA-INFORMED 59 DNP Trauma-Informed Yoga Program Lesson Plan-Week 3 G.R.A.C.E. Model: Awareness/Acceptance Welcome 6:00 pm-6:05 pm *Instructors may change the class plan at their discretion as needed. All changes will align with TIY standards. Meet in a seated position, encourage to keep eyes open to help remain present in the moment and increase sense of safety. Check-in with the breath. -Instrumental music (optional) -Check room temp -acknowledge unexpected “noises” (name them) -gender-neutral greetings e.g. “Friends” -pre/post-cleaning of space & equipment -Invitational language reminders: “When you feel ready...” “If you like...” “If it is calling to you...” “When it feels right to you...” “Invite/Explore/noticing/allowing.” Offer a reminder of the importance of survivors making choices for themselves regarding their needs above adhering to the structure of the class Note: Sanskrit terms provided on lesson plan. However, these terms are used selectively d/t potential to overwhelm students. 6:05 pm-7:00 pm OPENING / CENTERING - 5 MIN Introduction of theme: Awareness/Acceptance • Awareness: Cue class to become aware of sensations in a particular part of the body (e.g., bent forward leg in Warrior 1) • Acceptance: necessary to develop control over symptoms. Encourage to acknowledge any sensations and recognize them as temporary. • Offering to set personal intention for the class (e.g., I am present, I am listening to my body, I am strong) • Invitation to come to a standing position: • Tadasana/Mountain • WARM-UP - 10 MIN • Sun salutations x4 TARGETED WARM-UP // PEAK (OPTIONAL) - 20 MIN • Utthita Tadasana-Five-pointed star (step to right/look to right) Reminder of rest posture options and offer invitation to return to this place when needed at any time during the class Setup: Mats Bolsters Blanket Blocks Journals Instructor Notes/Verbiage Cues: *Hip openers IMPLEMENTATION OF A TRAUMA-INFORMED Utkata Konasana- Goddess Prasarita Padottanasana- Wide-legged fold (hand placement options) • Tadasana- Mountain • ½ Sun salutations x4 • Surya Namaskar- Sun salutation A • Kapotasana- Pigeon R *Acknowledge sensations • Surya Namaskar- Sun salutation A • Kapotasana- Pigeon L *Acknowledge sensations • Salamba Bhujangasana- Sphinx • Adho Mukha Svanasana-Downward-facing dog • Balasana (Child’s pose) • Option: Supported on bolster FLOOR / COOL DOWN - 10 MIN Seated • Ardha Navasana- Half Boat *building strength in core • Option: extend legs to Paripurna Navasana- full boat • Setu Bandhasana Sarvangasana-Supported bridge *allow/release/invite rest • Sucirandhrasana aka reclined or reverse pigeonEye of the needle (R & L) *R ankle to L knee, knee to chest, repeat opposite side • Viparita Karani-Legs up the wall • Check-in with breath. Transition to Savasana. • CLOSING - 10 MIN • Savasana (4-5 mins) lights remain on. Multiple resting postures offered. Students encouraged to assume any position of comfort that feels right in their body. • Closing meditation. *Acknowledge sensations • Option: Side-lying with bolster “I am healing. I am held. I am supported.” • Comfortable seated pose of choice (easy pose, closing intention setting, gratitude. Option to journal) • • 60 IMPLEMENTATION OF A TRAUMA-INFORMED 61 DNP Trauma-Informed Yoga Program Lesson Plan-Week 4 G.R.A.C.E. Model: Compassion Welcome 6:00 pm-6:05 pm *Instructors may change the class plan at their discretion as needed. All changes will align with TIY standards. -Instrumental music (optional) -Check room temp -acknowledge unexpected “noises” (name them) -gender-neutral greetings e.g. “Friends” -pre/post-cleaning of space & equipment -Invitational language reminders: “When you feel ready...” “If you like...” “If it is calling to you...” “When it feels right to you...” “Invite/Explore/noticing/allowing.” Note: Sanskrit terms provided on lesson plan. However, these terms are used selectively d/t potential to overwhelm students. 6:05 pm-7:00 pm OPENING / CENTERING - 5 MIN Introduction of theme: Compassion • Meditations/Mantras on being kind to self throughout class • Encourage to explore self-compassion • “Notice the way you speak to yourself in your head during the class-Try to find more positive self-talk statements” (e.g., “I honor my journey.” “I combat fear through self-compassion.” “I will be gentle and patient with myself.”) • Offering to set a personal intention for the class (e.g., I am brave, I am deserving of peace) • Invitation to remain in seated position of comfort: • Notice the rise and fall of the breath (hand to belly, hand to heart) • “This is your body and your practice. Take all the time you need.” WARM-UP - 10 MIN Meet in a seated position, encourage to keep eyes open to help remain present in the moment and increase sense of safety. Check-in with the breath. Offer a reminder of the importance of survivors making choices for themselves regarding their needs above adhering to the structure of the class Reminder of rest posture options and offer invitation to return to this place when needed at any time during the class Setup: Mats Bolsters Blanket Blocks Journals Instructor Notes/Verbiage Cues: *Heart openers IMPLEMENTATION OF A TRAUMA-INFORMED Seated sun salutations x4 Upavistha Bitilasana Marjaryasana-Seated cat/cow Virasana-Hero (or modified seated position of comfort) Gomukhasana-Cow facing arms Ustrasana-Camel Option: hands at hips, hands on ankles, forearms to the floor • Utthita Balasana-Child’s pose • Option: Supported on bolster. “Focus on selfcompassion. Take a moment to thank yourself for showing up to the mat today.” TARGETED WARM-UP // PEAK (OPTIONAL) - 15 MIN • Tadasana (Mountain) Re-grounding • Utthita Tadasana- Five-pointed star • Virabhadrasana 1-Warrior 1 (R&L) • Virabhadrasana 2-Warrior 2 (R & L) • Viparita Virabhadrasana-Reverse Warrior (R & L) • Utthita Trikonasana-Triangle (R & L) heart opener • Parsvottanasana-Pyramid (R & L) heart opener • Prasarita Padottanasana-Wide legged fold (focus on lifting the heart to the sky as you fold) • Vrksana-Tree (hands at heart or up overhead) • Tadasana • ½ sun salutations x2 • Option: chaturanga style push-up meet on belly or lower to belly savasana FLOOR / COOL DOWN - 10 MIN • Salama Bhujangasana-Sphinx (heart opener) • Bharmanasana-Tabletop to seated • Ardha Navasana-Boat (lift the heart) • Pavanmuktasana-Knees to chest (hug to chest) • Check-in with breath. Transition to Savasana. CLOSING - 15 MIN • Savasana (4-5 mins) lights remain on. Multiple resting postures offered. Students encouraged to assume any position of comfort that feels right in their body. • Closing meditation: Heart Meditation (Yamasaki, 2022). • Comfortable seated pose of choice (easy pose, closing intention setting and gratitude. Option to journal) 62 • • • • • • Yamasaki, Z.A. (2022). TraumaInformed Yoga for survivors of sexual assault W.W. Norton & Company. IMPLEMENTATION OF A TRAUMA-INFORMED 63 DNP Trauma-Informed Yoga Program Lesson Plan-Week 5 G.R.A.C.E. Model: Empowerment Welcome 6:00 pm-6:05 pm *Instructors may change the class plan at their discretion as needed. All changes will align with TIY standards. -Instrumental music (optional) -Check room temp -acknowledge unexpected “noises” (name them) -gender-neutral greetings e.g. “Friends” -pre/post-cleaning of space & equipment -Invitational language reminders: “When you feel ready...” “If you like...” “If it is calling to you...” “When it feels right to you...” “Invite/Explore/noticing/allowing.” Note: Sanskrit terms provided on lesson plan. However, these terms are used selectively d/t potential to overwhelm students. 6:05 pm-7:00 pm OPENING / CENTERING - 10 MIN Introduction of theme: Empowerment • Providing options within the various yoga positions • Allow participants to select which option works best for their bodies • 2-3 choices at most • Offering to set a personal intention for the class (e.g., “I will not doubt my value” “My needs are important.” “I honor my boundaries.” • Invitation to come to a standing position: • Tadasana (Mountain pose) • Empowerment meditation (preparing the mind for practice) Meet in a seated position, encourage to keep eyes open to help remain present in the moment and increase sense of safety. Check-in with the breath. Offer a reminder of the importance of survivors making choices for themselves regarding their needs above adhering to the structure of the class Reminder of rest posture options and offer invitation to return to this place when needed at any time during the class Setup: Mats Bolsters Blanket Blocks Journals Instructor Notes/Verbiage Cues: *Lengthening spine, Core work, Moving through standing “Being hurt repeatedly can lead to a sense of helplessness and powerlessness. Some survivors have used a submission-based survival response for many years, ignoring their own wants or needs in order to placate the demands of others. They may be confused about how they actually feel or what they want. In addition, because many trauma IMPLEMENTATION OF A TRAUMA-INFORMED Option: Tense & Relax Practice Spense (2021). Trauma-Informed Yoga: A toolbox for therapists. Ch. 3. PESI Publishing WARM-UP - 10 MIN • Sway arms side to side, Free movement, explore what feels right in your body. As always, you choose. You are in total control. • ½ Sun salutations x2 TARGETED WARM-UP // PEAK (OPTIONAL) - 20 MIN • Tadasana (Mountain) Re-grounding • Surya Namaskar-Sun salutation A x4 • Utthita Tadasana-Five-Pointed Star (step to right/look to right) -Moving through standing • Virabhadrasana 1-Warrior 1 (R) • Virabhadrasana 2-Warrior 2 (R) • Utthita Parsvakonasana-Extended side angle (R) • Starfish-Tadasana.Mountain • Virabhadrasana 3-Warrior 3 (R) • Tadasana-Mountain • Virabhadrasana 1-Warrior 1 • Virabhadrasana 2-Warrior 2 (L) • Utthita Parsvakonasana-Extended side angle (L) • Starfish-Tadasana.Mountain • Virabhadrasana 3-Warrior 3 (L) • Starfish • Prasarita Padottanasana-Wide-legged fold • Vrkasana-Tree (hands at heart or up overhead) • Tadasana-Mountain • ½ sun salutation (meet on belly) FLOOR /COOL DOWN - 10 MIN • Kumbhakasana-Plank (Core) • Vasishtasana-Side plank (Core) • Bharmanasana-Tabletop • Ardha Navasana- (half) Boat (Core) • Option: extend legs to Navasana-full boat • Dandasana- Staff (lengthening) • 64 survivors struggle with self-blame, they have learned not to trust themselves and their own instincts. Because of this loss of self-trust, a primary goal for survivors might be to rebuild their sense of confidence and empowerment.” (Emerson & Hopper, 2011. P. 112). IMPLEMENTATION OF A TRAUMA-INFORMED Check-in with the breath. Transition to Savasana. CLOSING - 10 MIN • Savasana (4-5 mins) lights remain on. Multiple resting postures offered. Students encouraged to assume any position of comfort that feels right in their body. • Closing meditation. • Option: Yamasaki (2022) p. 179. Danielle Koepke quote • Comfortable seated pose of choice (easy pose, closing intention setting and gratitude. Option to journal) • Emerson & Hopper (2011). Overcoming trauma through yoga. North Atlantic Books. Spense (2021). Trauma-Informed Yoga: A toolbox for therapists. Ch. 3. PESI Publishing. Yamasaki, Z.A. (2022). Trauma-Informed Yoga for survivors of sexual assault W.W. Norton & Company. 65 IMPLEMENTATION OF A TRAUMA-INFORMED 66 DNP Trauma-Informed Yoga Program Lesson Plan-Week 6 G.R.A.C.E. Model: Integration of 6 Themes Welcome 6:00 pm-6:05 pm *Instructors may change the class plan at their discretion as needed. All changes will align with TIY standards. -Instrumental music (optional) -Check room temp -acknowledge unexpected “noises” (name them) -gender-neutral greetings e.g. “Friends” -pre/post-cleaning of space & equipment -Invitational language reminders: “When you feel ready...” “If you like...” “If it is calling to you...” “When it feels right to you...” “Invite/Explore/noticing/allowing.” Note: Sanskrit terms provided on lesson plan. However, these terms are used selectively d/t potential to overwhelm students. 6:05 pm-7:00 pm OPENING / CENTERING - 10 MIN Introduction of theme: Integration of all themes Grounding, Reconnection/Relatedness, Awareness/Acceptance, Compassion, Empowerment • Offering to set personal intentions for the class (e.g., I feel grounded, confident, worthy, and whole, I feel the support of my fellow survivors on my healing journey. I am not alone in my experience.) • Invitation to remain in seated position of comfort *OPTION: Salamba Balasana-Supported Child’s Pose • Survivor Meditation (Incorporate all themes) WARM-UP - 10 MIN • “When you are ready, transition from Balasana supported child’s pose to a comfortable seated position with hands at the sides if that feels right to you. You may choose to place your hands on the ground and feel the stability beneath you. Take a moment to feel that same strength and stability within you. You are worthy of finding moments of grounding Meet in a seated position, encourage to keep eyes open to help remain present in the moment and increase sense of safety. Check-in with the breath. Offer a reminder of the importance of survivors making choices for themselves regarding their needs above adhering to the structure of the class Reminder of rest posture options and offer invitation to return to this place when needed at any time during the class Setup: Mats Bolsters Blanket Blocks Journals Instructor Notes/Verbiage Cues: Combination of weeks 1-5 IMPLEMENTATION OF A TRAUMA-INFORMED amid the storm. Inside you is a quiet, safe space you can always come home to.” • Hand to heart, hand to belly. Check-in with the breath. Feel your own internal rhythm • When you are ready • Shoulder rolls • Neck rolls • Surya Namaskar A-Sun salutations/Explore side stretch/leaning into the ground-feeling supported • Parighasana-Gate pose (explore sensations in the side body/lengthening) • Bharmanasana-Tabletop • Adho Mukha Svanasana-Downward dog • Step/hop or float to the top of the mat • Arms circle overhead, Inhale to standing, hands meet at heart center TARGETED WARM-UP // PEAK (OPTIONAL) - 20 MIN • Tadasana/Mountain: Re-grounding • Utthita Tadasana- Five-pointed star (step to right/look to right) • Utkata Konasana-Goddess • Prasarita Padottanasana-Wide legged fold (hands at hips) • Tadasana-Mountain • Garudasana-Eagle (R & L) -Peak/Balancing • ½ Sun salutations x2 (inhale arms overhead, exhale fold, inhale half lift, exhale fold, inhale to standing, hands meet at heart center) • Surya Namaskar-Sun salutation A (inhale arms overhead, exhale fold, inhale half lift, long exhale as you fold, two steps back, Chaturanga Dandasana, Urdhva Mukha Svanasanaupward facing dog, Adho Mukha Svanasana-downward facing dog, step/hop or float to the top of the mat, inhale half lift, exhale fold, inhale to standing, hands meet at heart center) • Kapotasana-Pigeon R *Acknowledge sensations • Surya Namaskar-Sun salutation A x1 • Kapotasana-Pigeon L *Acknowledge sensations • Adho Mukha Svanasana-Downward facing dog FLOOR / COOL DOWN - 10 MIN • Bharmanasana-Tabletop • Bitilasana marjaryasana-Cats/Cows • Vajrasana-Thunderbolt • Ustrasana-Camel • Ardha Navasana-Half Boat *building strength in core (option to extend to Paripurna Navasana-full boat) 67 IMPLEMENTATION OF A TRAUMA-INFORMED Sucirandhrasana aka reclined/reverse pigeon-Eye of the needle (R & L) *R ankle to L knee, knee to chest, repeat opposite side • Viparita Karani-Legs up the wall • Check-in with breath. Transition to Savasana. CLOSING - 10 MIN • Savasana (4-5 mins) lights remain on. Multiple resting postures offered. Students encouraged to assume any position of comfort that feels right in their body. • Closing meditation. *Acknowledge sensations • Comfortable seated pose of choice (easy pose, closing intention setting and gratitude. Option to journal) • 68 IMPLEMENTATION OF A TRAUMA-INFORMED Appendix F Project Timeline 69