**4. Yoga and Mental Health**

Post Traumatic Stress Disorder (PTSD) has been identified in individuals who have been affected by anxiety-producing circumstances caused by the COVID-19 pandemic. Being assaulted by an invisible enemy that could strike one or one's loved ones down at any moment is a perfect recipe for the kind of trauma that can lead to PTSD. There are many sources of trauma that operate on people infected by the disease, such as the difficulties of hospitalization, including possible intubation, stigmatization by families and friends, and the inability to be physically close to loved ones during infection. A meta-analysis of studies on the effects of COVID-19 noted that quarantine, lockdown, and the threat of severe illness and death during the pandemic have resulted in deleterious effects to the mental health of a significant number of individuals (Yunitri et al. 2022, p. 1). High levels of PTSD were noted in all sectors of society, including those infected with COVID-19, those working in hospitals, and in society at large, with the prevalence ranging around 17% across all the studies that were examined in the meta-study. Even those who did not contract the disease were shown to be at risk for PTSD due to the fear of infection and severe disruptions to social and work life effected by the pandemic. PTSD can cause serious impairment to all areas of mental function, as it impinges on the carrying out of daily routines, as well as many aspects of physical well-being (Cushing and Braun 2018, p. 21). Psychiatric consultations have soared since the pandemic began, and antidepressants have been prescribed at ever-increasing rates (Di Lorenzo et al. 2021; Rabeea et al. 2021).

In the midst of these social disruptions and traumatic assaults on mental and physical health, the practice of yoga has been shown to be effective at mitigating and even relieving many of the symptoms of PTSD. The practice is indicated in treating as well as preventing the psychiatric disorders such as anxiety, poor sleep, and depression that arise from this condition (Bushell et al. 2020, p. 5). A cross-sectional study from Brazil on the connection between yoga practice and mental well-being during the pandemic conducted in July 2021 examined the habits of practitioners of a variety of yoga modalities, such as Hat.ha, Vinyasa, ¯ Integral, Kundalini, Ashtanga, Raja, and Iyengar (Dos Santos et al. 2022, p. 127). The study surveyed 860 people and noted the length of time that a subject had been practicing yoga, the number of times per week that they had been practicing during the pandemic period, and the average length of each session. Next, the study correlated this data with assessments of mental well-being, including presentations of depression, anxiety, and stress. The results revealed a correlation between the level of yoga one had engaged in with assessed levels of depression, anxiety, and stress. The greater the level of yoga that a subject had practiced was, the lower their score related to these levels was (Kahya and Raspin 2017). Meta studies have also revealed that those who have a higher level of yogic discipline have the most improvement in mental well-being (Cushing and Braun 2018). As a result of these reported successes leading up to and now during the pandemic, more mental health care professionals and even primary caregivers are implementing yogic therapies into their existing clinical management of mental health disorders, emphasizing yoga's "relationship to distress, through mindful, non-judgmental acceptance of internal experiences through an enhanced capacity to tolerate distress and self-soothe" (Kahya and Raspin 2017, p. 116).

As a result, yoga's popularity as a psychological therapy is growing. One recent study has shown that yoga incorporating postures, breathing, and meditation administered to women suffering from treatment-resistant PTSD was able to alleviate the trauma in half of the women to levels below what would clinically be classified as PTSD, leading to a significant reduction in the severity of symptoms for those who were still clinically diagnosed (Van Der Kolk et al. 2014). This study suggests that yoga may provide a complementary approach to reducing PTSD by improving physical and emotional awareness and regulation. A second study demonstrated the efficacy of Trauma Center Trauma-Sensitive Yoga (TCTSY), which is a form of yoga that has been modified for use at trauma centers to make it accessible for people who need more gentle interventions due to trauma. In particular, TCTSY avoids requiring the instructor to physically touch and correct the student's postures and aims to give one more power over one's own body. In this study, the thirty-item Clinician Administered PTSD Scale measures dropped significantly in the trial group using yoga therapy, making them in line with the standard Cognitive Processing Therapy interventions commonly used to treat this condition. (Kelly et al. 2021, p. S-45). As the investigators report, yoga "may be an effective treatment for PTSD that yields symptom improvement more quickly, has higher retention than CPT, and has a sustained effect. TCTSY may be an effective alternative to trauma-focused therapy for women veterans with PTSD related to MST." (Kelly et al. 2021).

Telles and colleagues report that yoga was effective at improving mental health and alleviating anxiety in instances of severe trauma and loss, where symptoms of anxiety, sadness, and PTSD abated, attention span improved, and restlessness decreased among the subjects of the trials that were examined (Telles et al. 2012). Heart rates were additionally reduced when elevated, negative emotions were limited, and sleep quality was improved by sustained practice (ibid.). Physical postures were found to improve mood, and meditation was associated with increased rates of remission of depression. In the same study, yoga was also shown to help alleviate anxiety, with longer interventions lasting several months shown to be more effective than shorter interventions lasting only a few weeks. As Macy notes: "Based on the current evidence, clinicians and service providers working with individuals who are experiencing negative outcomes associated with traumatic experiences ... should consider using yoga as an intervention, but only in addition to other evidencebased and well-established treatments" (Macy et al. 2018, p. 52). (Macy et al. acknowledges that because of the holistic nature of yoga, it is difficult to isolate exactly what component of the practice is eliciting the documented efficacious outcomes and what the mechanisms for this might be. The studies were also statistically problematic by dint of their small sample sizes, poor quality baseline data, inconsistent evaluation and outcome measurements, lack of long-term follow-up to investigate the sustained effects of yoga, and poor documentation of methodological processes). Still, other significant studies are worthy of our attention. A treatment study entitled "Yoga Therapy for the Mind: Eight-Week Course" (YTFTM) addressed depression and anxiety through mindfulness-based interventions and yoga practice in female participants (Kahya and Raspin 2017, p. 123). This was followed years later by a similar study which conducted and evaluated a two-week virtual PTSD treatment of CPT for veterans with PTSD during the COVID-19 pandemic (Held et al. 2021, p. 543). Both studies uncovered multiple benefits in the target groups, including the appropriation of virtual mindfulness techniques, including trauma-sensitive yoga.

The combined take away of all of these studies suggests that those suffering from PTSD might view yoga as a long-term coping tool that could be appropriated in addition to other treatments, even if the mechanisms of yoga's functional contribution are not fully clear. It may be, as Schmalzl intimates, that breathing exercises and postures help combat PTSD by encouraging a lifestyle of self-love and self-health, a view which is reinforced by the rewiring of the subconscious away from negative coping mechanisms (Schmalzl et al. 2015, p. 235). While additional studies are needed in order to clarify these provisional explanations of yoga's efficacy, there is enough already to see the practice of yoga, though spiritual at its core, could become mainstream therapy for trauma-induced hardship as a result of COVID-19.
