Abstract
Background:
Seeking Safety (SS) is an evidence-based intervention that benefits patients living with co-occurring PTSD and SUD. Trauma Sensitive Yoga (TSY) has been found to be another beneficial treatment for this patient population. In this study, we examine the feasibility of implementing both SS and TSY within a residential addiction treatment program to support this patient population.
Methods:
We conducted a qualitative prospective evaluation at the Jubilee Treatment Centre in Timmins Ontario from March 2023 to October 2023. Staff members of this center delivered the SS intervention and the TSY was delivered virtually by a certified yoga teacher to the participants. The data sources included patient data, focus groups, and treatment satisfaction surveys to evaluate the effect of this blended intervention on study participants and program staff. A descriptive statistical analysis as well a thematic analysis was conducted to analyze both quantitative and qualitative data, respectively.
Results:
A total of 45 individuals, participated in this 6-month-long intervention. The average age of the participants was 37.88. 84.44% of participants experienced mental health problems in the last 90 days, and 80% used substances in the last 90 days. The paired t-test analysis indicated a significant difference in Trauma Symptoms Checklist 40 scores before and after the intervention.
Conclusion:
This study provided valuable insights into participants’ experiences of participating in this innovative intervention. The finding can benefit future researchers who seek to implement similar programs to support individuals with PTSD and SUD.
Keywords
Introduction
The prevalence of trauma-related disorders, such as post-traumatic stress disorder (PTSD), substance use disorders (SUDs), and co-occurring conditions, represents a significant public health challenge, particularly in vulnerable populations.1 -3 PTSD, as defined by the DSM-5, is a mental health condition triggered by exposure to a traumatic event, characterized by intrusive symptoms, avoidance behaviors, negative mood and cognition changes, and heightened arousal, persisting for over 1 month and causing significant functional impairment. 4 Similarly, SUD is defined as a pattern of problematic substance use resulting in significant distress or impairment, marked by impaired control, social dysfunction, risky behaviors, and physiological factors like tolerance and withdrawal, with severity ranging from mild to severe. 4 Among individuals with a history of trauma, the intersection of trauma and substance use is a common and complex issue that requires effective, integrated treatment approaches.5 -7 One promising avenue for addressing these dual concerns is the implementation of trauma-informed, evidence-based therapies that integrate both psychological and somatic healing techniques. Interventions that promote calming the nervous system, such as somatic practices or trauma-sensitive yoga, help to interrupt this cycle of hyperarousal, and promote physiological regulation. 8 By integrating approaches that combine cognitive, emotional, and somatic interventions, the current model offers a more comprehensive solution that is often missing in traditional treatments, which may focus predominantly on psychological or pharmacological interventions.9,10 Studies that support the self-medication hypothesis suggest that PTSD could predate the onset of SUD.11,12 Managing both disorders poses challenges to experts and clinicians as both present with a multitude of challenging and debilitating conditions.11,12 However, little is known about how to implement an evidence-based treatment plan for this patient population.11,12
Seeking Safety (SS) is an evidence-based treatment model and is widely implemented in various care settings. 13 This manualized cognitive-behavioral therapy for PTSD and/or SUD is designed to treat concurrent SUD and PTSD. This treatment model is also present-focused with an array of coping skills such as creating meaning, developing compassion, and honesty. 13 This model is highly flexible and maximizes acceptability and client access (eg, session length, pacing, and order of topics can vary). 13 SS can be delivered by peers and paraprofessionals, in addition to professionals. 13 The SS manualized program also provides information about topics illustrated in handouts to support retention of a variety of skills taught in the sessions. 13 The information delivered through the topics addresses the cognitive, behavioral, interpersonal, and case-management needs of persons with SUD and PTSD. 13 Research shows that multiple forms of SS have been effective when delivered in a group or with individuals, with individuals from marginalized populations, or via inpatient or outpatient services.14,15
The International Society for Traumatic Stress Studies (ISTSS) 16 Practice Guidelines recognized SS as an effective treatment model currently available for PTSD and SUD. This recommendation was based on 12 studies ranked as Level A to C in the ISTSS expert review process. 16 These studies included a range of participant groups from adolescents, people who are homeless, veterans, people who are incarcerated, and others.6,14,17,18
Over the past several years, neuroscientists have demonstrated that trauma impacts an individual at all levels including physiological, emotional, psychological, and social dimensions.19,20 Trauma specialist and researcher Bessel van der Kolk teaches that trauma is registered in the body, 21 and messages sent from the body have a profound impact over the mind. 22 It is thus clear that recovery from traumatic events is dependent on physical presence, self-awareness, and connection to bodily sensations.21,23 The mind-body connection or bottom-up approaches such as somatic experiencing therapies and yoga have thus gained attention for managing the sequelae of trauma.21,24
Trauma-Sensitive Yoga (TSY) is a form of body-oriented yoga designed to directly address symptoms associated with traumatic exposure and was designed for complex trauma survivors. 21 TSY has been studied in mental health and addiction treatment facilities. 25
Research has shown that TSY has positive impacts including reducing the debilitating effects of PTSD symptoms.21,26-29 van der Kolk et al 21 explored the efficacy of TSY with women who had chronic PTSD and were not responding to traditional psychotherapy treatment. It was found that PTSD symptoms were statistically significantly reduced for the participants in the TSY group, and that reduction was sustained over time. This contrasted with the control group participants’ symptoms which reverted to baseline scores after a slight decrease. 21
It is now evident that not only is there a reduction of PTSD symptoms but also a deeper connection between embodiment and cognitive healing when TSY is utilized in the treatment of trauma.21,30 This led to consensus in the literature that that trauma treatment should be approached holistically. 30 In many studies where TSY was utilized as an intervention, participants reported improvement in emotional and psychological functioning, including self-acceptance, understanding, and empowerment. Furthermore, similar reports from research participants indicated that there were experiences of enhanced self-regulation as well as a deeper sense of connection to self and others.21,26,27 Integrating SS with Trauma-TSY could offer a holistic approach to trauma and addiction treatment by addressing both cognitive-emotional and physiological-somatic aspects. By combining SS’s focus on safety and coping with TSY’s capacity to calm the nervous system and build a sense of safety in the body. Therefore, the objective of this study was to determine the feasibility of implementing Seeking Safety group counseling and Trauma Sensitive Yoga in a residential addiction treatment program.
Methods
This study evaluated the feasibility of implementing SS and TSY in an inpatient addiction program using a qualitative approach using narrative inquiry. Five focus groups were conducted with the program clients and 1 focus group was conducted with the staff members of Jubilee Centre. This paper only describes the perspective of clients. The study was approved by the Laurentian University Research Ethics Board approval number 6021262 in October 2022. This study included all clients who attended Jubilee between March 2023 and October 2023 and excluded individuals who did not consent to participating.
Setting
The intervention was implemented at the Jubilee Centre, a residential treatment center situated in Northern Ontario. Specializing in Substance Use Disorder Treatment, the Jubilee Centre provides a 28-day residential addiction treatment program for individuals aged 16 and older. Annually, the center extends its services to approximately 120 clients. The study was conducted from March 2023 to October 2023.
Intervention
The implemented intervention consisted of 2 components: (1) Trauma-Sensitive Yoga and (2) Seeking Safety group counseling delivered by Jubilee Centre staff members. Indigenous teachings were part of the interventions, specifically incorporated in the opening and closing of the sessions as part of the instructor’s spiritual practice and background. The use of smudging and a sacred bundle was integrated into the sessions to create a respectful and culturally relevant environment. Given that a high percentage of clients in Northern Ontario identify as Indigenous, these practices are common and hold significant cultural and spiritual meaning. Smudging, as a traditional healing method, was used to promote emotional and spiritual well-being, fostering a sense of connection and grounding for the participants.
Trauma Sensitive Yoga
Clients were expected to attend weekly 75 minute virtual TSY sessions, this included a 5 to 10 minute check, at Jubilee through secure videoconferencing. The sessions were done online due to the 300 km distance between the facility and the home of the nearest TSY-trained teacher. Each session included guiding participants through a series of TSY poses and a20 minutes guided mindfulness meditation, providing a holistic and enriching experience. The classes were lead a Yoga Teacher Training (YTT) certified teacher trained in Hatha, Moksha and TSY. The TSY training was a 1 year long training program in TSY and Trauma-Releasing Exercises. The teacher. The sessions were offered virtually due to the 300 km distance between the facility and the home of the nearest TSY-trained teacher. Jubilee staff routinely monitor for injuries or adverse events related to TSY and other elements of the program and onsite nursing staff are able to respond to any incidents. No adverse events happened during the study.
Seeking Safety Group Counseling
The SS sessions were provided to participants 4 times weekly, each session lasting 2 hours with a 5 to 10 minute checking as per the SS manual. At the time of the study, Jubilee had been facilitating SS for 3 years. Four staff members conducted Seeking Safety sessions outlined in the treatment manual. All staff participating in the intervention underwent training to implement and comprehend the Seeking Safety group counseling treatment model. The eight half-days of training on the Seeking Safety group counseling program included didactic, experiential, and small-group learning components as outlined in the SS manual. 13 Two staff members co-facilitated each session. The sessions commenced with a check-in, involving questions addressing participants’ feelings, coping strategies employed since the last session, any substance use or unsafe behavior, completion of commitments, and a community resource update (lasting up to 5 minutes per client). Clients received a handout on the session’s topic to actively engage with the content and enhance emotional involvement. A client read a quotation aloud, followed by the facilitator asking about the main point of the quotation, linking it to the session (2 minutes). The facilitator then delves into the core content, discussing the topic to connect it meaningfully to clients’ experiences. This constitutes the central portion of the session, utilizing specific and current examples from clients’ lives and providing intensive rehearsal of the material (lasting 30-40 minutes). The session concludes with a checkout, during which the facilitator guides the group. To reinforce clients’ progress and provide feedback to the facilitator, clients answer 3 questions: stating 1 thing they gained from the session (including any problems with it), identifying their new commitment, and specifying the community resource they will contact (up to 5 minutes).
Positionality
The main facilitator and PI is a psychotherapist, healer, author, and educator based in Sudbury, Ontario, with a background rooted in both African and Indigenous healing traditions. Originally from South Africa, she immigrated to Canada in 1992 and has since focused her career on trauma, addiction, and intergenerational healing, particularly within Indigenous communities. She is a certified psychotherapist, nurse, Somatic Experiencing Practitioner, yoga teacher, and qualitative researcher. Her research explores Indigenous health, trauma-informed care, and healing, and she has authored books on healing from addiction and trauma. Her personal experiences with intergenerational trauma inform her empathetic approach, blending cultural perspectives to address the challenges faced by Indigenous populations in Northern Ontario. The other facilitators assisting her had a range of bachelors and master’s level training in social work, psychology or addiction counseling.
Data collection
Program Data
Demographic details of clients were extracted from health records at the Jubilee Centre. The program data encompassed fundamental demographic information like age and sex, alongside the Trauma Symptoms Checklist (TSC-40 32 ) and Global Appraisal Needs Quick Version 3 (GAIN-Q3; Dennis & Davis, 2021 33 ). Further details about the clinical measures are available in the protocol paper. 31 The TSC-40 was administered both at enrollment and discharge of each client by clinicians in the program.
Focus Group Procedure
Five focus groups were conducted with program clients. All participants were aware of the goals and reasons for research which were outlined in the consent form. Clients participants had the chance to pose questions if they had concerns. Each focus group was 60 to 90 minutes long. One focus group was led by the principal investigator, 1 focus group was led by program staff, and the other 3 were co-led by researchers and staff, all interviewers were female. All interviews were conducted onsite at the Jubilee Centre. Each group consisted of 8 to 10 individuals. The focus group consisted of the following questions: (1) The impact of Seeking Safety group counseling and TSY on their treatment journey at Jubilee Centre; (2) Preconceived notions and beliefs of Seeking Safety and TSY; (3) Facilitators and barriers to adopt the lessons from the intervention; (4) Clients’ feedback on how to improve future sessions.
Focus Group Recruitment
All clients from the Jubilee treatment facility were invited to participate in the focus groups using convenience sampling. When participants enrolled in the Jubilee Center, a staff member asked for participants’ consent to participate in the study. Clients could refuse to participate in the study and were still able to enroll in the full treatment program. Before each focus group commenced, the research team obtained written consent from each of the participants specifically for the focus group. No compensation was provided to the study participants to remove any potential financial coercion.
Statistical Analysis
We summarized baseline demographic information through descriptive demographic statistics and performed a paired-sample t-test to assess the change in TSC-40 32 scores comparing before and after the 28-day program.
Focus Group Analysis
All 6 focus groups were recorded and transcribed verbatim. The student research assistant and 1 author read and re-read to identify and describe implicit and explicit ideas within the data separately. Codes were then developed to represent the identified themes and link the raw data as summary markers. Code frequencies and code occurrences were then compared, and the emerging relationships between the codes were graphically displayed. Finally, emerging themes were identified.
These themes were shared with the authors. We used Braun and Clarke’s inductive thematic analysis method to analyze the focus group data. The 5 steps were the following 34 : (1) The focus group transcripts were carefully read and re-read to achieve data immersion and enhance familiarity with the content. (2) Initial codes were then created by identifying key concepts within the dataset. (3) After creating the codes, similar codes were grouped to form potential themes. (4) Subsequently, we refined and reviewed the themes to ensure they represented participants’ experiences and addressed our research questions. (5) The last step was to narratively describe the findings with representative and illustrative quotes. We used Microsoft word and Excel to organize both quantitative and qualitative data.
Results
Table 1 includes the demographic of the 38 clients in this study. The study sample had a mean age of 37.88 years (SD = 10.98), ranging from 26 to 48 years old and the majority of participants identified as male (73.33%). Nearly one-quarter (24.44%) of participants reported Indigenous identity. In terms of educational attainment, 31.12% of participants had less than a high school education, 33.32% had completed high school, and 17.78% had some college or university education. Employment status varied, with 35.55% being employed and 46.67% unemployed, while 2.22% did not report their employment status. The primary sources of income included employment (26.66%), Ontario Disability Support Program (ODSP; 15.55%), and Ontario Works (8.88%). Regarding marital status, 24.45% of participants were married.
Client Demographic Characteristics.
SD, standard deviation, aODSP, Ontario Disability Support Program; bGAIN-Q3, Global Appraisal of Individual Needs-Quick 3.
The paired t-test analysis indicates a significant difference in TSC-40 scores before and after the intervention (t = 4.54, df = 32, p = .0001). TSC-40 scored decreased between before and after the intervention by an average of 21.66 (95% CI: 11.95-31.38).
Substance use in the past 12 months was prevalent, with alcohol being the most commonly reported substance (77.77%), followed by stimulants (57.77%), cannabis (55.56%), cocaine (62.22%), and opioids (51.11%). Non-medical injection drug use was reported by 8.89% of participants in the past 12 months, with 68.89% indicating they had never engaged in injection drug use. Mental health challenges were highly prevalent, with 84.44% of participants reporting mental health problems in the past 90 days, and 80.00% reporting substance use during the same period. The mean life satisfaction index score was 49.46 (SD = 17.62), while the mean quality of life score was 44.26 (SD = 18.07). The mean TSC-40 score pre-intervention was 49.37 (interquartile range (IQR) 15-112) and post intervention was 27.44 (IQR 3-81), a 21.93 absolute mean reduction.
Results From Thematic Analysis
The 5 core themes that emerged in the qualitative results were: (1) Healing through the exposure and teachings about the Seeking Safety model, trauma, and addiction; (2) Healing through experiencing and learning about TSY at a physical, emotional, Spiritual, and mental level; (3) Satisfaction with the Seeking Safety intervention; (4) Healing through sharing circles and Spiritual teachings; and (5) Finding community.
In this theme, what emerged from most of the participants were: dealing with trauma and addiction and understanding the link between the 2. As 1 participant described, “It explains a lot about having PTSD, drug use, and how they are intertwined. It’s difficult to get through that without dealing with both at the same time. It talks about anger healthy relationships, which are all helpful to understand and learn more about my PTSD.” Similarly, another participant described, “The Seeking Safety book is very helpful. I learned a lot about different topics of trauma and how to cope with all that has happened to me. It shows how trauma can relate to addiction, how they are connected.” In this theme the education about both trauma and addiction discussed through topics such as dealing with anger, PTSD, taking back your power, setting boundaries in relationships, and taking good care of yourself impacted this group in profound ways. As a participant explained, “I get so much out of it. It’s about learnings about self, and then, not only see in your past, but have complete knowledge about past and new ways to cope. I think it teaches you new ways of coping, safer ways of coping.” Most of the participants said that they came to treatment because they needed to understand why they kept hurting themselves with substances and that the SS information helped them to understand their affliction and learn about their addiction and the impact of trauma. Several participants mentioned that they heard the program now included trauma treatment, and most of them needed help for both disorders.
Subthemes that emerged included learning about health, self-care, and sobriety. What stood out was that most of the participants neglected themselves, beat themselves up whenever they used substances. They indicated that they felt weak, lazy, and damaged, but the SS information helped them realize that both trauma and addiction were not their fault. Most participants recognized experiencing suffering while using. As 1 participant stated, “I think it helped me to find out it was not my fault, it helped me to get rid of my shame. With the help of my counsellor and this circle, I know that it was not my fault. Now I know how to speak about what happened to me.” Another participant mentioned, “Most helpful was self-awareness that’s right through the program and the sessions. Realizing that I am a time bomb ready to blow up anytime. I have been conditioned to not feel because of my experiences and so I like that our feelings are dealt with and spoken about amongst my peers.” It was clear to note through many of the themes that most of the participants struggled with coping strategies and a lack of knowledge about the impact of both trauma and addiction on their lives. As in 1 voice they shared about all the coping strategies that were offered to them through the knowledge and teachings from the Seeking Safety topics. One participant described, “The thing I like the most is the huge number of coping skills it gives you to deal with the emotions and struggles we go through. Especially the topic about anger was so useful for me because I never thought I am an angry person, but you learn a lot of about yourself.” And another lamented, “As far as topics again, with the trauma and anger management, being able to have commitments that we learn about ourselves and learn with the group, it makes you look inside. It might be buried within yourself for a very long time. It helps you to get it all out. I love it.”
In this theme most of the participants reported that yoga gave them an immediate feeling of connection to mind-body and Spirit. Most participants expressed that the Jubilee Treatment Centre offered a holistic approach; for example, “A spiritual connection. Healing through movement and feeling my body. Feeling and finding myself.” Participants uttered that their needs were met through movement and that this movement helped them to release tension and find their way back to their bodies. For example, 1 participant said, “I think after stretching my abdomen muscles, it decreased my abdomen pain. I have -irritable bowel syndrome - IBS, but I have felt better after starting to do yoga. Just by stretching those parts and I find it. So yeah, I really notice a big difference now and I’m looking forward to the next session for yoga.”
Another participant stated, “I have never done yoga in my life. But I have never seen a person with trauma who is not tense. It’s good that in yoga we get to release all that tension.” Many of the participants also reported that they had received all they needed from this treatment. For example, 1 participant said, “I finally understand, I always assumed PTSD has something to do with my substance use but I did not know what it was. I always thought I am fighting with my body. So, Seeking Safety helped me to show me the connection between my PTSD and substance use. From the yoga, I took away how to connect with my body. Now I know because of my PTSD I was always in the defense mode, but now I know how to feel safe in my own body.” Interestingly, most participants applauded the fact that even though this was their first-time doing yoga, it not only helped them to connect, but it helped with releasing and letting go of stuff they carried for many years, like their hurt and pain. As 1 participant stated, “I had doubts, but it really helped me with my tension. Seeking Safety really drives a point across, and the yoga is helpful for releasing tension.” Most participants consistently talked about how grounding to the earth, connecting with their breath, and moving their bodies connected them to the parts of their bodies that felt disconnected due to the trauma and substance use. As 1 client noted, “I like the breathing part, it calms your mind. It gives you a little time to relax and be able to feel comfortable in my own skin. And it feels good, stretching the muscles, stretching my joints, knees, and my shoulders feels better.”
All the participants reflected on their satisfaction with all the SS interventions and reported that they learned something new every day, and through all the SS sessions they arrived at understanding the impact of trauma and substance use on their lives so much better. In general, most of the participants appreciated the SS program and the information. For example, 1 participant commented, “I think the most useful thing I learned is how intertwined substance use disorder and PTSD is. So, the breakdown is nice to know about. I think it is important to learn it as a whole. I think my favorite talk was about anger. One thing I do not like is commitment. I wish we could do the commitment as a group and support each other.”
Most of the participants reported feeling safe and supported by all the staff during the sessions. As 1 participant explained, “I like that I can say I feel really great afterwards. Like you know, I mean I have a hard time opening up and that’s kind of why I am here. I still get moved by everyone’s stories and share everybody else’s feelings.” Many identified self-awareness, self-acceptance, help with structure, enhanced self-esteem, and a deeper commitment in getting better and healing. For example, 1 participant said, “The treatment made me realize that I had more issues.” Another said, “When I first got here, it felt so good. I did not spend so many days here and got so much out of it. Doing different circles with different people, I think I get out something every day.” Most of the participants talked about the insight they gained from the SS topics, and they would specifically mention some of the topics. They could clearly explain sometimes in detail how their growth and understanding came. As 1 participant explained, “I learned how to be a little bit more patient towards myself, not being so hard on myself, giving myself a break, and that we are doing this to make ourselves better and nobody else.” Another stated, “The first time I did the SS and did the circle, I started crying, just tears coming out. I felt like that was the first time I felt the emotions.” Further demonstrating that participants experienced growth from the SS interventions
Participants expressed how much they learned and benefited from the fact that the SS sessions was done in the context of a sharing circle, sacred bundle, and smudging. Many of the participants talked about their introduction to wellness through traditional Indigenous healing practices. With each intake about 30% of the clients would identify as Indigenous. Many of the non-Indigenous participants experienced smudging and Indigenous teachings for the first time. As 1 participant said, “I like the smudging part. I can think more clearly and express myself more clearly, I like the healing aspect of it. I love it. You come in with, like, a clear mind.” Another echoed, “There’s so many different things involved in the bundle that we could connect to somebody at some point, or another’s connected to 1 thing in the bundle, so makes it easy to connect with spirituality. Like I grew up as a Catholic, but I was introduced to smudging. And if you can believe in 1 thing and a strong believer then you could believe in more than 1 thing.” Participants clearly learned throughout the treatment about the sacredness of life, finding a mind-body-Spirit connection, finding a higher power, patience with self, and good morals and values. All these themes emerged through the voices and viewpoints of the participants. For example, 1 participant said, “When the group is going, you feel that there is a different spiritual energy. There is a comfort. It slows me down, helps me to open a bit more. It helps me in a positive way. It helps me talk about my issues and becoming more honest.” Others claimed, “The lifestyle at Jubilee gave me the tools to change my life.” Another stated, “With both the Seeking Safety and yoga, the smudging, I feel like it really connects me with the spirituality which I don’t think I had much of before.”
The words, feedback, and stories of the participants demonstrated the connection these SS sharing circles brought to them. Many of the participants reported that they felt they could connect with each other in the circles. They shared deep experiences of what it felt like to learn with and from others in the circle. For example, 1 participant explained, “It’s great to hear everybody open up when they’re not used to doing that and it’s a great feeling to be able to share and to receive the information, the stories, and the advice and everything that goes along with it.” Other participants said, “I love to watch people come out of their shell. It’s like amazing when you see somebody. . .I don’t want to use an example friend, but just you opening up is just so wonderful to see you. And just to see that weight come off people just, you know, awesome. Thank you.” The words and stories of the participants provided a clear indication of reflective learning in a group, learning through the experiences of others, and the comfort such an environment could bring to people. Most of the participants expressed that topics helped them to feel safe with each other and took away the sense of isolation they experienced. For example, 1 of the participants explained, “I like to see that people can talk about the problems and feel comfortable about it. And then I’d like to see more, obviously that makes them feel better in the end. So, I like that it helps others, so I like to see that that they’re getting things off the shoulders, that’s all.” Others reflected on how difficult it was to hear some of the struggles and pain. One participant reflected, “The topics that we talk about, they are very heavy but it’s helpful. My only negative comment, I guess, would be that we do go through very fast and while we’re in our safety circle and most of what we do is just reading, and there’s some very heavy topics that, like, kind of left me wanting to throw up almost and feel nauseous.”
Discussion
This study explored the feasibility of a combination of SS group counseling and TSY with 45 participants who all completed the study. The impact of the 2 interventions expressed through the voices and viewpoints of the participants affirmed the feasibility of SS and TSY in a residential addiction treatment program. Our quantitative finding shows that participants experienced a clinically significant reduction in their trauma symptoms as measured by TSC-40 scores. However, due to the observational nature of this study, we cannot conclude whether this reduction on score was due to the implemented intervention alone or in combination with other elements of the residential treatment program. A recent scoping review identified that SS reduces PTSD symptoms of individuals with concurrent PTSD-SUD, 35 and this study shows that the combination of PTSD and TSY has similar effects on the participants. Although there is a clear improvement of PTSD symptoms among this patient population, this evidence needs to be used with caution since there is no control group in this study. Previous studies have identified that abstinence from substance use can improve PTSD symptoms without any intervention.15,36 Hence, simple within-group improvement on PTSD symptoms may not be enough to prove the utility of this intervention. Future work needs to be conducted to examine whether this intervention can outperform a control condition.
However, our qualitative findings show that participants had a positive experience participating in the intervention. The 5 themes that emerged from our study shows that the combination of SS and TSY had educational value for participants. This finding is supported in the previous studies, which suggests that a psychoeducational program can be effective in helping clients understand the interrelatedness of trauma and SUD, improving their self-esteem, as well as improving clients’ compliance with treatment. 37 Overall, our qualitative findings identified that the combination of SS and TSY is an acceptable and perceived as a potentially beneficial intervention for participants.
One novel finding of this study is that the participants perceived TSY to be a beneficial addition in their treatment plan. This is aligned with previous trials evaluating the efficacy of yoga as a complementary treatment for other traditional modalities such as pharmacotherapy or psychotherapy.38,39 which identified that yoga help reduce symptoms of many psychiatric conditions above and beyond pharmacological or psychotherapy treatments alone.38,40 Although acceptability of TSY has been in other patient populations 41 this study demonstrates the acceptability of TSY to patients with concurrent PTSD and SUD. Another unique finding of this study is that there is a clear acceptance for Indigenous healing practices among the study participants. This finding is supported by a recent study that demonstrates that it could be beneficial to incorporate Indigenous healing practices into the Western treatment model. Overall, the components of TSY and SS, including Indigenous healing practices, are perceived as beneficial among the study participants.
Limitations
There are several limitations in this study. First, this was a small, single-center study without a randomized control group. Hence, the effectiveness of the intervention cannot be assessed from this study. However, the findings of this study can inform future studies about participants’ experiences and the feasibility of this intervention. Additionally, the generalizability of the study findings is limited because of the small sample size as mentioned above. We did not perform a sample size calculation, as convenience sampling was used. This method may result in a sample that is not representative of the broader population. However, we reported detailed demographic information about the participants and study setting so that researchers and policymakers who seek to implement similar interventions in their own settings can make an informed decision about the applicability of this study finding in their own context. Thirdly, the study PI played a dual role in teaching yoga and conducting the focus groups. This duality of her role may have skewed participants’ responses during the focus group session. To mitigate this issue, the executive director of Jubilee led 1 and co-led (along with the PI) 3 out of the 5 focus groups. Additionally, TSC-40 is a self-reported measure therefore it may not fully capture complex trauma or comorbidities. Due to these limitations, TSC-40 is more suitable as a screening tool rather than a definitive diagnostic instrument. It is also important to consider that we did not measure substance-use related outcomes such as reduced cravings, or reduced substance use. Additionally, although Jubilee staff routinely monitor for injuries or adverse events related to TSY and other elements of the program and onsite nursing staff are able to respond to any incidents, we did not formally measure adverse events and we did not evaluate fidelity to the intervention. Lastly, it is important to note that our study does not include data on substance use-related outcomes. However, several studies have been published examining the impact of Seeking Safety and TSY on substance use disorder (SUD) outcomes across various settings. Future study is needed to expand outcome measures and specifically operationalizing and examining usability of these 2 interventions. Additionally, expanding the study to include staff perspectives, examining the long-term impact of the combined intervention, and assessing the feasibility of scaling the intervention in different settings.
Implication of Study Findings
This research has important implications for advancing trauma and substance use treatment by demonstrating the value of integrating somatic and spiritual approaches with TSY as a holistic model. The findings suggest that combining cognitive, emotional, somatic, spiritual, and social interventions can enhance outcomes beyond standard pharmacological and psychotherapy methods, particularly by addressing trauma’s physical and emotional impacts. Community-building and spiritual healing emphasize the importance of culturally responsive, inclusive care, which may be especially beneficial for Indigenous and marginalized populations. High levels of participant satisfaction and engagement point to the intervention’s potential for improving retention and long-term recovery. This study presents a promising model that could be scaled to other residential and community settings, informing policymakers and healthcare providers about the need for integrative, trauma-informed practices. Finally, the results underscore the importance of training providers to meet the complex needs of individuals with co-occurring trauma and substance use disorders.
Conclusion
This study demonstrates that the combination of SS and TSY is a feasible intervention to implement in residential treatment centers. The findings of this study provide valuable insights on patients’ needs and experiences of this novel intervention that supports patients with PTSD and SUD. This feasibility study demonstrates that there is a clear need for non-pharmacological treatment to support this complex patient population.
Footnotes
Acknowledgements
We thank Jubilee Centre staff and patients for their contribution to the study.
Ethical Considerations
The study was approved by the Laurentian University Research Ethics Board in October 2022.
Consent to Participate
Written informed consent was obtained by all participants.
Consent for Publication
Written informed consent for publication was provided by all the participants.
Author Contributions
TM: Conceptualization, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing; FT: Writing – original draft, Writing – review & editing; KM: Methodology, Project administration, Writing – original draft, Writing – review & editing; TL: Writing – original draft, Writing – review & editing; HJ: Writing – original draft, Writing – review & editing; DM: Conceptualization, Funding acquisition, Investigation, Supervision, Writing – review & editing.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the Northern Ontario Academic Medicine Association (NOAMA).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Data can be made available upon reasonable request.