How Trauma-Informed Fitness Helps Survivors Process and Heal Through Exercise

Newly out of graduate school in 2004, Jennica Mills was on the path to becoming a licensed social worker focused on psychotherapy with survivors of sexual assault and domestic violence. But something didn't feel right.

"Here I was working with people — in some cases they were severely sexually abused as children. We were talking about their feelings and their emotions and the story. At no point in the exploration were we talking about the physical body," she thought. "It didn't make sense for me. I was a competitive dancer for all my childhood until I was 18, and I relate to the world through my body."

Then, the San Diego-based yoga instructor discovered tension and trauma-releasing exercise (TRE), which is based in the mind-body connection. TRE is designed to help release patterns of stress that adherents believe are held in the muscles and the connective tissue surrounding them. "There was a turning point for me there, that this is the missing piece. The body is missing from this interaction that we're having in our regular therapeutic process."

TRE is part of a burgeoning field that marries exercise and fitness with trauma-informed practices. Practices that are trauma-informed recognize and address the effects of past traumatic experiences — such as sexual abuse, domestic violence, war, disasters, child neglect, personal illness, divorce or the death of a parent — on a person throughout their life, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

Undergoing trauma that results in psychological stress can raise your risk of experiencing mental illness, substance abuse and sleep disorders.

Stress is also linked with a heightened risk of heart disease. An older but influential September 2004 global study in ​The Lancet​ found people who had a first heart attack were twice as likely to report having "permanent" psychological stress at work or home than those who hadn't had a heart attack.

Chronic stress can also contribute to high blood pressure and lead to behaviors that raise your risk of heart problems, such as smoking, not being active enough or eating more than your body needs to fuel itself, according to the American Heart Association.

Stress might even contribute more to heart disease than other traditional risk factors, such as diabetes, cardiologist Sanul Corrielus, MD, MBA, tells LIVESTRONG.com. He points to a November 2021 ​JAMA​ study, which followed people with stable heart disease who were exposed to both mentally and physically stressful situations and developed myocardial ischemia (an obstruction of blood flow to the heart that can be damaging) as a result.

Those who experienced ischemia after mental stress were more likely to later die from heart-related causes, have a non-fatal heart attack or be admitted to the hospital for heart failure within a five-year follow-up period.

Also a personal trainer, Philadelphia-based Dr. Corrielus incorporates trauma-informed practices and exercise into his medical treatment. His goal is to reduce inflammation in patients, which can be caused by emotional stress, according to the American Psychological Association (APA).

Chronic stress can hamper the body's ability to regulate inflammation using the hormone cortisol. Over time that inflammation can contribute to arteries hardening and thickening with plaque, putting you at risk for heart attack, stroke and blood clots, according to Johns Hopkins Medicine.

"My intervention is often focused on identifying the source of the trauma that's leading to the inflammatory process, with coaching that directly addresses it," Dr. Corrielus says. The exercise he prescribes depends on a patient's unique circumstances and fitness level, but it can range from meditation and mindful breathing to walking, running and swimming.

Other practitioners of trauma-informed exercise look at different ways in which the body reacts to mental stress.

Shaking is one common way the body responds to both thrilling and scary experiences, says Phoenix-based trauma-relief specialist David Berceli, PhD, who developed the TRE technique that Mills discovered nearly two decades ago.

When you are in a fender bender, for example, "you might not be injured, but when you get out of the car and you're reaching for your purse or wallet and trying to take out your driver's license, you'll find your hands are shaking," he explains. "The tremor mechanism simply helps to burn off the large amount of adrenaline that was immediately pumped into your body." Adrenaline is the body's "fight or flight" hormone, and it can cause a jittery feeling, according to the Endocrine Society.

TRE exercises are meant to recreate the tremor response in a gentle and non-threatening manner. "The simple exercises help to stretch and mildly stress the muscles as a way of evoking a natural tremor reaction from the nervous system through the myofascial patterns," Berceli says. "This mild tremor reaction starts to release tension in the body and calm down the nervous system. It's designed as a self-help technique."

He offers the following example of a tremoring exercise:

1. Lie on your back with your legs in a butterfly position with the bottoms of your feet together.
2. Keep your knees open wide as you press your feet together and raise your pelvis several inches off the ground.
3. Hold for about a minute.
4. Lower your pelvis back down, with your feet still pressed together.
5. Close your knees about one inch and hold that position for one minute.You will likely notice that your legs are tremoring.
6. Close your knees another inch and hold for one minute.
7. Continue that sequence inch by inch until your knees are touching, feet flat on the floor.

"What that does is put the body in a conflictual state," Berceli says. "You're both stressing it and you're trying to relax it."

After tremoring, "I have softening in my tension points, which happen to be my jaw, shoulders and pelvic floor," Mills says. "I feel more receptive, and I'm a better listener. It really has turned on my social engagement."

Berceli is careful to call TRE a technique, because he says he doesn't have the peer-reviewed research to have it accepted as therapy. "We're working on it, but it's taking years," he says. Meanwhile, he says TRE has roughly 300 trainers and 600 providers, the latter including those who are using the techniques with themselves and family members.

Mills practices and teaches a variation of TRE that she co-developed with yoga instructor Maria Alfaro called neurogenic yoga. Rather than fatiguing muscles, her exercises are meant to relax the psoas muscles, which extend on each side of the pelvis from the low back to the thigh bone and allow us to walk, run and kick. Muscles can tense up in a stressful moment and then release when the moment has passed, but with chronic stress, muscles can remain tight, in a constant state of guardedness, according to the APA.

Mills' approach integrates the belief among many yoga practitioners that the psoas muscles have special importance to the fight-or-flight response (because they are important to fleeing) and polyvagal theory, which holds that trauma can affect the nervous system's ability to respond appropriately when danger has passed.

Psychiatry professor Stephen Porges, PhD originated polyvagal theory, and first described it in a February 2009 article in the ​Cleveland Clinic Journal of Medicine.​ The theory attaches special importance to the functioning of the vagus nerve, which helps the brain communicate with the part of our nervous system that restores calm after we feel unsafe, called the parasympathetic nervous system. (Much like general TRE, more research is needed before these theories can be considered evidence-based.)

In neurogenic yoga, "there's movement and sound that will actually start to tone that vagus nerve and bring it back online, which in turn balances our nervous system," Mills says. The postures and breathing aim to "soften" the psoas muscles, which presumably tightened up in the fight-or-flight response and aren't responsive to traditional stretches. She says they can in turn restore a sense of safety to the body.

She offers the following example of one such exercise:

1. Lie on your back with your knees bent, feet flat on the floor.
2. Breathe in from the diaphragm.
3. Exhale slowly through your mouth.
4. Continue for 2 to 5 minutes.

"In this position, the psoas muscles are able to relax inside of the pelvic girdle, so gravity is doing the work to soften them," Mills says.

To be clear, these exercise regimens aren't the only ones that can help address the effects of trauma. Any regular exercise can be restorative, reduce stress and improve mental health, according to the APA; although, of course, it is not a substitute for seeking care from a professional mental health care provider when you need it.

Sometimes even restorative exercise can be fraught for trauma survivors, says Darci Jo Revier, a Jacksonville, North Carolina-based certified strength and conditioning specialist (CSCS) and director of education for the National Exercise Trainers Association. "With yoga, simply the positions that your body is put in can bring up emotional responses. It is very daunting, but it can lead to healing,."

Re-experiencing the emotions that the trauma triggered, but in a safe space, can help a person to place them in the context of the past and begin to address them, she explains.

"One of the things we hear over and over again from people is how incredibly triggered they can be by really loud and surprising sounds in gym spaces, like someone dropping a really heavy barbell."

However, some trauma survivors don't feel safe at all in activities that are introspective, says Mariah Rooney, LICSW, a Denver-based licensed clinical independent social worker and co-founder of Trauma Informed Weight Lifting (TIWL), which trains coaches and personal trainers in trauma-informed techniques.

She bases this assertion on her prior experience teaching yoga to military veterans and incarcerated people. "It may be hard to get connected with their body by going inside, but [by] having something on the outside that provides a stimulus they can orient to the experience." Centering on the tactile sensation of, say, a barbell or kettlebell allows people to focus less on their bodies and trauma responses, she explains.

Exercise can also help trauma survivors regain their sense of power, Rooney says. After lifting something heavy or achieving another goal they never thought they would, "they're able to translate their experiences of weightlifting or in the gym to the rest of their life. They kind of go, ​Well, if I can do that, then I can do this thing over here in my life, too​."

A similar sense of empowerment can happen with CrossFit exercises, such as climbing ropes or jumping on plyo boxes, says Julie Mizak, LSCW-C, CPT, a licensed clinical social worker who does CrossFit and weightlifting personal training in Bel Aire, Maryland. "We work together to overcome obstacles in the exercise world to help them overcome things outside of the gym world," she explains.

Anyone who has been in the weight room of a gym knows it can be intimidating, lined with mirrors and full of people grunting and slamming equipment down. "We often associate fitness and strength with having this bootcamp, drill sergeant kind of mentality. That works well for some people, but it also can be really scary for a lot of people," Rooney says.

Trauma-informed gyms can take into account lighting, noise control, music and wall imagery, with an eye toward inclusion and creating a safe space, Rooney says. "One of the things we hear over and over again from people is how incredibly triggered they can be by really loud and surprising sounds in gym spaces, like someone dropping a really heavy barbell. Let's say that you are a combat veteran or someone who experienced trauma where noise is a particular trigger. That could completely set you off."

So can being touched by a yoga instructor or personal trainer without permission, notes Julia Simone Fogelson, LCSW, an Oakland, California-based licensed clinical social worker and former yoga instructor. In many yoga classes, the instructor will gently adjust your body into the correct pose.

"If you are trauma survivor, especially if touch was part of your trauma, then it's not a neutral thing for a stranger to come and touch you," Fogelson says. "For instance, some teachers pull the back of the hips back for downward dog and that could be very triggering."

More and more yoga studios are asking people for consent to be touched ahead of time, Fogelson says, sometimes using double-sided consent cards placed on the front of a person's mat that can be flipped over to display whether or not they want to be touched.

For some people, fitness culture itself can be traumatizing, says Ragen Chastain, a Los Angeles-based certified health coach and functional training specialist. "I had a client who had terrible experiences as a fat kid around fitness and fatphobia. Then, as an adult trying to get back into fitness, they were experiencing a ton of fatphobia at the gym and with the personal trainer they tried to work with."

Trained in the principles of the Health at Every Size (HAES) movement and herself an athlete in a large body, Chastain introduced the client to a private Facebook group of 11,000 members she co-founded named Fit Fatties: Weight Neutral Fitness for All Shapes and Sizes.

"I had them join that and just go through the pictures and posts of members and see what looked fun or cool. They saw a member who is a powerlifter and were like, 'That looks cool, I want to be able to lift super-heavy stuff.'" (Find health coaches who adhere to HAES principles at HAESCommunity.com.)

Chastain worked with the client's therapist and the gym staff to ensure their experience would not be traumatizing. Now the client is competing as a powerlifter. "They said, 'All anybody cares about is that I can safely lift heavy stuff. No one cares about my size,'" Chastain says.