Nearly three out of 20 individuals, or 42 million people, in the United States report having a disability (Houtenville & Boege, 2019), with these numbers increasing over time (American Community Survey; Kraus et al., 2018). Disability can be broadly referred to as any physical, intellectual, sensory, or developmental impairment (Centers for Disease Control and Prevention, 2019). These impairments affect individuals in multiple dimensions, such as impacting a person’s body or mental structure or function, limiting activities (e.g. difficulty with moving, hearing, seeing, social cues, problem solving, etc.), and restricting participation in daily activities (World Health Organization, 2001). Despite the prevalence of individuals with disabilities and potentially traumatic experiences related to disabling events, there is a major gap in the literature on the prevalence of traumatic experiences in this population.
Studies that examine the relationship between trauma and disability have found that having a disability increases the risk of victimization up to 1.6 times (e.g., Chan et al., 2016; for a review, see Jones et al., 2012). For youth, those with a disability are 3 to 4 times more likely to encounter physical abuse, sexual abuse, emotional abuse, or emotional neglect than their peers (Murphy, 2011), with level of victimization and prevalence of clinical depression being significantly higher in youth with disabilities than in youth without disabilities (Berg et al., 2015). These findings have clinical and practical relevance, but more research in this field is sorely needed. Shortages in robust evidence, well-designed studies, and low standards of measurement and assessment have limited the ability to establish factors that contribute to this relationship (Jones et al., 2012).
Disabilities and Mental Health
The combination of trauma history and disability may lead to significant mental health implications that warrant more attention. This significant relationship is likely due to the high comorbidity with disabilities and mental health disorders. Studies have found mental disorders to be just as disabling as chronic physical conditions (Scott et al., 2009), and adults with developmental disorders have significantly increased rates of all major psychiatric disorders (Croen et al., 2015).
In addition to mental health outcomes, those with a history of trauma and with disability are significantly impacted in related areas of their lives. More individuals with a disability live in institutional settings, do not receive a high school diploma, are unemployed, and live in poverty than individuals without a disability (Houtenville & Boege, 2019). Individuals with disabilities are disadvantaged in their social relationships and experience decreased wellbeing, quality of life, and physical health (Howlin & Moss, 2012; Kosma et al., 2009; Rimmer et al., 1996; Wilson & Clayton, 2010). Children with disabilities tend to have an overall lower level of fitness (Wilson & Clayton, 2010), which may manifest itself as health issues later in life. Further, disabled individuals experience higher rates of many medical conditions (e.g., immune conditions, gastrointestinal and sleep disorders, seizure, obesity, dyslipidemia, hypertension, diabetes, stroke and Parkinson’s; Croen et al., 2015).
As one might suspect, the evidence described suggests that any disability may have an impact on a person’s wellbeing, quality of life, and physical activity and fitness levels (Kosma et al., 2009; Rimmer et al., 1996; Wilson & Clayton, 2010). Despite the impact that a disability may have on an individual, these populations remain underserved and often excluded from communities. Taking action to support and facilitate disabled individuals’ integration within society is often lacking, and there has been scarce research on the development of more effective intervention programs (Howlin & Moss, 2012). Therefore, interventions that aim to address wellbeing are especially important for those with a disability.
Wellbeing and Physical Activity Programs
Implementation of such programs that address wellbeing have begun to develop in some areas of the world. In particular, adaptive sports, physical exercise programs, and adaptive yoga programs have been offered recreationally and as adjuncts to treatment for people with a disability. Of the studies that have examined the effects of these types of programs, many positive health-related outcomes have been noted.
Adaptive sports and physical exercise programs tend to address more of the physical aspects of disability and trauma. Studies have shown that participation in such programs have resulted in increases in levels of physical activity and overall physical fitness and health (Blauwet & Willick, 2012; Zabriskie et al., 2005). In addition to the physical benefits of recreational sports programs, studies have found that the programs benefit the individuals in mental and social domains as well. For example, studies indicate that adaptive sports and physical exercise programs lead to increases in self-efficacy, body image, empowerment, sense of belonging, and motivation for continued involvement (Blauwet & Willick, 2012; Côte-Leclerc et al., 2017; Zabriskie et al., 2005). Such programs have also led to reductions in tension, depression, and anger (e.g., Lundberg et al., 2011). Although these findings show promise for sports and exercise programs, more research is necessary; methodological rigor tends to be low, and mixed results have been found for particular outcomes, including self-esteem, quality of life, and life satisfaction (e.g., Bondar et al., 2019).
Some programs strive to address both the mental and physical conditions that stem from disability and trauma experiences. The implementation of adaptive yoga programs have become more popular as a mind-body integrated activity. Studies that compare the effects of yoga to other physical exercise programs suggest that yoga may be even more beneficial and cost-effective at preventing and treating health conditions for people with disabilities than general exercise programs (Cramer et al., 2013; Hartfiel et al., 2017; Saravanakumar et al., 2014). Again, the state of the literature for yoga with individuals who have disabilities is also in its nascency, but outcomes that tend to be studied show increases in exercise capacity, balance, physical function, and health- and memory- related quality of life (Desveaux et al., 2015; Immink et al., 2014; Saravanakumar et al., 2014; Sharpe et al., 2016). Reductions in anxiety and depression symptoms, pain and stiffness, and number of workdays missed due to disability have also appeared to stem from yoga programs (Desveaux et al., 2015; Hartfiel et al., 2017; Sharpe et al., 2016). One such study assessed perceived outcomes in a 10-week yoga program for patients with history of stroke, resulting in increased range of movement, walking ability, strength, calm feelings, and connection to and acceptance of the body (Garrett et al., 2011). Another pilot study assessed a weekly yoga-based mindfulness group for veterans and active duty service members with a history of traumatic brain injury. They found increases in perceived mindfulness, overall health and mood, and self-awareness (Combs et al., 2018). More research is necessary in particularly relevant outcomes, such as motor function, general health, and depression, as studies have found mixed results about the impact such programs have on these outcomes (Chan et al., 2012; Desveaux et al., 2015; Immink et al., 2014; Veneri et al., 2018).
In addition to programs developed for those with a disability, trauma-sensitive yoga is another option for populations with histories of trauma. While yoga has been shown to have an impact on elements of trauma symptomatology, some forms of yoga may be more triggering to survivors of trauma, such as certain poses that remind them of their abuse or that use instructive language from yoga instructors. Trauma-sensitive yoga was developed by the Trauma Center at Justice Resource Center in Brookline, Massachusetts to accommodate the needs of trauma survivors (Emerson et al., 2009). This form of yoga takes into consideration the environment, physical forms, teacher qualities, assists, and language to optimize the experience for survivors of trauma. Strong evidence exists that suggests yoga- and mindfulness-based interventions are beneficial for individuals with trauma history and lifestyle disorders (for a review, see e.g., Taylor et al., 2020). Research on yoga-based interventions have revealed reductions in depression, anxiety, and psychotic symptoms, all of which are commonly comorbid with posttraumatic stress disorder (e.g., Varambally & Gangadhar, 2016). One study found that yoga as an adjunct treatment to psychotherapy resulted in common themes of spiritual healing, increased self-confidence, and increased mind-body connection (Nguyen-Feng, Morisette, et al., 2019b). More high-quality research in this area is needed as well, as a systematic review revealed that the effectiveness of trauma-sensitive yoga as an intervention or adjunct to psychotherapy is muddled by low quality and high risk of bias in studies (Nguyen-Feng, Clark, et al., 2019a).
Research, Practice, and Policy Implications
Psychologists can use this information and generate higher quality research by not only carrying out more studies, but by making sure the studies that are completed are more thoroughly designed. The previously studied outcomes regarding trauma and disability need to be taken into account to design better studies which should take a multi-modal approach and integrate different approaches to research; for instance, it would be helpful to use mixed-method designs and third-party raters to provide a more comprehensive picture of the trauma and disability experience. Additionally, interventions need to be more clearly defined and holistic, especially for yoga interventions, as the existing research on this topic is lacking. More clearly defined interventions will lead to more thoroughly designed studies and research outcomes that psychologists can use to continue to build their practices aimed at serving disabled individuals.
Psychologists and practicing therapists should think more about integration of physical exercise and yoga programs as interventions to therapy. In particular, an emphasis needs to be placed more on the ability in disability. In other words, how can we best serve the particular populations with whom we work, and how can we promote positive outcomes by focusing on enhancing wellbeing rather than overfocusing on decreasing distress?
One possibility to explore for future programs may be a form of combining trauma-sensitive and adaptive yoga programs, especially considering the high co-occurrence between disability and trauma history. For example, while it might be unrealistic for some with a disability to do yoga without assists, a trauma-informed adaptive yoga setting may involve asking the participant when they need assistance, checking in with them frequently, and using less commanding instructive language. In that way, such a program would acknowledge the need for a balance between interpersonal trauma and physical limitations by promoting holistic growth.
Making such programs more accessible would be beneficial for many, as this may mean availability of services for practicing professionals as well as affordability and feasibility for clients. For some institutions, this may look like better allocation of funding for programs that promote wellbeing. On a broad scale, it is imperative that policies to promote insurance coverage for wellbeing practices and adjunct programs to psychotherapy be created and enforced. For this to occur, further understanding needs to be placed on the need for more interdisciplinary work, e.g., rehabilitation medicine, psychology. As research suggests, integrating the physical and mental needs of a person’s health within the healthcare system provides better outcomes for the individual as a whole. For someone with trauma history, disabilities, a mental health diagnosis, or all three, this is especially important as multiple aspects of their lives are affected by both physical and mental limitations.
Disabilities impair a person’s life in multiple ways, relate to increased risk of trauma victimization, and are highly comorbid with mental health disorders. While evidence suggests that any disability negatively affects individuals in many areas of their life, there are still gaps in the research and lack of support for disabled individuals’ integration into society. Participation in adaptive physical activity programs that do exist has resulted in improvements in physical, mental, and social domains. Adaptive yoga has emerged as a mind-body activity that may be even more effective than other adaptive sports programs. Trauma-sensitive yoga provides similar benefits to adaptive yoga and is designed to optimize the experience for trauma survivors, although integration of adaptive and trauma-sensitive yoga has not been implemented yet. To best support disabled individuals, psychologists should use this information to continue to build more inclusive practices (e.g., trauma-informed adaptive yoga), conduct more thorough research, and create better policies and systems.
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Megan J. Sundstrom is a second-year Clinical-Counseling Psychology M.A. student at University of Minnesota, Duluth. Her research interests are centered around psychological wellbeing, mindfulness and mindfulness-based interventions, and emotional abuse. Megan is a Graduate Research Assistant for the Mind-Body Trauma Care Lab and a graduate mentor for first-year graduate student Linda Zheng and undergraduate student Alexa Asplund. Megan enjoys climbing, running, and visiting new places in her free time.
Alexa L. Asplund is a student at the University of Minnesota, Duluth, working towards a Bachelor of Science in Biology and minoring in Psychology. She is an Undergraduate Research Assistant for the Mind-Body Trauma Care Lab. Her research interests include working with those whose sociodemographics (e.g., age), medical concerns, or psychological symptoms impact their ability to receive help. This includes working with children, those who have experienced childhood trauma, and those whose help seeking is limited. In her free time, Alexa enjoys golfing, wakeboarding, and playing with her dog.
Dr. Viann N. Nguyen-Feng is an assistant professor in the Department of Psychology at the University of Minnesota, Duluth. She serves as core faculty in the counseling/clinical master’s program and directs the Mind-Body Trauma Care Lab. For more information about Viann, see her lab website: https://z.umn.edu/MindBodyTraumaCare.