Yoga Therapy in the National Health Service: Experiences with Non-Epileptic Attack Disorder

by Susi Wrenshaw

Intended audience: yoga teachers, yoga therapists, interested yoga practitioners

Originally published in Yoga Therapy Today, a publication of the International Association of Yoga Therapists (www.iayt.org). Shared with permission.

During my time as a yoga therapist in the Neuropsychology Department at Salford Royal Hospital, I had almost 1,000 individual appointments with patients who were diagnosed with non-epileptic attack disorder (NEAD). This article shares some of my experiences with NEAD—also known as psychogenic nonepileptic seizures, dissociative seizures, or functional seizures—as well how I became a yoga therapist in this clinical setting. Having recently completed this contract, my time there will stand out for me as a cornerstone in the development of my own therapy practice and because it involved the groundbreaking step of the U.K. National Health Service (NHS) employing a yoga therapist in a psychology department.

 

My Path to the NHS

 

Before training as a yoga teacher, I worked in disability support and assisted in special educational needs schools. I founded a community interest company (an organizational form set up by the U.K. government for businesses with specific social aims) that used theater and film to explore social issues and trauma in disadvantaged communities and as a way to give a public platform to often-unheard voices. I did this in collaboration with probation centers, women’s refuges, addiction recovery centers, and international refugee services. This gave me a strong foundation in leading groups and developing trauma-sensitive workshops. I have been delivering training, running workshops, coaching, mentoring, and teaching for 16 years. I was a simulated patient and facilitator in communication and consultation skills at Manchester University School of Medicine for more than 10 years. These experiences contributed to my fairly high comfort level in medical settings and helped me bridge the gap between Eastern and Western approaches to health while respecting both.

 

For the last 7 years, I have run a private therapy practice in the United Kingdom, Trauma Therapy Manchester, delivering body oriented therapy. Many of the people I work with in private practice have gotten as far as they could with talk therapies, and some have been discharged by multiple therapists and services for an alleged “inability to engage.” I suggest that what is often seen as an inability to engage could more accurately be called a trauma response. Yoga therapy may offer significant hope to this population because of the combination of compassion, presence, and total acceptance that yoga therapists cultivate within themselves along with the flexibility to find a route in that is accessible and psychologically safe enough for clients to test out while the therapeutic relationship develops.

 

Two clinicians from the Department of Clinical Neuropsychoogy in the Manchester Centre for Clinical Neurosciences at Salford Royal NHS Hospital attended More than Words, my 2-day body oriented training course for therapists. This course introduced talk therapists to ways to integrate the body into their work for mental health and trauma. The course draws on Stephen Porges’ polyvagal theory as a way to explore the three gunas (qualities found in all living beings) in a biopsychosocial approach to psychological wellbeing. This approach had a positive impact on the clinicians’ patients. When a vacancy opened at the hospital, I was invited to apply. Of course, there was no job role for a yoga therapist in the NHS at that time; it was in fact a post for a clinical psychologist or cognitive behavioral therapist. I applied, interviewed, and was offered the job, with a newly created title within the department of “yoga therapist.”

 

It can be valuable to understand the psychiatric diagnostic system as well as the most common psychiatric medications so that you can understand what limiting beliefs a person may have received about themselves and how their medications may be interacting with their response to therapy.

 

What Is NEAD?

 

NEAD happens when a person goes into the freeze survival response. One might describe this through the gunas as either a combination of rajas (the guna of passion and action) and tamas (the guna of heaviness and inactivity) resulting in tonic immobility caused by severe sympathetic and parasympathetic dorsal vagal response, or as tamas (collapsed immobility due to a debilitating parasympathetic dorsal vagal response). People with NEAD may have spent much of their life in a rajasic state that tipped into tamas more and more over time.

 

Unlike epilepsy, NEAD is not caused by electrical activity in the brain and does not directly harm a person in the short term (although people may get injured from falls), but repeatedly going into the freeze response has an impact over time regardless of whether NEAD is present. When you see someone having a NEAD episode they might stare blankly, lose awareness or the ability to speak, drop to the ground, and experience spasmodic jerking and trembling. In other words, it looks very much like an epileptic attack, but NEAD has little else in common with this neurological brain disorder.1 Only a specialist, usually a neurologist, has the training and scope of practice to make a NEAD diagnosis.

 

NEAD is a response to overwhelm from an emotional or physical (e.g., pain) source. It is common not to feel this overwhelm before the episode happens, which is part of the reason for the attack. Life events can cause some people to disconnect from their emotions and bodies so that they feel less and less. This often happens when they have had to cut themselves off from overwhelming vulnerability, usually early in life. In the majority of cases this is from complex developmental trauma—when the primary caregivers were unable (perhaps despite their intentions) to be sufficiently present, consistently available, attuned to, or able to hold the developing infant physically and/or emotionally. Secondary traumas such as abuse, loss, and neglect may also be present.

 

This description is not intended to blame individual parents in their particular circumstances, but rather to offer an understanding of how the stress of intergenerational trauma, inequality, economic factors, disintegration of attachment communities, social norms, and other pressures create an environment that is not supportive to healthy neuropsychological development. Sometimes there are also more obvious and acute traumatic events, but these are almost always layered on top of developmental trauma.

 

A habitual disconnection from self means a person can push through experiences that would cause others to ask for help, take time off, give up, try something else, or rest. The lack of awareness that developed as a protective mechanism early in life could be described as avidya (ignorance). This klesha (destructive state of mind) creates impressions in the subconscious (samskara, or neural pathways). Neuroscience references this phenomenon as Hebb’s rule, often simplified for lay people with the axiom “Neurons that fire together, wire together.”

 

In yogic terms, we could say that those with NEAD have a deep samskara that continues to trigger episodes. People with NEAD often don’t realize they are living in a highly stressed (rajasic) or numbed (tamasic) state. They may even confuse their lack of feelings with peacefulness—sattva (the guna of serenity and mental fortitude, or a parasympathetic ventral vagal response).2 If you’ve never experienced anything but stress and the relative lack of it, how could you compare your experience to any healthy mode of living? People who have or develop NEAD are unaware of how hard they are pushing themselves; they put everyone else first and rarely say no, often holding beliefs that it is selfish to take care of one’s own needs. The cost of constantly living beyond their capacity becomes apparent when a protective shutdown response develops (NEAD or dissociation: the freeze response). Chronic fatigue syndrome, autoimmune diseases, digestive problems, and fibromyalgia are other possible responses that happen when the body must take over and “say no” because the whole person cannot.3

 

Over time, this response gets triggered by smaller and smaller things because, in a sense, the shutdown is working—it’s keeping the person alive and forcing a conservation of energy until the perceived danger has passed. With repetition and strengthening of this neural response, vasanas form (tendencies or karmic influences that affect behavior).4 I have observed through taking histories of NEAD patients that in the years before treatment, their windows of tolerance decreased. Often, people with NEAD have gone from being able to take more emotional or physical stress than their contemporaries to being able to handle significantly less (before a NEAD episode is triggered). This can have a huge impact on quality of life and the ability to engage in living.

 

NEAD is reversible.5 Recovery may require a life-changing shift in values, relationships, and identity, along with lifestyle changes and a retraining of the autonomic nervous system. Often, NEAD patients have a supporting or caretaking role in relationships, to their own detriment. To evolve from this is to let go of a socially constructed identity and discover the true Self (Atman). Yoga therapy is well placed to step in here.

 

Yoga Therapy in a Psychology Department

 

My NEAD team was very receptive to a yoga therapy approach, and now half of the team has attended my More Than Words course. The department (around 30–40 clinical psychologists and neuropsychologists) was welcoming, interested, and supportive. Within the first few months, I was invited to do a continuing professional development session for the whole department. Despite it being a hot summer day and everyone being packed into a small room (preCOVID, obviously!), everyone took part in the practical exercises and had good discussions afterward. During the annual Away Day (a common team-building practice in U.K. office culture), I led the department, including our fantastic admin team and managers, through a yoga session that people still mentioned to me 6 months later. I had taught breath-led asana that could be done in normal clothing, standing, and with limited space. The sequence I shared was based on Dru Yoga’s Earth Sequence.

 

In the interest of informed consent and co-creation of the therapy process, on the job I spent plenty of time on psychoeducation (vidya), exploring with patients how human physiology works and interacts with how we think, feel, and behave, as well as how we develop certain patterns over our lifetimes. (And how we can change them!) When patients understood and experienced how yoga therapy works, they could become quite skilled in shaping and shifting their physiology, allowing other possibilities to open up for them.

 

A client’s first two appointments with me involved assessments to explore the reason for referral and helping them understand and come to terms with their diagnosis and make a treatment plan. These sessions also involved risk assessments and linking up with other support services as needed. I used the panchamaya kosha model (the five layers of self ) in these assessments and included talking as well as observation of breathing patterns, posture, movement, and visible indications of autonomic nervous system regulation— that is, whether someone was in fight-or-flight mode (rajas), rest-and-relate (sattva), or freeze/shutdown (tamas). I would also consider their prakriti dosha (physical and mental tendencies, or blueprint) and their vikruti (current imbalances). It was common to find an excess of vata dosha (air/space) among NEAD patients.

 

Following the assessments, I either referred people to our yoga therapy-based NEAD group to learn physical- (annamaya kosha) and energy-based (pranamaya kosha) strategies for managing NEAD or I took them on for individual therapy. If people had difficulty relating, cognitive challenges, were a risk to themselves or others, or had a dual diagnosis of epilepsy, they would bypass the group. Other factors prompting individual sessions included availability and preference. Those who attended the four group sessions would then be offered a review and individual therapy. For those needing individual therapy, I would see them every 2 weeks for anywhere between 10 and 20 sessions. Many people would only need the group intervention and would not require individual therapy. I made clinical notes on an electronic health records system only accessible to the psychology department.

 

Yoga Therapy and NEAD

All the patients I saw had received a NEAD diagnosis and had usually been referred by the neurology department. Some also had a diagnosis of epilepsy. Many had other functional neurological disorders, chronic fatigue syndrome, fibromyalgia, and chronic pain, which the panchamaya kosha yoga therapy approach takes into consideration—in contrast to the often reductionist Western medical approach.

 

I use a nonpathologizing approach to mental distress that appreciates how a person’s history creates their patterns of relating. I could see that all of my patients had traumatic experiences and/or relationships, often very early in life, that led to the development of thoughts, feelings, and behaviors that made it difficult to have healthy, emotionally balanced, satisfying relationships.

 

For accessibility and clarity I used plain English to explore these concepts with patients, colleagues, and in communications with other healthcare professionals. I had and still have mixed feelings about this, as I wish to honor the history and origin of yoga as a philosophy and spiritual practice from India, yet meeting people where they are is an important part of yoga therapy. As a White woman practicing in the West, I recognize I am in a privileged position to be able to bring yoga into healthcare and share it with people who wouldn’t usually access yoga. I have my own daily yoga practice and am committed to continually questioning my role in delivering a yoga-based approach.

 

The approach

 

A personal plan is created in collaboration with the patient. Svadhyaya (self-study) is a key foundation. This may include

  • understanding patterns in relationships, habits, and emotional reactions;

  • identifying how daily life affects the mind-body and how to make changes or develop acceptance;

  • increasing the ability to tolerate the feeling of subtle and unsubtle changes in the body without shutting down6 ;

  • releasing blocked emotions that can build up if left unaddressed;

  • reprocessing memories or difficult life events that were too overwhelming for the brain to effectively process at the time;

  • learning techniques to release physical and emotional tension; and

  • working with the nervous system to reset an easily triggered or chronically activated stress response (moving from exhaustion, shutdown, and blankness to a responsive state that primes the mind-body for good long-term health, enjoyment, and human connection).7

 

I would often work with the first three koshas to effect change in the others and to ultimately help patients get closer to consciousness and their Atman through their own spirituality. This was often a long way away from their starting points.

 

People with NEAD may have spent much of their life in a rajasic state that tipped into tamas more and more over time.

 

As a foundation, annamaya-based experiences send new information to areas of the brain that do not process words and cannot respond to rational thinking.

 

Whatever we learn during these experiences updates our internal map of the world, including

  • how fearful we feel,

  • whether we see harmless things as a threat (neuroception),

  • our boundaries (what is acceptable and unacceptable to us),

  • how we relate to others,

  • connection to self and others,

  • self-esteem,

  • the drive to take care of ourselves,

  • emotional reactivity (numbness or over-reaction),

  • subjective experience of pain, and

  • sense of direction and purpose in life.

 

Yoga therapists doing this kind of work need regular clinical supervision, their own support networks, strong boundaries, and good self-care practices. I took additional training on top of my C-IAYT yoga therapy training. Solid education in suicide prevention, risk assessment, and suicide first aid is essential. Professional integrity and humility—knowing your limits and being confident to ask for help and/or to refer on—are as important as anything you know; staying within your scope of practice is relevant to all therapists. Although yoga therapy sees the whole person and not simply the diagnosis, it can be valuable to understand the psychiatric diagnostic system as well as the most common psychiatric medications so that you can understand what limiting beliefs a person may have received about themselves and how their medications may be interacting with their response to therapy. One must also recognize that some medical professionals will not understand yoga therapy and may not want to—and be okay with this and accepting of where these people are.

A Bittersweet Ending

 

Along with the individual therapy sessions, I have loved helping to shape the group therapy offerings, designing and recording an online NEAD course, and providing support for hospital staff on the COVID wards. My work had a steep learning curve, and it was one that I relished. The biggest challenge was developing a shared language and way of working between therapists, patients, other clinicians, and medical doctors that was transparent and understandable without being overly formulaic, goal-oriented, rigid, or prescriptive. I also worked with many interpreters throughout my time there, something I’d never done in therapy before. After COVID19 restrictions started, all of my appointments were remote, either by video or telephone, and this added a further level of complexity.

 

I still have mixed feelings about leaving my team and the patients I’d been working with, some for a long time. I’m also incredibly grateful for everything I’ve learned and how I’ve grown in confidence as a therapist. Leaving the hospital was a hard decision to make, but I know it’s the right one as I look ahead to my new therapy clinic opening and a new program of professional training courses to deliver.

 

I hope the accomplishments of my team will inspire other psychology services to consider yoga therapy. It may even be more accessible than talk therapies for many people struggling with emotional regulation; autonomic nervous system dysregulation; and communication, memory, and other cognitive or relational difficulties.

 

Yoga therapy is well placed to be part of a psychology service. It can guide people toward a greater sense of self, aliveness, connection, and community, as well as supporting positive lifestyle change. Feature Yoga therapy can also help people build skills in self-regulation and interoception. It supports agency and responsibility without denying the role that society, inequality, and injustice have on an individual’s well-being. Ultimately, the role of yoga therapy is to guide an individual, and through that person, humanity, toward moksha (liberation).

 

YTT Susi Wrenshaw, C-IAYT, founded Trauma Therapy Manchester. Her practice integrates yoga therapy, eye movement desensitization and reprogramming, emotional freedom techniques, and ayurveda. Wrenshaw is also training in the Compassionate Inquiry method developed by Gabor Maté, MD, and in the NeuroAffective Relational Model founded by Laurence Heller, PhD.

 

References

1. Binnie, C. D. (1994). Non-epileptic attack disorder. Postgraduate Medical Journal, 70(819), 1–4. https://doi.org/10.1136/pgmj.70.819.1

2. Emerson, D., & Hopper, E. (2011). Overcoming trauma through yoga: Reclaiming your body. North Atlantic Books.

3. Maté, G. (2011). When the body says no: Exploring the stress-disease connection. John Wiley and Sons, Inc.

4. Iyengar, B. K. S. (1996). Light on the Yoga Sutras of Patanjali. Thorsons Publishing Group.

5. Lortie, A. (2013). Psychogenic non-epileptic seizures. In O. Dulac, M. Lassonde, & H. B. Sarnat (Eds.). Handbook of clinical neurology, Volume 112: Pediatric Neurology Part II (pp. 875–879). Elsevier.

6. Van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Publishing Group, LLC. 7. Justice, L., & Brems, C. (2019). Bridging body and mind: Case series of a 10- week trauma-informed yoga protocol for veterans. International Journal of Yoga Therapy, 29(1), 65–79. https://doi.org/10.17761/D-17-2019-00020