Yoga in Psychotherapy

YOGA IN PSYCHOTHERAPY
Running Head: YOGA IN PSYCHOTHERAPY
Yoga in Psychotherapy: Best Practices for Treating Anxiety and Depression
by
Ginnie Schuster Cramer
A thesis submitted in partial fulfillment of the requirements for the degree of
Master of Arts in Counselling Psychology
City University of Seattle
2011
Approved by
Glen Grigg, Ph.D., Advisor, Counselling Psychology Faculty
Monica Franz, M.A., Faculty Reader, Counselling Psychology Faculty
Division of Arts and Sciences
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ABSTRACT
Many psychotherapy clients are using complementary and alternative therapies, most commonly
mind-body therapies such as Yoga, to deal with depression, anxiety, fatigue, insomnia, and
chronic pain. The prevalence of anxiety and depression coupled with the increased use of Yoga
for psychiatric and medical problems underscores the need for an increased understanding as it
relates to the effectiveness and value of Yoga as an adjunct to psychotherapy in session-based
counselling and psychotherapy Yoga appears to be an effective clinical intervention for anxiety
and depression. This thesis addresses the empirical research on Yoga as an effective,
complementary, clinical intervention for anxiety and depression based on examination of studies
published from 1979 to 2011. This thesis uses a best practices approach to identify potential
best practices and to analyze and synthesize a representative sample of best practices. This study
offers a foundation for a clinical protocol for integrating Yoga and psychotherapy to the
profession of psychotherapy in order to be disseminated and tested more formally.
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ACKNOWLEDGEMENTS
It is a pleasure to thank those who made this thesis possible. First and foremost, I offer
my sincerest gratitude to my advisor Glen Grigg who provided supervision, advice, and guidance
from the inception of this thesis. With his guidance, the scholarly foundation for this thesis was
formed and, with his support, the ideas I wished to research got clear direction. Glen, I am
indebted to you for helping me mature as a student and researcher.
I owe a world of gratitude to Gerda Wever my wonderful thesis editor who provided the
road map for organizing and presenting my research. With her support, the research took shape.
Gerda always offered me her professional advice and scholarly editing with incredible
cheerfulness and patience. Gerda, I am grateful in every possible way and hope we will remain
friends and, perhaps collaborate again in the future.
Many heartfelt thanks also go to Monica Franz, my faculty reader, and a wonderfully
inspiring teacher, for her valuable advice and help in further editing the presentation and
discussion of my research. With Monica’s help, the thesis gained clarity. I am deeply indebted
to her for offering her precious time and tremendous intelligence reading this thesis and for
kindly offering her refinements.
I am indebted to all of my Yoga teachers over the years who have passed down the
ancient wisdom of Yoga through their particular lineages, who persisted in encouraging me to be
true to my practice, and who taught me to practice and teach Yoga ‘from the inside out.’ I
especially offer my heartfelt gratitude to Gioia Irwin, Dona Holleman, and Orit Sen-Gupta for
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being dedicated and inspiring western Yogis and teachers. I also wish to thank my students and
clients who have been my greatest teachers on this path.
I must thank my cohort for rooting for me when I felt like I could not go on and for
heaping lavish praise and encouragement that I clearly needed upon completion of the smallest
tasks—you know who you are!
Where would I be without my family? I wish to thank my mother Heidi who always
showed me the joy of learning and academic pursuit ever since I was a child, and who raised me
with her caring and gentle love. Wendy, thanks for being my loving and supportive sis. Thanks
to my beloved children Dylan and Gabrielle for admitting that they were secretly proud of me for
pursuing these studies when other parents weren’t. My heartfelt thanks go to my dearest Emily
and Lucas, for regularly inquiring how it was going and for rooting me on.
Words fail to express my love and gratitude to my husband Brad whose enduring love,
dedication, and confidence in me helped me to persevere. His intelligence, passion, and dreams
mixed with mine to create a perfect alchemy of love, inspiration, and unwavering support that
helped me stretch and breathe and carry this thesis through to completion.
I extend my heartfelt gratitude to my truly gifted physiotherapist Bev Kosuljandic who
helped repair my body/mind and literally helped me screw my head back on straight after hours
at the computer, when Yoga, string, and duct tape were just not enough!
I absolutely must also thank the amazing librarians at City University in Seattle who,
magically, were always able to seek out and provide even the most obscure articles for this
research with incredible professionalism and friendliness.
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TABLE OF CONTENTS
Abstract................................................................................................................................ii
Acknowledgements............................................................................................................iii
Table of Contents................................................................................................................vi
CHAPTER 1 INTRODUCTION..................................................................................1
Context for this Study......................................................................................................4
Structure of the Thesis....................................................................................................11
CHAPTER 2 LITERATURE REVIEW.....................................................................14
Yoga Defined.................................................................................................................16
Yoga and Therapy..........................................................................................................18
Clinical Findings: Anxiety.............................................................................................20
Breath Work...............................................................................................................20
Physical Postures........................................................................................................24
Meditation...................................................................................................................25
Yoga Theory...............................................................................................................26
Clinical Findings: Depression........................................................................................26
Breath Work...............................................................................................................28
Meditation...................................................................................................................31
Explanations of Yoga’s Efficacy................................................................................35
Breath Work...............................................................................................................35
Meditation...................................................................................................................42
Research Critique...........................................................................................................43
Summary .......................................................................................................................44
CHAPTER 3 METHODOLOGY...............................................................................46
Research Objectives.......................................................................................................46
Best Practices Research Methodology...........................................................................47
Rational for Choosing Best Practices Approach............................................................50
Development of Themes................................................................................................51
Creating Categories and Building Inferences.................................................................52
Limitations.....................................................................................................................52
CHAPTER FOUR RESULTS.......................................................................................54
Externally and Internally Validated Styles of Yoga and Interventions..........................54
Counterindications of Using Yoga Therapy...................................................................55
Therapeutic Yoga Interventions—Toward a Protocol For Counsellors.........................59
Anxiety – Calming Yogic Interventions........................................................................59
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Pranayama (breathing practices):...............................................................................59

Asanas (physical postures):........................................................................................61
Meditation...................................................................................................................62
Additional Suggestions that Support Best Practices for Using Yoga for Anxiety.....64
Depression – Effective Yoga Interventions...................................................................66
Pranayama (Breathing Practices)...............................................................................66
Asanas ...................................................................................................................69
Meditation...................................................................................................................70
Additional Suggestions that Support Best Practices for Using Yoga for Depression
...................................................................................................................71
Theories of Counselling Employed with Yoga..............................................................71
Yoga as Supplement to Psychotherapy..........................................................................73
Yoga Integrated with Psychotherapy..........................................................................75
Determinants of the Effectiveness of Yoga Interventions.............................................77
CHAPTER 5 DISCUSSION......................................................................................81
Calls for Research..........................................................................................................82
The Future of Combining Yoga with Psychotherapy.....................................................84
Appropriate Standards and Practices for Two Worlds Colliding...................................85
Best Practices in Integrating Yoga with Psychotherapy................................................87
REFERENCES..................................................................................................................90
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YOGA IN PSYCHOTHERAPY 1
CHAPTER 1 INTRODUCTION
yogas citta-vritti-nirodhah
Yoga is the cessation of the fluctuations of the mind. (Patanjali, Yoga Sutra, 1.2)
The purpose of this study is to explore how Yoga practices are successfully being
integrated into psychotherapy practice. The intention behind this study, which is informed by the
existing research and clinical expertise in the current literature, is to provide a foundation for a
clinical protocol for an integration of psychotherapy and Yoga for anxiety and depression.
Given that Yoga is already taking its place in the spectrum of therapeutic services, therapeutic
guidelines towards professional standards for those wishing to use Yoga in counselling and
psychotherapy are a much-needed contribution to the profession.
As interest in Yoga burgeons in the west (Kornfeld, 2009; Feuerstein, 1997) and more
people experience the many physical, mental, and spiritual benefits of Yoga in classes at their
local Yoga studios and community centres, physicians and therapists have begun encouraging
patients and clients to attend Yoga classes. In addition, a growing number of health
professionals have begun integrating Yoga into their clinical practices (Visceglia, 2011; McCall,
2007). Yet despite the fact that there is currently “a proliferation of claims that certain postures
and practices are effective for treating a variety of allopathically defined disorders, including
depression, anxiety, back pain, and others” (Laurence, 2010, p. 46), there is a lack of research
about the effectiveness of Yoga interventions in therapy. In a search of PsycArticles, ERIC,
Academic Search Complete under the keywords “Yoga” and “Psychotherapy” and “Counselling”
only seven references were found in the past ten years and, of these, only two considered the
integration of the dual interventions of Yoga with psychotherapy.
Yoga has, arguably, a natural place in psychotherapeutic practice because its root
traditions emphasize a unity of the physical, spiritual, and psychological realms. Ancient Yogis
and Ayurvedic doctors referred to the wisdom of Vedic sages to describe the myriad ways in
which people suffer physiologically and psychologically. Most also did not, for the most part,
separate mind and body ailments. Laurence (2010) wrote that
[for those of us ] within yoga, we often value an intuitive and individualized approach
and we wish to retain the ability to modify our methods to suit the present context, rather
than following a prescriptive sequence based on a prior assessment and diagnosis. Yoga
is a wholistic practice and approach to life and “many yoga practitioners oppose the
analytic, reductionist, and evidence-based focus of Western medicine. (p. 45).
While Laurence proposes an outcome-based focus as the future for Yoga therapy, he stated that
“much current Yoga practice is informally outcome- oriented, and many practitioners eschew
explanation and theory in favor of outcome” (Laurence, 2010, p. 46).
For the development of this growing profession and for the safety of clients, a growing
number of clinicians and researchers agree on the importance of investigating which Yoga
interventions or approaches to Yoga are superior to others in Yoga therapy (Kalsa, 2007,
Laurence, 2010). There are various effective methods and treatments in Yoga therapy. What are
commonalities between them? What, in all that diversity, works for people? This study will
look for common factors among the variety of effective Yoga approaches to therapy.
This study will provide an examination of the literature to look for the ways in which
Yoga therapy is being used in mental health care for treating anxiety and depression, and
whether or not Yoga is being prescribed according to allopathic definitions and current theories
of psychotherapy. The frame of reference will include traditional Yogic definitions, Ayurvedic
definitions, or other intuitive and untraditional approaches. Understanding the context of culture,
inquiry, and philosophy in which the research or therapies are based will help future Yoga
therapists and consumers decide which approach may be most beneficial for their healing work.
Yoga therapy came into its own in India in the early part of the 20th century (Payne,
2010, in Feuerstein & Payne, 2010). “Yoga therapy” is a modern term and according to
Feuerstein “represents a first effort to [describe] integrating traditional Yogic concepts and
techniques with western medical and psychological knowledge” (2006, par. 12). Whereas
traditional Yoga is primarily concerned with personal transcendence on the part of a "normal" or
healthy individual, Feuerstein (2006) asserted “Yoga therapy aims at the holistic treatment of
various kinds of psychological or somatic dysfunctions ranging from back problems to emotional
distress” (par. 12). Yoga therapy has continued to develop in the west and while sometimes
combined with Ayurveda is increasingly utilized as a complement to western-style integrative
medicine (Payne, 2010). Yoga therapy is gaining popularity amongst professionals in both the
fields of mental health and of Yoga. As of 2010, the International Association of Yoga
Therapists has supported research and education in Yoga and serves as a professional
organization almost 2,600 Yoga therapists and teachers worldwide (International Association of
Yoga Therapists, 2010). A number of Yoga teachers are learning Yoga therapy in order to help
their students address the emotions that arise during class or in private sessions. Additionally, a
number of psychiatrists, psychologists, counsellors, and social workers have begun to
incorporate a variety of Yoga practices such as Yoga postures, Yoga breathing, and meditation
into their sessions to help empower their patients as well has to prime them to access and heal
their deepest emotions.
Psychotherapy, for purposes of this study, is defined as “a process whereby
psychological problems are treated through communication and relationship factors between an
individual and a therapist . . . [and is] based on therapeutic principles, structure and technique”
(Herkov, 2006, par. 1-2). Psychotherapy and counselling are often used interchangeably as
therapeutic terms (CCPA, 2008). For the purpose of this study the terms Psychotherapy and
Counselling will be used interchangeably to define the process by which mental health
practitioners utilize “psychotherapeutic approaches [which] are conceived as existing on a
continuum of verbal interactions and an integration of awareness of the body (Leijssen, 2006).
Many mental health professionals agree that the body and mind are not separate, especially those
professionals who subscribe to theoretical orientations such as behavioural therapies or
transpersonal, humanistic, or existential psychologies (Leijssen, 2006).
Context for this Study

The tradition of Yoga has been around for over 5,000 years (Feuerstein, 1997,
p. xiii). Yoga is defined as “a comprehensive, ancient Indian philosophy of daily living, which
involves multiple branches including morality, spirituality, and physical health” (Michaelson,
2005, p. 5). The therapeutic use of Yoga also dates back thousands of years as it was a
component of Ayurveda (life science), which is the traditional ancient Indian system of medicine
that focuses on disease prevention and takes a whole-person approach. Feuerstein (1997)
pointed out that Ayurveda and Yoga have influenced each other during their long history. The
therapeutic benefits of Yoga have long been accepted in Indian culture and are understood
according to various ancient Indian physiological, psychological, and spiritual systems.
Dass (2005) described Ayurveda and Yoga as sister Vedic sciences which have been
united for thousands of years for the sake of healing body, mind, and consciousness. Generally
speaking, Ayurveda deals more with the health of the body, while Yoga deals with purifying the
mind and consciousness, yet the two complement and embrace one another (Dass, 2005). The
ancient rishis (seers) were the masters of all the Vedic sciences and they understood that good
health is a great asset on the path toward Self-realization, and that if a body is neglected it can
become an obstacle to spiritual practice. Both Ayurveda and Yoga share the same philosophical
foundation, and have similarities in relation to attitude, nutrition, hygiene, exercise, cleansing
practices, as well as spiritual practices (Dass, 2005). Both share the same psychological view,
which is that understanding our true nature requires attaining mental peace once the fluctuations
of the mind have been stilled (Patanjali, 150 BCE or 200BCE). Currently Ayurvedic therapies
are primarily more concerned with herbal treatments, diet and lifestyle considerations, while
Yogic therapeutic interventions generally involve asanas, the physical Yoga postures,
pranayama, Yogic breath practices, and/or dhyana, Yogic meditation practices.
The principles of both of these systems are documented in ancient Vedic and Yogic texts
many of which are extant and commonly referenced in the context of Yoga teacher and Yoga
therapy training today.
Yoga philosophy has been used for millennia to experience, examine, and explain the
intricacies of the mind and the essence of the human psyche (Valente & Marotta, 2011). With
the current popularity of Yoga in the west, a modern day resurgence of Yoga philosophy is
being embraced by many practitioners of Yoga to explain how Yoga is enhancing their quality of
life. Yoga philosophy is also being applied as a Yoga therapy intervention to bring relief to those
suffering physical and mental afflictions.
In western psychology, the concept of healing the mind via the body, and visa versa, has
been around for centuries. The ancient Greek physician Hippocrates developed a bodily
humours theory about shifts in human moods arising as a consequence of imbalances of one of
the four bodily fluids, Galen in Roman times worked to advance this theory with a typology of
human temperaments, and Abbess Hildegaard of Bingen, a 12th century mystic and healer,
recognized the interplay between psychological trauma and emotional distress and physical
illness and articulated herbal and other remedies for healing the physical body in addition 35
spiritual forces of the human soul and spiritual practices to help “cure the soul from within”
(Strehlow, 2002). However, these systems, like Yoga, are holistic and do not easily lend
themselves to the specification of particular causes of physical and psychological change in short
periods of time. Rather, holistic approaches tend to bring about systemic change over time, and
western paradigms of research, focused on pathology and specific etiology, have failed to
integrate these approaches. With the coming of systems theory (Bateson, 1972), cybernetics
(Keeney, 1983) and interpersonal neurobiology (Siegel, 2009), new paradigms have become
available to western researchers for understanding the processes and effects of Yoga therapy.
Visceglia (2009), a New York based psychiatrist and Yoga therapist, reminded us of
more modern body/mind physician when she spoke of how
Freud used to work with hysterical women with unconscious conflicts that they couldn’t
express through words and only through looking at the symptoms of their body [such as
phantom pregnancies] could they even get to what was psychologically needed for
healing. (Kornfeld, 2009, par.6)
More recently, the mind-body relationship is being empirically researched in the west. Kornfeld
(2009), in summarizing decades of empirical body-mind research, concluded that not only is
mental health and mood dependent on numerous physical factors like exercise, but also
unchecked stress, anxiety and depression can affect physical health, increasing blood pressure,
heart disease and even risk of death. Much current research is demonstrating the benefits of
Yoga in the treatment of anxiety and depression, schizophrenia, substance abuse, and other
psychiatric disorders.
Outcome studies and efficacy studies that measure variables in Yoga therapies as well as
studies that isolate specific Yoga interventions, as variables in mixed therapeutic approaches are
limited. Even fewer studies exist about how Yoga approaches can be effective in combination
with psychotherapy. Does Yoga make a difference in counselling and psychotherapy? Does it
make more or less of a difference than other approaches? If so, what is it in Yoga that makes
this difference? I hope to show how psychotherapists are using Yoga practices successfully in
their therapy. My hope is that this study will point out what is not, but especially what is
working when it comes to Yoga infused psychotherapy. This will, I hope, contribute to
standards and guidelines for Yoga therapists in the future and to ensure more successful
outcomes for clients and patients—who may stand to benefit from the multitude of wholistic,
empowering, preventive, and healing aspects of Yoga therapy.
In the past century such mental relaxation techniques as autogenic training (Schultz,
1932), systematic desensitization (Benson, 1975), and biofeedback-assisted relaxation (Shearn,
1962), have been shown to produce subjective improvement as well as clinically significant
improvement in somatic as well as emotional well-being. Studies such as these of the subtle
mechanisms of psychosomatic medicine are the core of a branch of psychology called psycho-
neuroimmunology, which studies the interaction between the nervous, endocrine and immune
systems. A major integration of these approaches is found in the work of Kabat-Zinn in the well-
validated Mindfulness Based Stress Reduction (MBSR; Kabat-Zinn, 1990) protocol.
''More and more doctors are seeing the value of these [relaxation] techniques as a way to
tap the inner capacity of patients to help with their own healing,'' said Kabat-Zinn (1985),
director of the Stress Reduction and Relaxation Program at the University of Massachusetts
Medical School in Worcester (cited in Goleman, 1986, par. 8). Intensive relaxation techniques
have been shown to improve physical health and immunity from illness. Benson (1975), a
pioneer in mind/body research who has studied the relaxation response extensively in medicine
stated ''you need to use a relaxation technique that will break the train of everyday thought, and
decrease the activity of the sympathetic nervous system” (cited in Goleman, 1986, par.5). Such
somatically focused therapeutic practices have been shown to lower base physiological arousal
levels caused by stress.
The sympathetic nervous system reacts to stress by secreting hormones that mobilize the
body's muscles and organs to face a threat. Sometimes this mobilization includes a variety of
biological responses, or hyper-arousal, including shifting blood flow from the limbs to the organs
and increasing blood pressure (Pinel, 2008). The stress response does not require an emergency;
it can be activated merely by everyday worries and pressures, which is why these matters
concern most of the population. In contrast, the relaxation response releases muscle tension,
lowers blood pressure and slows the heart rate and breath rate. In addition to these changes shifts
in hormone levels occur which seem to produce beneficial effects on the immune system.
Jasnoski, a psychologist and researcher, has shown that relaxation alone can increase defences
against upper respiratory infections (as cited in Goleman, 1986, par.29). In research conducted at
the Harvard Medical School, associates of Dr. Benson found that regular sessions of a simple
meditation technique decreased the body's response to norepinephrine, a hormone released in
reaction to stress. Relaxation techniques have also been found to be highly effective in managing
chronic pain (Kabat-Zinn, as cited in Goleman, 1986).

Approximately 50% of American adults suffer from a mental health disorder at some
point in their lives, the most prevalent being depressive and anxiety disorders (Kessler, Berglund,
Demler, Jin, Merikanagas, & Walters, 2005). Almost all anxiety disorders are characterized by a
cluster of symptoms related to chronic hyperarousal, as described above, as well as difficulty
managing emotions (van der Kolk, Pelcovitz, & Roth, 1996). Arousal symptoms found
commonly among survivors of childhood sexual abuse survivors include poor concentration,
insomnia, restless sleep, exaggerated startle response, attention narrowing, panic attacks and
chronic muscle tension (Brier & Runtz, 1987; Southwick, Yehuda, & Wang, 1998; van der Kolk,
et al., 1996).
Western body/mind researchers study another form of focused relaxation called
Mindfulness Meditation. This field of neurobiology research with its special focus on neurology,
structure and hormonal patterns of brain and the mind is showing that
how we focus our attention could actually change the firing in our brains, leading to
changes in the connections among neurons that make up the actual structure of the
brain . . . the mind (the flow of energy and information we direct by the focus of our
attention) can change both the activity and then the structure of the brain. (Siegel, 2007,
par.10)
The mental, physical, and social health implications of these empirical findings are significant.
Siegel, a neurobiology scientist, psychiatrist, and mindfulness researcher who studies the
reported that this research revealed

several important processes, including how we balance our emotions and how we have
insight into ourselves, are the outcome of attuned, healthy relationships. Studies of the
brain revealed that a form of neural integration that takes place in the regions of the
prefrontal cortex was essential in attaining healthy attachments and perhaps mental
health in general. (Siegel, 2007, par.8)
Although Mindfulness Meditation and Yoga are often practiced together, Yoga may have the
potential to achieve the same outcomes as these talk therapies and relaxation techniques by
working more directly through the body, teaching people who practice Yoga how to trust, accept,
and listen to the wisdom of their own bodies. Yoga offers numerous benefits to physical health,
including strength and flexibility development, as well as enhancement of organ functioning,
generally not found in most psychotherapies. On a psychological level, the introspection
promoted by Yoga is essential to the self-knowledge process that fuels psychic transformation
(Sauys, 2006). Sauys (2006) correlated the western models of psycho-neuroimmunology of the
relaxation response with a Yogic explanation for how relaxation works:
The different relaxation techniques of yoga allow the troubled mind to calm and
decrease its activity while promoting stability. Yoga considers the psyche to be spread
in different centers along the body (chakras), each related to a nervous plexus, an
endocrine gland, an organ or group of organs and specific psychic qualities. By acting
upon the chakras, yoga brings light to any psychic blockages, making them available to
the conscious mind. (Sausys, 2006, par.5)
Crisswell, a licenced psychotherapist who has taught courses in the psychology of yoga at
California’s Sonoma State University since 1969, stated that “for the general person, Yoga
greatly enhances mental health: mood, sense of self, motivation, sense of inner direction and
purpose, as well as physical health – and physical health is so important for mental health” (as
cited in Brahinsky, 2006, par. 5).
Yoga has the possibility of combining the best of both talk therapies and physical
therapies because it is a wholistic approach whose practices work symbiotically with one
another. It is a path to reconnect and integrate parts of oneself and it is a strategy for self-care
and as such appears to have much to offer those who incorporate what they have learned about
Yoga in classes into practices at home and in their daily lives.
Khalsa, assistant professor of medicine at Harvard Medical School and director of
research for the Kripalu Center for Yoga and Health, is one of several scientists currently
conducting research studies on the efficacy of Yoga and Yoga therapy. He suggested that “yoga
may provide benefits above and beyond those provided by traditional therapies” (Khalsa, 2004).
Structure of the Thesis

In this study, the current literature will be examined to identify the specific types and
sequences of Yoga interventions used by these professionals who have been trained to work with
matters of the mind and trained in employing primarily verbal and expressive techniques in their
therapy rooms.
In chapter two will explore the current literature to describe which Yoga interventions are
successfully being used in therapy sessions, how they are being used, which theories of
counselling are being employed, and how therapists and clients measure the success of the
treatments. I will look for similarities and contrasts between the wide variety of Yoga practices
as well as in how clients and therapists determine the efficacy and impact of these interventions
or other conditions in the therapy.
In chapter three, I will define and describe my research methodology, which will be
qualitative. Specifically, I will use a best practices approach to analyze and synthesize the data I
find in the literature, which is the first part of a complete conceptual framework for development
of my conceptual model of a complete Best Practices analysis. The second part would involve
interviewing practitioners such as Yoga therapists, psychotherapist, counsellors, and patients or
clients, which is beyond the scope of this study. By “conceptual framework,” following the
recommendations of Mold and Gregory (2003), I mean I will make a flow diagram that captures
all of the component parts of the analysis process, and when appropriate, the steps immediately
before and after it. Mold and Gregory (2003) suggested that determining the meaning of “best”
in Best Practices was to “involve creating a list of desirable qualities, prioritizing them, and
setting minimum standards for each.” The first evaluation phase will involve identifying
potential best practices and evaluating a representative sample of them, which shall be done do
from the limited vantage point of an exhaustive literature review without the valuable
contribution of interviews as they are beyond the scope of this paper. The best practices for
individual steps will then be described and combined. The ultimate purpose of this is to offer this
combined method through this study to the profession to be disseminated or tested more formally
(Mold & Gregory, 2003).
In chapter four I will analyze and synthesize the data from the literature bringing the
similarities and contrasts between Yoga therapies and counselling therapies together to show
how the two practices of Yoga therapy and psychotherapy can be integrated. I will then choose
best practices from this analysis and synthesis to be a foundation piece for further treatment of
this topic in a broad Best Practices analysis. Following the research methodology, a thematic
analysis will be applied and results will be presented by the themes that have emerged from this
study.
In chapter five I will offer implications for counsellors, focusing on how Yoga can be
best facilitated and integrated in therapy. I will also offer considerations for a professional body
of therapists who offer Yoga infused talk therapy. Lastly, areas for further study will be
recommended.
I will now proceed with a review of the clinical research and practical applications in
current literature to examine how the successful incorporation of Yoga or Yoga therapy occurs in
psychotherapy and counselling sessions and how the efficacy of these interventions are measured
by clinicians and clients.

CHAPTER 2 LITERATURE REVIEW
tapah svadhyaya-isvara-pranidhanani kriya-yogah

Kriya Yoga (skill in action) requires [the cultivation of all of these three]: willful practice, self-
observation, and surrender. (Pantanjali, Yoga Sutras, 2.1)
The purpose of this chapter is to review research on Yoga in general, applications of
Yoga in the treatment of anxiety and depression, and theories relevant to understanding the
causes for the positive impact of Yoga. The literature review will first explore the current
literature, which defines the complex tradition of Yoga as well as that which defines the various
styles and schools of Yoga therapy. Then it will follow with a description of relevant research
on how Yoga is successfully being used to treat anxiety and depression, the two most prominent
mental health disorders in the west: it will explicitly explore within each topic, key aspects of
Yoga breath work, postures and meditation as they pertain to each of those topics. The review
will end up at a discussion of the research that may offer explanations of Yoga’s potency.
The scope of this review is restricted to reports of clinical trial studies on use of Yoga or
Yoga-based techniques in the treatment of medical or psychiatric conditions or their associated
symptoms. Studies examining meditation alone without simultaneous incorporation of yogic
breathing and/or specific Yoga postures have not been included.
I searched ERIC, Academic Search Premier, Medline, PsycArticles and PsycINFO, and
International Journal of Yoga Therapy using the search terms “Yoga” and “psychotherapy” as
well as “Yoga therapy” and psychotherapy” and found few results. I searched bibliography lists
on any relevant review articles. My criteria for inclusion were 1) clinical research about benefits
of Yoga on mental wellness; 2) traditional Yoga styles and prescriptions for psychological well-
being 3) western adaptations of specific intervention arms that involved predominantly Yoga
interventions used in research with participants diagnosed with the psychological disorders of
anxiety and depression.
There is a paucity of research literature on how Yoga can be successfully integrated into
psychotherapy. This literature review therefore relied on efficacy studies on physical postures,
breathing exercises, and meditation on mental illness, specifically for anxiety and depression, as
well as scholarly investigations into the factors that may account for Yoga’s healing effects. I
will specifically present research on how Yoga has successfully been used to help with anxiety
and depression. I will later extrapolate from the specific Yoga practices that are described in
some of these studies to consider if there are enough suitable data to make recommendations for
some of these practices and/or sequences to be used as interventions in a standardized treatment
for future studies on the efficacy of Yoga and Yoga therapy and how it may be used with
psychotherapy.
Anxiety and depression are the two most prevalent mental health disorders in the west
today (Kessler et al, 2005; Forfylow, 2011). I will present relevant research on how Yoga can
effectively help both anxiety and depression as well as on which Yoga practices were used and if
they were used in separate Yoga classes or in combination with psychotherapy. This discussion
will be organized for both anxiety and depression using three components of Yoga: breath work,
physical postures, and meditation (Forfylow, 2011, p. 136).
Like Salmon, Lush, Jablonski and Sephton, (2009), I capitalize the word ‘Yoga’
throughout in recognition of its historical stature as a highly evolved complex system of beliefs
and practices, even though clinical applications tend to ‘de-contextualize’ it from its cultural and
spiritual roots.
Yoga Defined
Yoga is an ancient Indian system of philosophy and practice (Desikachar, 1999;
Govindan, 2001; Iyengar, 2002. The word Yoga is a Sanskrit word whose root is ‘yoke’ or
‘union’, which reflects its goal in joining the mind and body in harmonious relaxation (Dey,
Barrett, & Yuan, 2003, p. 172; Forfylow, 2011). McGonigal (2009) described the practice of
Yoga as a reunion of the five aspects of one’s true nature: body and mind, which are in turn
comprised of breath, wisdom, and joy. Yoga allows the practitioner to take refuge in her or his
own body and mind, in the present moment, to experience peace. In 2004, about 5% of all US
adults practiced Yoga (Barnes, Powell-Griner, McFann, & Nahin, 2004), in 2008 this figure had
increased to 6.9%. Nearly 8% of all Americans who do not currently practice Yoga say they are
very or extremely interested in Yoga and plan to start practicing soon (Yoga Journal, as cited in
Simpkins & Simpkins, 2011). Most people practice Hatha Yoga, which focuses on training the
body and heightening mental awareness as a means to balance or improve physical, emotional,
and spiritual health (Feuerstein, 1996). Key components of Hatha Yoga include breath control
(pranayama), physical postures (asanas), and meditation (dhyana). In North America most
people practicing Yoga put less emphasis on the philosophy of Yoga and more on the physical
postures, breathing techniques, and different forms of yogic meditation (Austin & Laeng, 2003).
There are many different Hatha Yoga styles, and these vary in emphases. For example, in
Iyengar Yoga, the focus is on correct alignment of the body (asanas), and students may practice
Yoga for several years before working with the breath (pranayama) (Iyengar, 2002). In contrast,
in Vinyasa Yoga (which means “to flow”), the focus is on breath-linked movement as it is in
Ashtanga Yoga (Riley, 2004). Participants move from one posture to the next when coordinating
their breath with each movement. Integral Yoga, with its focus on function over form, aims to
integrate various aspects of the body-mind through a combination of postures, breathing

techniques, deep relaxation, and meditation. Kripalu Yoga is a three-stage Yoga tailored for
western students, which focuses initially on postural alignment and coordination of breath and
movement, and secondly, introduces meditation so that in the final stage the practice of postures
becomes a spontaneous “meditation in motion” (Feuerstein, 2003). Kundalini Yoga is an
independent approach of Yoga and is also the name of a style of Hatha Yoga. Its purpose is to
awaken the serpent power (kundalini), which is thought to reside at the base of the spine by
means of postures, breath control, chanting, and meditation (Feuerstein, 2003). All Hatha Yoga
styles involve concentrated breath work through a variety of standing, seated, and balancing
postures followed by forms of twists and backbends or inversion, and end with a relaxation or
meditation posture (Austin & Laeng, 2003; Forfylow, 2011). Sudarshan Kriya Yoga (SKY),
which has its roots in traditional Yoga, teaches a type of controlled breathing, involving several
types of cyclical breathing patterns, ranging from slow and calming to rapid and stimulating, and
is taught by the nonprofit Art of Living Foundation. There are also styles of Yoga that focus on
Yoga Nidra, which is a kind of Yoga “sleep,” that are incorporated into psychotherapeutic realms
and is currently a popular Yogic intervention for war vets struggling with PTSD (Miller, 2010).
A number of schools of Yoga and Yoga Therapy utilize the techniques of chanting and hand
mudras to induce the healing of psycho-spiritual states. LifeForce Yoga (Weintraub, 2008), one
of these schools of Yoga therapy, proposes a practice that includes Yogic breathing exercises
(pranayama and kriya), visualization (bhavana), intention (sankalpa), hand gestures (mudra),
chanting (mantra) during postures (asana), and either a relaxation (Yoga nidra) or a meditation.
Yoga Chakra Clearing Meditation, which includes two rounds of an energizing bellows breath
(bhastrika), three rounds of a calming brahmaribee breath practiced on the exhale only, and
seven mantras and mudras is thought to stimulate the seven energy centers of the body, which
roughly correspond with the major glands of the body (Bennett, Weintraub, Khalsa, 2008, p.50).
Judith (1996) a psychotherapist and Yoga teacher who focuses primarily on Yoga practices that
balances these chakras, (wheels or disks), which signify “seven basic energy centers in the body
that correspond to nerve ganglia branching out from the spinal column, as well as states of
consciousness, developmental stages of life, archetypal elements, body functions, colors,
sounds” (Judith, 1996; Chakra Portal, par. 3).
Yoga and Therapy

The limited application of Yoga techniques for specific disorders is recent relative to the
ancient origins of Yoga (Gharote, 1982; Khalsa, 2007). The “therapeutic aspect of Yoga does not
feature in any of the traditional systems of self-help . . .Yoga therapy was not a developed branch
of yogic discipline as such” (Gharote, 1987, p. 4). Goyeche (1979) posited that because the
primary goal of Yoga practice is spiritual development, its beneficial medical consequences
[could] be more precisely described as positive side effects (in Khalsa, 2007, p. 449). There are
examples, which may be interpreted as exceptions in Patanjali’s Yoga Sutras, where he included
vyadhi (disease, in Sanskrit) in the list of disturbing factors of mind that are obstacles to
liberation. Although Yoga therapy was not a developed branch of Yogic discipline as such, we
do get a glimpse of the therapeutic effects of the practices in some of the Hatha Yoga literature
such as the Hatha Yoga Pradipika (Khalsa, 2004). Originally developed with the aim of spiritual
enlightenment, Yoga is now more commonly used, at least in the west, for relieving physical and
mental suffering, and possibly for enhancing “well-being” (Sherman, 2006). Despite the lack of
conclusive research evidence to support integrating Yoga as an effective clinical treatment, Yoga
continues to be popular as a complementary and alternative treatment for mental wellness
(Shapiro, Cook, Davydov, Ottaviani, Leuchter & Abrams, 2007). Yoga therapy—tailoring a
custom Yoga regimen to treat a client’s specific psychological and physical health concerns—is
increasing in popularity and acceptance (Khalsa, Shorter, Cope, Wyshak, & Sklar, 2009).
In recent years, Yoga has become a supplementary treatment to conventional treatments
for clients with various mental health disorders, including anxiety and depression (Butler et al.,
2008; Gerbarg & Brown, 2007; Forylow, 2011; Shapiro et al., 2007; Khalsa et al., 2009). An
abundance of studies examine Yoga as an effective clinical treatment intervention for
psychological and physiological concerns (Khalsa, 2004; Forylow, 2011). Recently, the practice
of Yoga has received increasing attention in the literature as a way to cope with depression
(Weintraub, 2004; Butler et al., 2008; Chen, Chen, Chao, Hung, Lin & Li, 2009; Franzblau,
Echevarria, Smith, & Van Cantfort, 2008; Krishnamurthy & Telles, 2007; Shapiro et al., 2007;
Woolery, Myers, Sternlieb, & Zeltzer, 2004), anxiety (Descilo, Vedamurtachar, Gerbarg,
Nagaraja, Gangadhar, Damodaran & Brown, 2010; Javnbakht, Kenari, & Ghasemi, 2009; Khalsa
et al., 2009; Kozasa, Santos, Rueda, Benedito-Silva, De Moraes Ornellas & Leite, 2008; Lavey,
Sherman, Mueser, Osborne, Currier, & Wolfe, 2005; Telles, Guar, & Balkrishna, 2009; Telles,
Naveen, & Dash, 2007; Telles, Singh, Joshi, & Balkrishna, 2010), and addiction (Khalsa, Khalsa,
Khalsa, & Khalsa, 2008) .
By integrating Yoga with psychotherapy, mental health professionals may be able to
work more collaboratively with clients (Forlylow, 2011, p.143). Uebelacker, Tremont, Epstein-
Lubow, Gaudiano, Gillettte, Kalibatseva & Miller (2010) posited that here are many similarities
between psychotherapy and Yoga. They stated that “like psychotherapy, Yoga is a multifaceted
behavioral intervention that can be taught in many different ways, depending on the teacher’s
training and personality, as well as other factors” (Uebelacker et al., 2010, p. 259). Forbes
(2011), a clinical psychologist and Yoga teacher who integrates Yoga into counselling sessions,
found psychotherapy and Yoga to be “a natural fit.” Forbes argued that therapy—which means
healing in Greek—is naturally integrative and involves both the mind and the body.
Psychotherapy implies a rich collaborative relationship that addresses thinking and emotion;
Yoga is fluent in the language of the physical body, yet also affects the mind (Forbes, 2011, pp.
x-xi). Leijjsen (2006) argued that psychotherapy can benefit from taking full account of the
experience of interweaving thinking, feeling, and bodily sensations and expressions and that
body-oriented interventions can draw from a wide variety of disciplines.
Clinical Findings: Anxiety

The number of studies examining Yoga in relationship to anxiety disorders is limited and
findings in relation to Yoga and anxiety disorders are not as clear-cut as those in relation to Yoga
and depression (Da Silva, Ravindran, & Ravindran, 2009). There is some evidence to suggest
that Yoga may benefit some anxiety disorders but the effects of Yoga on anxiety are largely
unknown. Khalsa (as cited in Richards, 2009), in a review of the literature of Yoga as therapy,
also found it is difficult to assess the impact of the many varieties of Yoga practices on discrete
anxiety disorders.
Breath Work
A number of studies show that Yogic breathing is an effective method of combating
anxiety (McCall, 2007; Vahi, Jeste, Kapoor, Indubala, & Nath, 1973; Harrigan, 1991; Platania-
Solazzo, Field, Blank, Seligman, Kuh, Scanberg, & Saab, 1992) and researchers speculated that
concentrated Yoga breath work would substantially aid in the reduction of symptoms of anxiety
(Forflylow, 2011, p. 136; Descilo et al., 2010; Khalsa et al. 2009; Kozasa et al. 2008; Telles,
Singh et al., 2010). Harrigan (1991) compared Yoga postures with and without diaphragmatic
breathing exercises to breathing exercises alone. Subjects took a 30-minute class twice a week
for six weeks and were asked to practice half an hour per day on their own. When the postures
were done without attention to the breath, there was no significant reduction in anxiety as
compared to a control group, which only heard lectures. Group members who only did
diaphragmatic breathing experienced a significant reduction in anxiety. The best response,
however, was seen in the group that did the postures combined with diaphragmatic breathing.
This points to the synergistic effects of different aspects of Yoga practice (Harrigan, 1991;
McCall, 2007).
Shannahoff-Khalsa and Beckett (1996) gave eight subjects who were diagnosed with
obsessive-compulsive disorder (OCD), a difficult to treat disorder with a strong anxiety
component, a specific Yoga breathing technique for OCD along with several others for
generalized anxiety and a one-year follow up course of therapy. They all showed improvement
on anxiety, global severity, and stress indexes (Shannahoff-Khalsa & Beckett, 1996). Kozasa et
al., (2008) also found state and trait anxiety level scores in participants were great reduced after
one month of Siddha Samadhi Yoga breathing and meditation. They involved in their study 22
volunteers, inexperienced in Yoga and meditation, ranging in age from 19 to 61 years, who
reported anxiety complaints with no previous history of psychiatric or neurological disorders:
none of the subjects was not taking psychotropic medications nor was not in psychotherapy.
Fourteen volunteers were in the Siddha Samadhi Yoga group, while eight were on the waiting-
list control group. The Yoga program lasted two weeks. Participants were asked to sit in
vajrasana pose (sitting on their heels or extended legs if needed) while they practiced 11 rounds
of pranayama (focusing on Ujjayi breathing in a cycle performed in 3/2/5/2 rhythm: three counts
to inhale, two to retain, five counts to exhale, and two to hold with “empty” lungs). They were
then taught a 20 minute Siddhi Samadhi meditation practice in a chair focusing on watching the
spontaneous flow of thoughts and using a mantra that was given to them at the beginning of the
program to help stop the flow of thoughts. Using Beck Depression Inventory (BDI), State and
Trait Inventories, Well-Being and Tension Analog Scales, researchers found significant
decreases in scores for depression and anxiety (state and trait) in the Yoga group compared with
the control group. There was also significant increase in subjective well-being as well as release
of tension. In a study of performance anxiety in musicians, Khalsa, Shorter, Cope, Wyshak and
Sklar (2009) reported that after two months of Yoga practice, with particular focus on breathing
techniques, the physical and cognitive symptoms of performance anxiety decreased. Young
adult professional musicians who volunteered to participate in a two-month program of Yoga
and meditation were randomized to a Yoga lifestyle intervention group (n = 15) or to a group
practicing yoga and meditation only (n = 15). Additional musicians were recruited to a no-
practice control group (n = 15). Both Yoga groups attended three Kripalu Yoga or meditation
classes each week. The Yoga lifestyle group also experienced weekly group practice and
discussion sessions as part of their more immersive treatment. Both Yoga groups showed a trend
towards less music performance anxiety and significantly less general anxiety/ tension,
depression, and anger at end-program relative to controls, but showed no changes in
performance-related musculoskeletal disorders (PRMDs), stress, or sleep. Similar results in the
two Yoga groups, despite psychosocial differences in their interventions, suggested that the Yoga
and meditation techniques themselves may have mediated the improvements (Khalsa et al.,
2009). Descilo et al., (2010), in a non-randomized study took 183 tsunami survivors living in
refugee camps eight months after the 2004 South East Asia tsunami who scored 50 or above on
the Post-traumatic Checklist-17 (PCL-17) and assigned them by camps to one of three groups:
Yoga breath intervention (SKY yoga breathing), Yoga breath intervention (SKY) followed by 3–
8 hours of trauma reduction exposure technique or 6-week wait list. Measures for post-traumatic
stress disorder (PCL-17) and depression (BDI-21) were performed at baseline and at 6, 12, and
24 weeks. The effect of both treatments versus the control was significant at 6 weeks, with
measures for PTSD in PCL-17 scores decreased by 60% and measures in depression in BDI
(Beck’s Depression Inventory) decreased by 90% and these scores were maintained at 24 weeks.
Descilo et al. (2010) concluded that Yoga breathing could be an effective intervention in
reducing symptoms of depression and anxiety, particularly posttraumatic stress disorders
(PTSD), which is an extreme form of anxiety. Telles et al., (2010) concluded in their study on
Yoga breathing that comprised 50% of a Yoga class on Bihar flood victims a week of Yoga
practice, that “survivors showed a significant decrease in self-rated sadness while the non-Yoga
control group showed an increase in self-rated anxiety” (p. 6). In a study of 22 volunteers, all
males with the group average age 31.5; they were assigned to two groups, Yoga and a non-Yoga
wait-list control group. The Yoga group practiced Yoga for an hour daily while the control
group continued with their routine activities. Both groups’ heart rate variability (HRV), breath
rate, and four symptoms of emotional distress using visual analog scales, were assessed on the
first and eighth day of the program. There was a significant decrease in sadness in the yoga
group and an increase in anxiety in the control group. These findings were similar to results
found in Telles et al., (2008) who found that SKY Yoga breathing techniques helped reduce
anxiety in tsunami survivors in the Andaman Islands.
Gerbarg and Brown (2009), in their review of a number of ancient breathing practices
and meditation, provided clinical evidence of how Yoga breathing and meditation can positively
affect increase resilience to stress and diminish symptoms of anxiety and depression.
Physical Postures
Streeter et al., (2007) found that after a one hour physical Yoga practice, experienced
Yoga participants had higher levels of GABA and reported decreased levels of anxiety,
depression, and feelings of anger. In a study comparing GABA levels of 8 experienced Yoga
practitioners after one hour of Yoga practice and 11 non-Yoga practitioners after one hour of
reading there was a 27% increase in GABA levels after a 60 minute session of Yoga, but no
change in GABA levels in the control group after 60 minutes of reading. Streeter et al. (2007)
suggested “that the practice of yoga should be explored as a treatment for disorders with low
GABA levels such as depression and anxiety disorders [and that] future studies should compare
yoga to other forms of exercise to help determine whether yoga or exercise alone can alter
GABA levels” (p. 419). Berger and Owen (1988) found that in Hatha Yoga classes with a strong
exercise dimension involving stretching, balancing, and breathing routines subjects reported
being less anxious, tense, angry, fatigued, and confused than those who participated in
swimming, fencing, and body conditioning practices. In this study, 87 college students from a
“normal population” with no diagnosed mood disorders volunteered to take a class in swimming,
Hatha Yoga (which included postures and breathing), or attend lectures on the subject of health
over the course of a semester. The researchers measured short-term mood changes on three
separate days during the semester to discern whether there was a relationship between expertise
in the activities or physical conditioning and mood change. Swimmers and Yoga participants
exercised for about 60 minutes per week in class settings and were taught by the same instructor
(Berger) and the control group met in 50 minute classes three times a week for 12 weeks. Those
who engaged in Yoga showed greater acute decreases in scores for anger, tension, and fatigue
than those in the swim class or the leading control group (Berger & Owen, 1992). Brown and
Gerbarg (2009) advise that “caution should be used in extrapolating findings in normal
populations to patients diagnosed with depression” (p. 59).
Michaelson et al., (2005) studied 24 women with anxiety, comparing a three-month
program of Iyengar Yoga to a control group placed on a waiting list. The two weekly 90-minute
classes emphasized backbends, forward bends, standing poses, and inversions. Compared to the
eight controls, the 16 women in the Yoga group demonstrated “pronounced and significant
improvement” (Michaelson et al., 2005, p. CR555) in perceived stress, anxiety, well-being,
vigour, fatigue, and depression.
Javnbakht, Kenari and Gasemi (2009) reported that state and trait anxiety scores
increased significantly in women 30 to 40 years old after practicing Yoga twice a week for two
months. Participants were randomly divided into an experimental and a control group. The
experimental group (n 1⁄4 34) participated twice weekly 90 min classes of Ashtanga yoga
exercises (Iyengar method) over a two-month period. The control group (n 1⁄4 31) was assigned
to a waiting list and did not receive any yoga. Both groups were evaluated again after two
months. Javnbakht et al. (2009) attributed participant’s ability to reduce anxiety scores in to
Yoga’s ability to increase body awareness, and to foster a sense of confidence and control.
Movement-based interventions such as Yoga have been implemented for victims of
torture (Harris, 2007), and could potentially serve as here-and-now ‘grounding techniques’
(Crosby, Mashour, Grodin, Jiang, & Osterman, 2007) for PTSD and other trauma patients (in
Salmon et al., 2009, p. 62).
Meditation
Subramanya and Telles (2009) compared the effects of cyclic meditation (Yoga postures
followed by supine rest) with supine rest only (savasana) and found that a short Yoga practice of
cyclic meditation was significantly more effective in increasing memory scores and almost four
times as effective in decreasing anxiety as the same amount of supine rest. In 57 male volunteers
(average age 26.6 years), the immediate effect of two yoga relaxation techniques was studied on
memory and state anxiety. All participants were assessed on the Wechsler memory scale for 1)
attention and concentration and 2) associate learning. They were assessed using Spielberger’s
State-Anxiety Inventory for state anxiety. These inventories were administered before and after
1) cyclic meditation practiced for 22:30 minutes on one day and 2) an equal duration of supine
rest or the corpse posture (savasana), on another day. There was a significant improvement in
the scores of all sections of the studied after both cyclic meditation and supine, but the
magnitude of change was more after cyclic meditation compared to after supine rest. The state
anxiety scores decreased after both cyclic meditation and supine rest, with a greater magnitude of
decrease after cyclic meditation. Subramanya and Telles (2009) concluded that movement as a
part of cyclic meditation may actually facilitate performance in attention and memory tasks more
than an equal duration of time in a conventional relaxation posture (shavasana).
Yoga Theory
Khalsa et al. (2009) and Telles et al. (2009) concluded that both practicing Yoga and
learning Yoga theory are effective in reducing stress and symptoms of anxiety (in Forfylow,
2011. p. 137). When Yoga was compared to conventional relaxation techniques designed to
decreased anxiety and aid in stress management (e.g., progressive muscle relaxation), Smith,
Hancock, Blake-Mortimer and Eckert (2007) found that Yoga was equally as effective and
concluded that Yoga might be a safe way for people to assist themselves in managing symptoms
related to anxiet and stress (cited in Forylow, 2011).
Clinical Findings: Depression

“Clinical depression is a life-threatening medical condition in which sadness and other
symptoms can be so overwhelming the person is incapacitated or even suicidal” (McCall, 2007,
p. 262). McCall (2007) said that the term ‘depression,’, as used by doctors, refers to much more
than feeling blue or down in the dumps and that “sadness is something that all people feel from
time to time” (p. 262). He also elaborated that depression should be differentiated from grief
which is the natural and healthy reaction to loss whether it is the loss of a beloved person or pet,
or a job, or home, or one’s health, but also cautioned that normal grief can turn into depression.
Depression is a worldwide epidemic (Brown, 2004). Depression is the leading mental health
illness in adults and often occurs with other serious illnesses, such as heart disease, stroke, and
arthritis (Brown, as cited in Weintraub, 2004, p. xv). Brown (as cited in Weintraub, 2004, p. xv)
warned that the depression epidemic is worse in developing countries and predicted that it will
increase as people live longer. Mainstream medicine describes depression as an “overactivation
of the stress-response part of the nervous system and an underactivation of the well-being
(parasympathetic) part of the nervous system” (Brown, 2004, p. xv). McCall (2007) posited that
Yoga may help alleviate symptoms of depression and lift mood because of its proven ability to
alleviate tension and lower cortisol levels which tend to be elevated during times of stress. Of
studies evaluating the effectiveness of Yoga treatment for psychiatric or psychological
conditions, those that evaluate patients with depression, dysthymia, or anxiety make up a strong
majority (Khalsa, 2004 p. 453). The current medical treatment of depression predominantly
focuses on antidepressants, which calm the stress-response system (Brown, 2004; McCall, 2007).
Brown (2004), an associate professor of clinical psychiatry at Columbia University College of
Physicians and Surgeons said that what he has seen “so often is that medication reduces the
desperation and suicidality that the depressed person feels, but it does not touch the whole being”
(p. xv). He continued that medications do not bring out the feelings of joy and love inside all of
us (Brown, 2004, pp. xv-xvi). Ten years ago, after discovering a wealth of medical and
psychiatric research on the healing benefits of Yoga, he began to train in techniques of Yoga
breathing and other Yoga practices to offer this depth of Yogic healing to his patients and other
health care providers who suffer from stress and depression.
Breath Work
Franzblau et al. (2008) found a significant decrease in depression scores in battered
women’s depression if they received Yoga breath work training (45 minutes for four days).
Bennett, Weintraub, and Khalsa (2008) conducted a small naturalistic pilot study taking data
from participants in numerous LifeForce Yoga training courses of retreats during a one-year
period where participants were in direct contact with the Yoga teacher leading the program for
roughly 8-10 hours per day, or 40-50 hours total. Yoga practice sessions consisting of 40%
breathing practices and 30% physical postures (with breathing practices added) as well as 30%
relaxation and meditation, lasted approximately 1.5 to 2.5 hours. At the completion of the five-
day retreat or training period, home practice was encouraged. The participants completed the
same set of questionnaires following two weeks of home practice, and again two months after
their completion of the LifeForce Yoga (Weintraub, 2004) program by mail. The efficacy of
LifeForce Yoga for depression (Weintraub, 2004), previously only validated through anecdotal
and qualitative evidence, reported significant decrease in reported depressive symptomatology,
particularly mood disturbance, on tension, anxiety, depression, fatigue and confusion subscales,
and significant increase in a vigour subscale. Researchers concluded that “participation in a
comprehensive Yoga program designed specifically to address mood can lead to decreased
symptoms of depression and associated physical or mood states” (Bennett et al., 2008, p. 49).
In clinical case studies Forbes, Akturk, Cummer-Nacco, Gaither, Gotz, Harper, and
Hartsell (2008) observed that the nervous system and mental body of clients with mixed affective
disorders (especially anxiety and depression) were successfully addressed through simple
breathing (pranayama) techniques that were practiced while clients were in restorative Yoga
poses. For an anxious nervous system and mental body, 2:1 breathing (exhaling for twice the
count of the inhalation) or an exhalation that is longer than the inhalation, were most frequently
used, as these helped to slow the heart and calm the nervous system. On occasion, before the
restorative Yoga practice, chandra bhedana (inhaling through the left nostril and exhaling
through the right nostril, with the exhale twice as long as the inhale) were used. For a more
depressed nervous system and thought pattern, 1:1 breathing (in which the inhale and exhale are
equal in length) was found to be more helpful (Forbes et al., 2008).
Physical Postures
The practice of Yoga appeared to result in increases in positive moods, decreases in
negative moods, and increases in energy level regardless of the physical postures practiced
(Shapiro & Cline, 2004). Despite the effort and sustained physical exertion in Yoga, Shapiro and
Cline (2004) found that psychological well-being was enhanced after an Iyengar Yoga class. The
participants were 11 healthy Yoga students in a nine-session Yoga course in which three
different types of Yoga poses were compared: back bends, forward bends, and standing poses.
Each 90-minute class focused on one of the three types of poses with three repetitions of each
type of class. Self-ratings of 15 moods dealing with positive, negative, and energy-related
emotional states were obtained before and after each class. Personality traits of depression,
anxiety, and hostility were assessed at an initial orientation. Regardless of the specific Yoga
pose, positive moods increased, negative moods decreased, and energy-related moods increased
in participants from before to after classes with most changes lasting for two hours. Specific
poses resulted in differences in how moods were affected. In particular, back bend postures were
associated with greater increases in positive moods. Some mood changes appeared to be
dependent on participant’s characteristic personality traits. The positive mood effects of back
bends were greater for participants who were relatively hostile or depressed (Shapiro & Cline,
2004).
Streeter et al. (2007) found that after participants had completed a one hour session of
Yoga postures GABA levels increased by approximately one-quarter when compared with
baseline measurements, in all the styles of Yoga practiced.
Yoga may increase serotonin levels in people with depression, but “there have been no
studies published on Yoga’s effect on serotonin levels” (Forfylow, 2011). Netz and Lidor (2003)
examined the effects of mindfulness exercise (e.g., Yoga) versus aerobic exercise (e.g.,
swimming) on anxiety and depressive mood. They concluded that after just one session Yoga
more effectively reduced anxiety and increased positive mood than the swimming session and
suggested that this may be due to the cognitive focus found in mindful activities such as Yoga.
Exercise psychologists suggest that the differential effect of Yoga and aerobic activity is
attributed to Yoga’s added emphasis on breath, relaxation, and predictability in routine (Berger,
1994).
Woolery, Myers, Sternlieb, and Zeltzer (2004), in a study on the effects of a one-hour
Iyengar Yoga class over a five-week period on young adults with mild depression, found that the
physical postures, particularly inversions, vigorous standing poses, and postures that open and
lift the chest (simple backbends) were effective in reducing depression scores by almost one-
third and also effective in significantly improving mood. Woolery et al. proposed that the doing
the Yoga postures, including ones that were challenging improved “feeling of mastery . . . [and]
may have countered the slumped body posture associated with depression” (p.62).
Shapiro et al., (2007) also found that an Iyengar Yoga practice of physical postures that
included inversions, standing poses, and chest expanding postures helped diminish depressive
symptomatology in people experiencing symptoms of remission who were taking antidepressant
medications for unipolar major depression (Shapiro et al., 2007). They attributed the physical
postures to reported increases in positive mood characteristics (e.g., confidence and happiness)
and energy levels (e.g., attentiveness), as well as decreases in negative mood characteristics (e.g.,
frustration and pessimism) (Sharpio et al., 2007).
There are no published reports of Yoga interventions being used in patients with
psychotic depression or bipolar disorder, to date (da Silva et al., p. 11).
Meditation
Mindfulness is a central aspect of Yoga practice. Desikachar (1999) wrote that “yoga
attempts to create a state in which we are always present—really present—in every action, in
every moment” (p. 6). This description is similar to published descriptions of mindfulness in
contemporary psychological literature. For example, a recent definition suggested that
mindfulness involves two components: “the self-regulation of attention so that it is maintained
on immediate experience, thereby allowing for increased recognition of mental events in the
present moment” and adopting an “orientation towards one’s experiences in the present moment,
an orientation that is characterized by curiosity, openness, and acceptance” (Bishop et al., 2004,
p. 232). Meditation, including mindfulness meditation, is believed to help bring greater attention
to present situations (Bishop, 2002), “a quality that may better equip individuals to select
situations with attention to their potential emotional consequences” (Weinstein, Brown, & Ryan,
2009, p. 384). Some evidence for this came from two experience sampling studies (Brown &
Ryan, 2003) showing that those higher in trait mindfulness engaged in more volitional, or self-
endorsed activities on a day-to-day basis that were related to higher emotional well-being.
Weinstein et al. (2009) proposed that with a higher prevalence of self-endorsed activity, “more
mindful individuals may also be exposed to fewer stressors over time, providing additional
support for well-being” (Weinstein et al., 2009, p. 384).
Shannanoff-Khalsa (2004) listed numerous Kundalini meditation techniques for treatment
of numerous psychiatric disorders. He proposed the use of three of these meditations from
Kundalini’s OCD protocol as a great asset to help with relief of depressive symptoms. Again, he
has only anecdotal evidence to support these meditation techniques but clinical case studies
found that ‘Spine Flexing for Vitality’ in the OCD protocol had a substantial effect on depression
alone if it was practiced for 11–15 minutes (Shannahoff-Khalsa, 2003a).
Krishnamurthy and Telles (2007) found that severely depressed seniors who practiced
Yoga showed significantly reduced decreases in depression compared to those receiving
Ayurveda medicine (herbal preparations). This study found that Yoga was more effective in
reducing depression scores than Ayurveda treatment (traditional Indian medicine) or no
treatment. Participants were all living in a residential home in India and were randomly assigned
to a Yoga group (mean age = 70.1), an Ayurveda group (mean age = 72.1), or a control group
(mean age = 72.3 years). The 75-minute Yoga sessions consisted of 10 minutes of breathing
exercises, 5 minutes of loosening exercises, 20 minutes of physical postures, 10 minutes of
pranayama (breathing), 15 minutes of guided relaxation, and 15 minutes of bhajans (devotional
singing). The intervention lasted 24 weeks, and the Yoga group practiced six days a week. The
three groups did not differ in their depression scores at baseline, as measured by the Geriatric
Depression Scale-15. The Yoga group significantly decreased their depression scores at both
three and six months, whereas the other two groups did not show significant improvement.
Krishnamurty and Telles (2007) reported that participants most enjoyed the last 15 minutes of
the practice spent on devotional spiritual meditation songs.
Mindfulness-based stress reduction (MBSR) (Kabat-Zinn, 1990) is an eight-week
program in which participants attend weekly classes and learn to practice mindfulness
meditation, with the goal of increasing mindfulness in daily life. Although MBSR does include
some Yoga stretching (asanas), Yoga is not the primary focus of the program. A mindfulness
intervention that included breathing, meditation, and Yoga has been shown to significantly
decrease anxiety and depression among adults with an anxiety disorder or panic disorder (Kabat-
Zinn et al., 1992). Controlled trials (Speca, Carlson, Goodey & Angen, 2000; Shapiro, Schwartz
& Bonner, 1998) suggested that MBSR may reduce symptoms of depression and anxiety in
different samples. Particularly relevant, mindfulness-based cognitive therapy (MBCT) was
developed to prevent depressive relapse among remitted depressed patients. MBCT is an eight-
week group treatment that integrates MBSR and cognitive therapy (Teasdale, Williams, Segal,
Soulsby, Ridgeway & Lau, 2000). Teasdale et al. (2000) observed that “MBCT was specifically
designed for remitted depressed patients and is unlikely to be effective in the treatment of acute
depression, where factors such as difficulties in concentration and the intensity of negative
thinking may preclude acquisition of the attention control skills central to the program” (p. 622).
Kingston, Dooley, Bates, Lawlor, & Malone (2007) found that MBCT appeared to be acceptable
(i.e., very few drop-outs), probably not dangerous (only 4/50 patients experienced an increase in
depression symptoms), and potentially helpful. However, the researchers in this study
emphasized the importance of activity and Yoga. They wrote that: “the yoga component of the
course may also have acted to counteract the cycle of inactivity or agitation frequently
encountered in depression” (p. 623). Qualitative feedback from participants in another study
(Finucane & Mercer, 2006) emphasized that some participants had difficulties with lengthy
seated meditation, thus suggesting that other ways of learning mindfulness that do not involve
sitting still for long periods of time (e.g., Yoga) may be needed (in Ubelacker et al., 2010, p. 26).
In a randomized pilot study Butler et al. (2008) investigated the effects of meditation with
Yoga (and psychoeducation) versus group therapy with hypnosis (and psychoeducation) versus
psychoeducation alone with 46 individuals with long-term depressive disorders. The
meditation/Yoga sessions followed the Inner Resources (IR) program (Waelde, 1999), which
includes instruction and group practice in meditation, Hatha Yoga, breathing techniques, guided
breathing imagery, and mantra repetition. The IR program emphasizes the meditative practice of
surrender that involves observing thoughts and feelings as they arise and then consciously letting
go of these thoughts and feelings using breathing and visualization. Participants were encouraged
to use surrender during periods of sitting meditation and to cope with their depressive thoughts
and feelings in daily life. IR includes techniques found in mindfulness programs, such as focused
on breathing and mindful Hatha Yoga (see Kabat-Zinn, 1994), but also included additional
techniques drawn from the Classical Yoga tradition (Waelde, 2004). Other IR techniques drawn
from the Yoga tradition include mantra repetition and surrender. Nolen-Hoeksema (2000)
suggested that such an approach seems particularly suited to mood disorders, which may be
maintained by depressive rumination. Butler et al. (2008) found that the participants who
received the Yoga and meditation training had a 77% remission rate and did not develop any new
depressive episodes regardless of using medications or receiving psychotherapy. Eight hypnosis
group participants also experienced a remission, but the difference from controls was not
statistically significant (Butler et al. 2008, p. 806).

Explanations of Yoga’s Efficacy

After practicing Yoga, people often report many “beneficial emotional, psychological,
behavioral, and biological effects” (Shapiro et al., 2007, p. 501) and an increased feeling of well-
being (Dey et al., 2003). People experience beneficial changes to both the mind and body
because “yoga creates change in the neurophysiology of the body” (Douglass, 2009, p. 127).
The connection between Yoga and psychophysiology is gaining interest from researchers, and
several hypotheses have been put forth to explain why Yoga creates cognitive and physical
changes. Researchers strongly suspect that Yoga is effective because it positively alters brain
neurochemistry (Streeter et al., 2007), and it “counteract[s] stress and reduce[s] autonomic
arousal” (Khalsa, 2004, p. 277) of the autonomic nervous system (ANS), including the
sympathetic nervous system (Ross & Thomas, 2010).
The causes of anxiety and depression can be “genetic, environmental, psychological,
emotional, and social” (Forbes et al., 2008, p. 88), all of which change neurobiology (Forbes et
al., 2008). Recently, researchers examined the effect of Yoga on several neurotransmitters
known to be involved with anxiety and depression: cortisol, gamma-aminobutyric acid (GABA),
serotonin, and melatonin are strongly related to the regulation of stress and mood (Douglass,
2009).
Michaelson (2005) warned that while Yoga can become a resource for self-soothing
safety and stability in therapy as well as in the Yoga class should be paramount. She cautioned
that when Yoga fails to serve this function for those who are profoundly depressed, are in
extreme crisis, or experiencing severe psychotic or dissociative symptoms “its use should be re-
evaluated” (Michaelson, 2005, p. 121).
Breath Work
Researchers examined autonomic nervous system (ANS) functioning and noted that Yoga,
especially the breath work, increases heart rate variability (HRV) (Khattab, Khattab, Ortak,
Richardt, & Bonnemeier, 2007), decreases blood pressure levels (Harinath et al., 2004), and
decreases respiratory rates (Raghuraj & Telles, 2008). For people with mild to moderate
depression, practicing Sudarshan Kriya Yoga (SKY) was found to improve depressive symptoms
(Brown & Gerbarg, 2005b). For people with anxiety, practicing Ujjayi breath work as part of
SKY “can restore a sense of control” (Brown & Gerbarg, 2005b, p. 713). Thus, using Yoga
breath work counteracted the tendency of a stressed autonomic nervous system (ANS) of
“becoming hypo-reactive or hyper-reactive” (Brown & Gerbarg, 2005a, p. 195) and caused both
the sympathetic and the parasympathetic nervous systems to function effectively in response to
stress.
Physical Postures
The practice of Yoga appears to result in increases in positive moods, decreases in negative
moods, and increases in energy level regardless of the asana practiced (Shapiro & Cline, 2004).
Bonura (2011) found in a study on Yoga with seniors that Yoga increased the capacity for self-
regulating physiological arousal, which may reflect both improved awareness and greater control
of the body and body functions. Tangible impact of Yoga on physiological processes, such as
brain wave patterns (Corby, Roth, Zarcone, & Kopell, 1978; Dostálek, 1970; Dostálek 1979;
Elson, Huri & Cunis, 1977; Lou, Kjaer, Friberg, Wildschjodtz, Holm & Nowak, 1999; Roldán &
Dostálek, 1985; Roldán, Dostalek, & Bohdanekcy, 1983; Yamazaki, Mitsuhashi & Yamada,
1987), body temperature (Benson, Lehman, Malhotra, Goldman, Hopkins, & Epstein, 1982), and
sensory perceptions (Telles, Nagaratha, & Nagendra, 1995; Telles & Naveen, 2004) were
previously noted. The psychological control—which is developed through Yoga practice—may
lead to physiological and hormonal changes, which in turn may contribute to healthy and
positive psychological changes. While Yoga clearly has an impact on physical health (exercise),
and on mental health (through improved cognitive strategies), it may also have a more subtle
impact on neurological and hormonal processes. Shapiro et al. (2007) found that Yoga practice
positively affects respiration. Yoga also affects other physiological pathways that impact on
mood such as increases in HF-HRV (high frequency heart rate variability), which may stimulate
vagus nerve tone, an effect that is known to be helpful in treating depression (Porges, 2003;
Shapiro et al., 2007). The evidence in various studies supports the polyvagal theory of Porges
(2003) on the role that vagal tone plays in social behaviour and the regulation of emotions
(Porges, 2003, van der Kolk, 2006). Low HRV has been associated with anxiety and depression,
with coronary vascular disease, and increased mortality, while high HRV is associated with
positive emotions and resistance to stress. After 20 classes of Iyengar Yoga, participants (27
women and 10 men, with 17 completers) diagnosed with unipolar depression in partial remission
showed that at times both after each class, and after the series was over most with higher resting
vagal tone became actively engaged in coping with their depression and improving their mental
health (Shapiro et al. 2007). Significant reductions were shown for depression, anger, anxiety,
neurotic symptoms and low frequency heart rate variability in the 17 completers. Eleven out of
those completers achieved remission levels post-intervention. Participants who remitted differed
from the non-remitters at intake on several traits and on physiological measures indicative of a
greater capacity for emotional regulation (Shapiro et al. 2007).
The impact of Yoga on neurological and hormonal processes may be a causative factor in
cognitive and psychological improvements (Shapiro et al., 2007; van der Kolk, 2006). Some
researchers attributed these feelings of relaxation to decreased cortisol levels; “cortisol is referred
to as the ‘stress hormone’” (Douglass, 2009, p. 128) and is released during stress to prepare the
body for a stress response (Ross & Thomas, 2010). Granath, Ingvarsson, von Thiele, and
Lundberg (2006) found that after 10 sessions of a Yoga practice focused on physical postures, an
increased level in cortisol, interestingly, occurred in participants. In their study, a stress
management program based on cognitive behavioural therapy principles was compared with a
Kundalini yoga program. A study sample of 26 women and 7 men from a large Swedish
company were divided randomly into two groups for each of the different forms of intervention;
a total of four groups. The groups were instructed by trained group leaders and 10 sessions were
held with each of groups, over a period of four months. Psychological (self-rated stress and
stress behaviour, anger, exhaustion, quality of life) and physiological (blood pressure, heart rate,
urinary catecholamines, salivary cortisol) measurements obtained before and after treatment
showed significant improvements on most of the variables in both groups as well as medium-to-
high effect sizes. However, no significant difference was found between the two programs.
Woolery, Myers, Sternlieb, and Zeltzer (2004) also found that after 10 Yoga classes emphasizing
Iyengar style postures, those who completed a regular one-hour practice, twice a week, had
higher levels of morning cortisol by the end of the five weeks than the control group who did not
participate in Yoga activities. Higher levels of cortisol are usually associated with a response to
stress. Lydiard (2003) hypothesized that in those people who experience above-average levels of
a stress response, normal homeostasis of neurobiological systems may be disrupted. Thus,
researchers suggested that finding increased levels of morning cortisol might be a positive
measure (Granath et al., 2006; Woolery et al., 2004), especially for those people with anxiety or
depression who may have a lowered or altered homeostasis of neurobiology.
The therapeutic significance of movement-based interventions including Yoga, Tai Chi,
and others was recently emphasized by van der Kolk (2006) in a discussion about neuro-
cognitive aspects of PTSD. Van der Kolk (2006) presented compelling evidence that regulation
of physical movement is a fundamental priority of the nervous system, perhaps from an
evolutionary standpoint even more important than regulation of emotional functions. Physical
therapies may benefit from ‘pre-wiring’ that augments their impact on patterns of behavioural
reactivity commonly associated with various clinical conditions. In addition, physical activity
provides a rich source of present-moment interoceptive cues that can serve as a focal point for
mindful attention that is comparatively well tolerated by trauma victims, who may otherwise feel
overwhelmed by inner sensations (Salmon et al., 2009).
P300 event-related potential amplitude, which measures abnormality of a specific
brainwave in depressed individuals compared to normal controls (Bruder, Tenke, Stewart,
Towey, Leite, Voglmaier, & Quitkin ,1995; Murthy, Janakiramaiah, Gangadhar, &
Subbakrishna, 1997), was found to return to normal status after Yoga (Murthy et al., 1997).
Fifteen patients each of dysthymia (eight males) and melancholia (depressive episode or
recurrent depression with somatic syndrome: six males) were the participant sample. SKY was
the sole treatment consisting of ‘three successive components of specified rhythms of breathing’
for about half-an-hour daily and continued for 3 months. SKY was taught by a SKY teacher
during the first 10 days. Low pretreatment P300 event related potential (ERP) amplitude
‘normalised’ with improvement in both dysthymic (n= 5 15) and melancholic (n=5 9) patients on
SKY therapy (Murthy et al., 1997), similar to earlier reports with somatic treatments such as
antidepressant medications and ECT (Blackwood, Whalley, Christie, Blackburn, St. Clair &
McInnes, 1987; Gangadhar, Ancy, Janakiramaiah & Umapathy, 1993).
Plasma prolactin, the production of which tends to be blunted in depression and has been
associated with increased risk of recurrence of depression even after successful treatment
(Golden, Heine, Ekstrom, Bebchuck, Leatherman, & Garbutt, 2002), was increased in levels
after Yoga therapy (Janakiramaiah, Gangadhar, Murthy, Harish, Subakrishna & Vedamurtachar,
1998). Though there is no current evidence for the effect of Yoga on prolactin levels in anxious
human populations, prolactin increase has been associated with reduced anxiety in animal
models (Brown and Gerbarg, 2005a). It has been suggested that reduced sympathetic activity
and improved parasympathetic drive, normalization of the activity of the hypothalamic pituitary
adrenal axis, and monoamine changes, may mediate such treatment response (Brown & Gerbarg,
2005a; Riley, 2004).
Lower GABA levels have been found in people with depression (Brambilla, Perez, Barale,
Schettini, & Soares, 2003) and anxiety (Lydiard, 2003). Streeter et al. (2007) speculated that the
physical postures of Yoga would increase GABA activity levels in the brain, thus decreasing
anxious and depressive symptoms. After the participants in the study completed a one-hour
session of Yoga postures, Streeter et al. (2007) found that GABA levels increased by
approximately one-quarter when compared with baseline measurements, regardless of the type of
Yoga practiced (in Forflylow, 2011, p.140).
Hatha Yoga involves physical activity, and in general both physical activity and exercise
have been linked to a variety of neurophysiological effects including endorphin release and
altered brain neuro-transmitter levels, especially dopamine and serotonin, which have emotion-
enhancing effects (Buckworth & Dishman, 2003). However, many of these changes occur in the
context of relatively high intensity activity, which involves heightened activation of the
sympathetic nervous system (SNS). In contrast, most forms of Yoga (excluding high intensity,
aerobic variants such as Ashtanga Yoga) elicit the ‘relaxation response’ described by Benson
(1975), a state of physiological de-activation reflecting dominance of the parasympathetic

nervous system (PNS) (Salmon, Lush, Jablonski et al., 2009). Davies, Hood, Argyropoulos,
Morris, Bell, Witchel, and Potokar (2006) found that serotonin regulated both psychological and
cardiovascular responses to stress in people with anxiety. No published studies were found
about Yoga’s effect on serotonin levels.
Netz and Lidor (2003) examined the effects of mindfulness exercise (for example, Yoga)
versus aerobic exercise (e.g., swimming) on anxiety and depressive mood. Netz and Lidor
conducted a study of 193 middle-aged Israeli women who were general curriculum or physical
education teachers attending a teachers college in part to study the effectiveness of mindful
modes of exercise such as Feldenkrais (n= 37) and Yoga (n=31), both low intensity styles of
exercise which have an emphasis on proprioceptive awareness, with more aerobic exercise like
swimming (n=22) and dance aerobics (n=28) on mood alterations. A baseline analysis was
conducted on the second class for each mode of exercise testing for anxiety, depression, well-
being and personality. Then pre-and post-tests were done again just before and just after the 14th
class. The results showed that after just one session, mindful exercise more effectively reduced
anxiety and increased positive mood than aerobic exercise (Netz & Lidor, 2003). Netz and Lidor
proposed that this finding may be due to the cognitive focus found in mindful activities.
From a Yogic perspective there is a connection between posture and mood and Yoga can
help improve posture. Walden, (in McCall,(2007) said that when Iyengar (1996) used to give the
instruction “if you keep your armpits open you’ll never get depressed” (p. 261) what he meant
was that a depressed person often has a defeated sunken chest posture. When Iygenar spoke of
keeping the armpits open, Walden elaborated, he meant “[as] the space between the armpit and
chest grows, become wider and more lifted, so the lungs are lifted, the physical heart lifts, you’re
able to breathe more deeply. [Also] your thoracic spine begins to elongate, and those simple
things have a [positive] effect on your physiological and mental state” (Walden, as cited in
McCall, 2007, pp. 264-265).
Meditation
Melatonin is believed to regulate mood and sleep patterns (Douglass, 2009). Harinath,
Malhotra, Pal, Prasad, Kumar, Kain and Sawhney (2004) found that participants had increased
melatonin levels after practicing Yoga, particularly meditation. Thirty healthy men in the age
group of 25–35 years volunteered for the study. They were randomly divided in two groups of 15
each. Group 1 subjects served as controls and performed body flexibility exercises for 40
minutes and slow running for 20 minutes during morning hours and played games for 60 minutes
during evening hours daily for three months. Group 2 subjects practiced selected Yogic asanas
(postures) for 45 minutes and pranayama (breathing exercises) for 15 minutes during the
morning, whereas during the evening hours these subjects performed preparatory Yogic postures
for 15 minutes, pranayama for 15 minutes, and meditation for 30 minutes daily, for 3 months.
Yogic practices that were sustained for three months resulted in participants showing an
improvement in cardiorespiratory performance and psychologic profiles. The plasma melatonin
also showed an increase after three months of Yogic practices. Harinath et al. (2004)
hypothesized that the participants’ positive reports may be due to increased levels of melatonin.
Additionally, researchers found that people with depression who practiced Yoga reported
feeling more positive about themselves and their health and also reported sleeping better (Chen
et al., Chen, Chao, Hung, Lin & Li, 2009). Chen et al. (2009) conducted a study of 139
participants who were recruited from eight senior centres and randomly assigned to either the
Silver Yoga group or a wait-list control group. The Silver Yoga Program includes 20 minutes of
warm-up and loosening exercises, 20 minutes of Hatha Yoga designed to increase range of
motion and muscle relaxation, 10 minutes of relaxation, and 15 minutes of guided-imagery
meditation (Wang, 2009, p. 93). Participants were assessed for sleep quality, depression, and
self-perceived health status at the beginning, middle, and end of the study period. Yoga classes
occurred three times a week for six months. Three months into the intervention, there were
significant differences between groups in depression and self-perceived physical and mental
health, but not total sleep quality score. At the end of the six-month period, there were significant
differences between groups in depression, physical and mental health, and sleep quality, with the
Yoga group showing significant improvements from baseline to the six-month mark in all
outcomes (Chen et al., 2009).
Aside from helping a depressed person learn how to modulate their response to stress, the
Yogic tool of self-study (svadhyaya) (Patanjali, Sutra I.28) may be useful to help the person see
whether their depression is a reaction to something in their lives, rather than to something wrong
inside of them, that needs to be looked at and changed. According to ancient Yogic philosophy
of Patanjali (2nd C., BCE, Sutra I.2-3), Yoga, specifically the practice of meditation, stills the
fluctuations (vrittis) of the mind (chitta). When fluctuations of the are stilled and the mind
becomes calm through meditation practice, Patanjali (2nd C., BCE) continued, the true nature of
the mind reveals itself to the Yoga practitioner, self-study may begin and the practitioner may
become keenly aware of unhealthy mental or physical habits and relationships that may be
keeping them depressed and begin to work at changing them.
Research Critique
The methodologies of these studies may limit the validity of these studies. Forfylow
(2011) pointed to four methodological issues in the research supporting Yoga as a clinical
intervention for anxiety and depression. First of all, only half of the studies in this review were
randomized controlled trials (RCTs). Secondly, researchers have not determined “which type of
Yoga, which aspect of Yoga, or what amount of Yoga creates the most psychological benefit for
those with anxiety or depression” (Forfylow, 2011, p 141) because researchers used a range of
Yoga interventions, with variety in the length of time, amount of time, and intensity of practice
(Forfylow, 2011). In a review of the literature, Khalsa (2004) also pointed to the research
challenges of the wide variety of Yoga techniques that contributed to the interventions,
ranging from individual physical postures or breathing techniques to complete Yoga
lifestyle interventions involving dietary and psychospiritual components, [and that]
application of the interventions were equally varied and ranged from individual practice
to group sessions, from daily practice sessions to weekly sessions, and from short-
duration to long-duration sessions. (Khalsa, 2004, p. 452)
A third methodological problem is that generalizations were difficult to form regarding Yoga’s
effectiveness to all people with anxiety and depression because participants in all the studies
varied in ethnicity, sex, Yoga experience, motivation, and severity of anxious or depressive
symptoms (Forfylow, 2011). Fourth, there is almost no information on the safety or
contraindications of Yoga practice, with only occasional reference made to possible adverse
effects of Yoga practice, in the studies reviewed.
Summary
Despite methodological flaws, studies reviewed in this chapter show that Yoga appears to
reduce anxiety for people with state, trait, and performance anxiety. The breath work practice,
meditation practice, and learning about Yoga practices decreased feelings of anxiety, whereas the
physical postures decreased the physical symptoms of tension and anxiety. Given that Yoga was
found to be as effective as conventional relaxation techniques in reducing stress and anxiety,

people with anxiety may wish to also consider the unconventional relaxation techniques of Yoga.
Yoga reduced depression for people with many forms of depression, including those who
were taking antidepressant medications or participating in conventional psychotherapy.
Particularly, the physical postures of Iyengar Yoga had many physical and cognitive benefits for
people with depression. Focusing on postures that open and lift the chest counteracted feelings
of depression, increased positive mood, offset the collapsed body posture, and helped people
with depression. Additionally, the breath work practices gave people with depression a sense of
control over their bodies, while the meditation practices allowed people with depression to
release patterns of rumination on depressive thoughts.
Studies showed that Yoga improved participants’ psychophysiology. For example, the
autonomic nervous system response became regulated, and neurotransmitter and hormone levels
positively changed. After practicing Yoga, a form of homeostasis was created in the body
similar to the effects of conventional medications. Javnbakht, Kenari, and Ghasemi (2009) and
Forfylow, (2011) asserted that Yoga may be an appropriate non-pharmacological clinical
intervention for treating anxiety and depression.

CHAPTER 3 METHODOLOGY
viveka-khyatir-aviplava hana-upayah
The means of [attaining] cessation is the unceasing vision of discernment. (Patanjali, Yoga
Sutras, 2.26)
This chapter will describe the methodology used in this qualitative study. First, research
objectives will be described and the best practices methodology that was chosen to attain these
objectives will be introduced. Secondly, the specific variation or part of a best practices analysis
and how it links to a complete best practices analysis will be described. Thirdly, an explanation
of how the analysis was divided into themes and topics will be offered. Lastly, the process by
which categories were created and inferences built shall be set out.
The purpose of this study is to explore how Yoga practices are successfully being
integrated into psychotherapy and counselling practice. The intention behind this study, which is
informed by the existing research and clinical expertise in the current literature, is to provide a
foundation for a clinical protocol for an integration of psychotherapy and Yoga. The emphasis
of this study is to offer therapeutic guidelines towards professional standards for those wishing to
use Yoga in counselling and psychotherapy.
Research Objectives
1) To investigate which Yoga interventions or approaches to Yoga are superior to others
in Yoga therapy for helping clients suffering from depression or anxiety either in
conjunction with psychotherapy sessions or in other Yogic contexts.
2) To identify common factors among these superior diverse methods in treatments in
Yoga and Yoga therapy toward the development of a protocol for therapeutic Yoga
practices for use by practitioners in conjunction with talk therapies.

3) To identify theories of counselling being employed when Yoga is successfully being
used with counselling, and to identify how therapists and clients measure the success
of the treatments.
Best Practices Research Methodology

There are many definitions and some controversy about what defines “Best Practices”
research. Best practices research was defined by Mold and Gregory (2003) as a
systematic process used to identify, describe, combine, and disseminate effective clinical
and/or management strategies developed and refined by practicing clinicians. It involves five
steps: development of a conceptual model or series of steps, definition of “best” based on
values and standards, identification and evaluation of potentially effective methods for each
component or step, combination of most-effective methods, and testing of combined
methods. (Mold & Gregory, 2003, p. 133)
The US Department of Health and Human Services defined a best, or promising, practice as,
one with at least preliminary evidence of effectiveness in small-scale interventions or for
which there is potential for generating data that will be useful for making decisions about
taking the intervention to scale and generalizing the results to diverse populations and
settings . . . [and that] the manner in which a method or intervention becomes a best practice
can take some time and effort. (U.S. Department of Health and Human Services,
Administration for Children and Families Program Announcement, 2003, p. 3)
Conducting current and best practices research is critical “to developing a full
understanding of a problem and all of its components from multiple and varied perspectives”
(Eglene, 2000, p.1). Research into current practice is an organized attempt to learn from the
experience of others in similar fields: “this research involves formulating research questions,
identifying likely sources of expertise, and probing for frank advice” (Eglene, 2000, p.1). “Best”
practices are those that were deemed to be most successful after probing all of these sources of
expertise. The fundamental goal of best practices research is to share between practitioners,
knowledge, and experiences of these best practices that others would like to emulate, rather than,
unknowingly, replicating the mistakes of others (Eglene, 2000; Tranfield, Denyer & Smart,
2003). The idea that evidence of an intervention’s efficacy from carefully controlled trials could
be generalized as the best practice for widely varied populations and situations “has been
inherent from the beginning of research and evaluation in every field of engineering and human
service” (Green, 2001, p. 4). Green (2001) posited that the areas of health promotion and other
applications of health behavioural research need to replace the term ‘best practices’ with ‘best
processes’ because the interventions in fields that intervene on living organisms, such as
medicine, can be counted on to have a similar efficacy on the organism across the human
species, but social and behavioural aspects of human services must make infinitely more
adjustments of their interventions than dosages by age and sex (Green, 2001). Despite
controversy regarding exporting a medical model of best practices research into the social
sciences, Tranfield et al. (2003) insisted that although systematic reviews have traditionally been
applied in fields and disciplines privileging a positivist and quantitative tradition, they may also
be used in the social sciences. The Campbell Collaboration (February, 2001) named after
American psychologist and evaluation guru Campbell was developed, “to help people make
well-informed decision about the effects of interventions in the social, behavioural and
educational arenas” (Campbell Collaboration, 2001). The collaboration (Campbell
Collaboration, 2001) was significant for health behaviour and health promotion because
it [sought] to prepare and promote access to systematic reviews of studies on the

effects of social and educational policies and practices outside medical care settings, as
in much of the research on mental health and substance use (Green, 2001, p. 6).
The Campbell Collaboration addressed the need for research to be well founded and socially
robust, which fits with the fundamental tenets of best practices research noted above, and
emphasized that key characteristics of an evidence-based approach involves “producing a
science base, which is both rigorous in formulation and relevant to practice” (Tranfield et al.,
2003, p. 210).
The U.S. Department of Health and Human Services described a three-step process for a
‘promising practice’ in social sciences and health promotion to achieve the status of research
validated best practice:
1) Promising Practice: A program, activity or strategy that has worked within one
organization and shows promise during its early stages for becoming a best practice
with long term sustainable impact. A promising practice must have some objective
basis for claiming effectiveness and must have the potential for replication among
other organizations.
2) Field Tested Best Practice: A program, activity or strategy that has been shown to
work effectively and produce successful outcomes and is supported to some degree
by subjective and objective data sources.
3) Research Validated Best Practice: A program, activity or strategy that has the highest
degree of proven effectiveness supported by objective and comprehensive research
and evaluation. (U.S. Department of Health and Human Services, Administration for
Children and Families Program Announcement, 2003, p.4)
Since evidence of effectiveness, potential for taking the intervention to scale, and
generalizing the results to other populations and settings are key factors for best practices, the US
Department of Health and Human Services explained that “the manner in which a method or
intervention becomes a best practice can take some time and effort” (US Department of Health
and Human Services, Administration for Children and Families Program Announcement, 2003,
p. 5).
Rational for Choosing Best Practices Approach

A best practices approach was chosen to offer a protocol to therapists wishing to utilize
Yoga or Yoga therapy in conjunction with talk therapy “a replicable, scientific and transparent
process” (Tranfield et al., 2003, p. 210) by which to utilize successful Yoga interventions with
their clients. First, an extensive literature review was conducted, in an attempt to “minimize bias
through [this] exhaustive literature search of published and unpublished studies and by providing
an audit trails of the reviews decisions, procedures and conclusions” (Grigg, personal
communication, July 14, 2011; Cook, Mulrow & Haynes, 1997; Tranfield et al., 2003, p. 209).
The second part of a best practices analysis is to identify, describe, and study the effectiveness
and efficacy of expert practice through interviews with experts in the field, and the third to
examine the needs and rights of clients, the most vulnerable other half of the participants in any
health practice or protocol, through interviews (Grigg, personal communication, July 14, 2011).
The first part, the extensive literature review, was conducted in this study to provide a
foundation for subsequent full spectrum Best Practices analyses. The review of the available
literature was conducted to “assimilate ‘best evidence’ to provide insights and guidance for
intervention into the operational needs of practitioners and policy-makers” (Tranfield et al.,
2003, p. 208). The analysis and synthesis of the literature are an “iterative process of definition,
clarification, and refinement (Clarke & Oxman, 2001). In a discussion of how systematic review
processes developed in fields [such as the field of medicine] that are striving to become more
evidence based and to synthesize research in a systematic, transparent, and reproducible manner
they posited that these processes may inform the review process of other fields such as the social
sciences “to help create rigorous and relevant reviews” (Tranfield et al., 2003, p. 212). Mold
and Gregory (2003) delineated that the first step in best practices research is the development of
a conceptual model (p. 133). The literature review is the first step in developing this model, and
second is the conducting interviews with stakeholders such as therapists and clients. The
creation of a unified conceptual model and/or a list of its components is based on analyzing and
synthesizing the components plucked from these sources to create proposed combined methods.
The specific goal of the review in this study is to offer these combined methods to be
disseminated or tested more formally (Mold & Gregory, 2003). Specifically this analysis of the
literature will identify those documented Yogic practices for working with people who struggle
with depression and anxiety in the hope that it will provide helpful insights and guidance for
therapists who wish to use Yoga interventions in combination with talk therapy. The best
practices review will include definitions of both Yoga and Yoga therapy, and a review of
research findings for clinical studies conducted on yoga and anxiety, as well as yoga and
depression, from 1986 to 2011.
Development of Themes
This study was restricted to clinical trial studies appearing in research journals and Yoga
journals, which report on interventions incorporating Yoga or Yoga- based techniques for the
treatment of psychiatric conditions, specifically depression and anxiety, or their associated
symptoms. Each study was evaluated as to the presence of a control group and whether subjects
were randomized to different study arms, to yield three categories: uncontrolled trials, controlled
trials, and randomized controlled trials (RCT’s). I will take a broad approach and include the
perspectives of both researchers and Yoga experts, as well as evidence based studies.
Creating Categories and Building Inferences

This research is aimed at examining Yoga interventions that can be used in conjunction
with psychotherapy as an effective clinical treatment intervention for psychological concerns,
especially depression and anxiety, the two most common mental health disorders being treated
by Yoga therapy as well as ways in which mental health professionals may refer clients to
suitable Yoga classes or to a suitable Yoga therapist. The discussion of the relevant research
studies conducted on Yoga and anxiety, as well as Yoga and depression is organized for both of
these ailments using the three major components of Yoga: breath work, physical postures, and
meditation. Plucking successful techniques from these three categories, including sequences of
Yoga interventions and assessing the most successful styles of Yoga, will be key in analyzing
and synthesizing the most effective interventions to begin creation of a list of key components or
unified conceptual model for how practitioners may use Yoga interventions in conjunction with
psychotherapy to help clients struggling with depression and anxiety.
Limitations
Interpreting the literature for best practices has its challenges because there is no single
standardized Yoga practice format, and there is a very wide range of the types of Yoga
interventions used in this literature, ranging from individual breathing or postural techniques to
complete Yoga lifestyle interventions involving dietary and psycho-spiritual techniques.
Application of the interventions is equally varied, from individual practice to group sessions,
from daily practice sessions to weekly sessions, and from short duration to long duration
sessions. Also, the quality of publications included in this review varies dramatically, with some
publications presenting less material than is apparent in many abstracts. Lastly, there is a “lack
of congruence between Western quantitative research methods and the Eastern philosophy of
complementary and alternative medicine; the individualized comprehensive, and
multidimensional nature of these interventions is difficult to measure quantitatively with RCTs”
(Spencer, as cited in Forfylow, 2011, p. 142). All these challenges will limit generalizability of
results.
CHAPTER FOUR RESULTS

sthira-sukham-asanam
The posture should be steady and comfortable. (Patanjali, Yoga Sutras, 2.46)
The purpose of this chapter is to analyze and synthesize the results of the literature review
investigation towards a best practices approach for incorporating Yoga or Yoga therapy with
psychotherapy. Best practices approaches for Yoga interventions to help clients suffering from
depression or anxiety will be discussed. Common factors among these superior methods will be
discussed. Then theories of counselling employed when Yoga is successfully being used with
counselling as well as the ways in which therapists and clients measure the success of treatments
will also be discussed.
Externally and Internally Validated Styles of Yoga and Interventions

There was a paucity of research literature to fail to reject a null hypothesis about the
effectiveness of Yoga in treating anxiety and depression.
Overall, all of the three main aspects of Yoga—physical postures, breathing exercises, and
meditation—showed benefit as monotherapy or as augmentation to antidepressants in mild to
moderate depression or to psychotherapy (e.g. Bennett et al., 2008; Forbes et al., 2008; Franzblau
et al., 2008; Janakiramaiah et al., 2000; Krishnamurthy & Telles, 2007; Michaelson, 2005; Netz
& Lidor, 2003; Shannahoff-Khalsa & Beckett, 1996; Shapiro & Cline, 2004; Street et al., 2007)
and as monotherapy in severe depression (Khumar et al., 1993). The style of Yoga appears to be
less important than the fact that Yoga does three things—physical postures, breathing exercises,
and meditation—all of which have been shown to have an impact on stress responses inherent in
all forms of anxiety and depression. Studies reviewed show that Yoga reduced anxiety for
people with state, trait, and performance anxiety as well as for people with PTSD. Breath work
practice, meditation practice, and learning about Yoga practices decreased feelings of anxiety,
whereas the physical postures decreased the physical symptoms of tension and anxiety. Yoga
reduced depression for people with many forms of depression, including those who were taking
antidepressant medications or participating in conventional psychotherapy. The physical
postures of Yoga had many physical and cognitive benefits for people with depression. Focusing
on postures that open and lift the chest counteracted feelings of depression, increased positive
mood, offset a collapsed body posture, and helped people with depression. Additionally, breath
work practices gave people with depression a sense of control over their bodies, while meditation
practices allowed people with depression to release patterns of rumination on depressive
thoughts.
SKY Yoga (Sudarshan Kriya Yoga breathing) was externally validated as a treatment
system for anxiety disorders (Descilo et al. 2010; Murty et al., 2007; Telles et al., 2007; 2010)
and Iyengar Yoga was externally validated as a treatment system for depression disorders
(Franzblau et al. 2008; Michaelson, 2005; Shapiro & Cline, 2004; Woolery et al., 2004).
It appears that the style and method of Yoga when used therapeutically may not matter
quite as much as the actual interventions, namely, breathing (pranayama), postures (asana) and
meditation (dhyana), which appear to be what give all the Yoga styles employed internal
validity.
Counterindications of Using Yoga Therapy

There is a shortage of research information “on safety or contraindications with respect
to yoga for psychiatric disorders” (Kirkwood, Rampes, Tuffrey, Richardson & Pilkington, 2005,
p. 889). Little information is given in the studies reviewed about adverse effects of the practice
of Yoga. Shannonoff-Khalsa (1996) reported no adverse effects in the randomized control trial
of Yogic meditation with obsessive-compulsive disorder (OCD), but few other researchers
reported any contraindications. Some articles refer to potential for injury (Ernst, 2001; Crews,
2005) and this may have negative implications for one’s mental state (such as, anxiety or
depression about injury, re-injury, or pain). Salmon (2001), when referring to exercise in
general, pointed to some concern that undertaking a program that is too intense for a person can
lead to a worsening of mood.
Assessments for physical conditions must be part of a best practices approach. Even
though different Yoga therapists follow different procedures, a general procedure should first
determine:
1) the condition to be treated, 2) an evaluation of the individual's general abilities, 3)
choosing appropriate techniques from the various disciplines which best serve the
therapeutic process, 4) determining the order of the practice and the number of
repetitions to practice on his or her own, or with the therapist and, finally, 5) always
assessing and modifying the practice according to client's needs. (Sausys, 2006, par.
7-8).
There have been reports of deleterious effects of meditation on mood. Shapiro
(1994) found that 62.9% of the subjects reported adverse effects during and after
meditation and 7.4% experienced profoundly adverse effects. The length of practice
(from 16 to 105 months) did not make any difference to the quality and frequency of
adverse effects. These adverse effects were relaxation-induced anxiety and panic;
paradoxical increases in tension; less motivation in life; boredom; pain; impaired
reality testing; confusion and disorientation; feeling 'spaced out'; depression;
increased negativity; being more judgmental; and, ironically, feeling addicted to
meditation. Other adverse effects described (Craven, 1989) were uncomfortable

kinaesthetic sensations, mild dissociation, feelings of guilt, and, via anxiety-provoking
phenomena, psychosis-like symptoms, grandiosity, elation, destructive behaviour and
suicidal feelings. Kutz et al. (1985a;b) described feelings of defencelessness, which in
turn produce unpleasant affective experiences, such as fear, anger, apprehension
and despair. Sobbing and hidden memories and themes from the past, such as incest,
rejection, and abandonment appeared in intense, vivid forms and challenged the
subject's previously constructed image of their past and themselves.
The side-effect profile summarised also resembles many of the
neurotic/anxiety constellation of symptoms. None of the studies reviewed tried to
disentangle the effects of meditation per se from the influence of the presenting
problem or/and premorbid personality of the subjects. It is unclear whether certain
personality types are more likely to try meditation or whether the effect of meditation
increases the awareness of those feelings, symptoms and personality traits (Morse,
as cited in Perez-di-Albeniz & Holmes, 2000).
There may be also be contraindications for using Yoga in psychotherapy when
clients have been assessed with serious psychiatric disorders. Counsellors should know
that there are a few reports of psychosis or mania induced by Yoga and Zen meditation in
people who have had diagnoses of schizophrenia or bipolar disorder. This is possibly due
to meditation’s “apparent potency at inducing euphoric states of consciousness”
(Yorston, 2001, p. 212). Khalsa (2004) pointed out that
one cannot rule out the possibility that such events were simply spontaneously
generated in accordance with the natural history of the disorder, and may have
been triggered by other ongoing ordinary life circumstances. Further, he added

that many of these negative case reports involve individuals who are practicing
techniques on their own in an overintensive or contraindicated manner. (p. 454)
and
that it should go without saying that treatment of any medical or psychiatric
condition with potentially serious consequences (psychosis, major depression,
epilepsy, diabetes) should be treated under the careful and regular supervision of
an appropriately qualified clinician, regardless of the presumed benign nature of a
treatment. (p. 454).
Khalsa (2004) balanced this with another safety measure of Yoga as an adjunctive
clinical therapy when he stated that “under the supervision of a qualified and experienced
yoga instructor, yoga therapy would usually be practiced in a less intensive format, which
would likely minimize the risk of adverse events” (Khalsa, 2004, p. 454) and posited that
more likely, unexpected positive benefits might appear with Yoga therapy, such as a
“resolution of stress-related symptoms other than those that constitute the primary
complaint” (Khalsa, 2004, p. 454). Yorston (2001) also suggested that “adequate practice
and supervision may enable the subject to learn to control the emergence of intrapsychic
material” (p. 212).
A best practices approach to integrating Yoga with psychotherapy must first and
foremost strive to preserve the safety of the client by assessing for such psychiatric
diagnoses as psychosis, schizoid and schizotypal personality, dissociative states,
hypochondrial and somatization disorders, as there is a risk that the client will be
distressed and overwhelmed by the experience of symptoms during meditation (Shapiro,
1994).
Therapeutic Yoga Interventions—Toward a Protocol For Counsellors
Anxiety – Calming Yogic Interventions
Pranayama (breathing practices):

Traditional Yoga breathing practices such as diaphragmatic breathing, either as a separate
practice, or in conjunction with restorative postures are recommended for calming anxiety
because they help develop awareness of the involuntary and unconscious process of breathing
“to help gently redirect breathing in new and better habitual ways . . . leading to greater vitality
and calm” (Simpkins & Simpkins, 2011). The practices may be done sitting upright or lying
down and “supports should be used to make the posture in which the person does pranayama
more stable and comfortable” (Mohan & Mohan, 2004, p. 139). The generally recommended
ratio of inhalation to exhalation for reducing anxiety is 1:2 (Emerson & Hopper, 2011; Forbes,
2011; McCall, 2007; McGonigal, 2009). The act of quietly observing breath helps to slow it
down and then a conscious lengthening of the exhalation with either open mouth, pursed lips, or
closed mouth helps slow it down further to help reach or approach the suggested 1:2 ratio of
inhalation to exhalation. This breathing practice reduces stress and pain by
 slowing the breathing and extending the exhalation to trigger the relaxation response
(Brown & Gerbarg, 2005a, 2005b; McGonigal, 2009) and by
 focusing the mind on something simple to control, “creating a sense of safety that can
make the mind and body less sensitive to threat and pain” (McGonigal, 2009, p. 41;
Emerson & Hopper, 2011).
In the Kundalini Yoga tradition this technique of long deep breathing is taught early in Yoga
training and therapy because it can help the practitioner understand the movement of the
diaphragm; it may also help encourage deeper breathing to offset the shallow breathing often
associated with anxiety (Shannanoff-Khalsa, 2010).
Obsessive-compulsive disorder (OCD), an anxiety disorder, which includes intrusive
thoughts or obsessions that are accompanied by ritualistic and repetitive behaviours or
compulsions, is the fourth most common psychiatric problem in the west (Shannahoff-Khalsa,
1996). A Kundalini breathing technique for OCD that stimulates the right side of the brain, often
impaired in patients with OCD (Weintraub, 2004, p. 65), requires the client to sit with a straight
spine, either cross-legged or in a chair. The client then blocks the right nostril while breathing
deeply in and out of the left nostril. Citing Yogi Bhajan, who introduced Kundalini Yoga to the
west in 1969, psychiatrist, researcher, and Yoga therapist Shannahoff-Khalsa wrote that
practicing this technique 31 minutes a day for 90 days, at a rate of one breath per minute, will
eliminate obsessive-compulsive behaviours (Shannahoff-Khalsa, 1996).
Chandra Bhedana was also indicated for easing anxiety: this entails inhaling through the
left nostril and exhaling through the right because in Yoga anatomy according to the Hatha Yoga
Pradipika (Swatamarama, 13th century CE) it is believed that the left side of the body is
associated with the cool, relaxed, parasympathetic part of the body, and the right side is the hot,
active, and sympathetic part of the body. Inhaling through the left nostril and exhaling through
the right is believed to help stimulate the calming qualities of the body’s left side (McCall,
2007).
Victorious breath (Ujjayi breathing) is a recommended pranayama practice for anxiety as
a separate breathing practice or as a breathing practice in conjunction with physical postures. In
a pranayama practice of Ujjayi breathing it is recommended that the practitioner count to

measure the length of the inhalations, breath retention, and exhalations, and breath retention at
the end of the exhalation. Various counts have been taught, but most recommend that, for
anxiety, the exhalation be longer than the inhalation (e.g., inhale 4: hold 2: exhale 4–8; hold 2).
Both rhythmic breathing and counting are known to have calming effects on the nervous system.
Alternate nostril breathing (Nadi Shodona) has been used extensively to help balance the
sympathetic and parasympathetic branches of the autonomic nervous system and is so effective
in promoting the relaxation response that it “is considered the perfect prelude to meditation”
(McCall, 2007, p. 62).
SKY (Sudarshan Kriya Yoga breathing) a rhythmic three stage breath consisting of slow
breathing (7-8 breaths), medium breathing (15 breaths), and fast breathing (30 breaths) has also
been successfully clinically offered to help treat anxious clients (Brown, Gerbarg & Muskin,
2009; Descilo et al., 2010; Gerbarg & Brown, 2007).
Asanas (physical postures):

Any of the Yoga postures or sequences of postures, if done mindfully, which means with
conscious relaxed breathing to help cognitively monitor the body and mind’s responses in the
postures, postural alignment and doing the postures with variations that are appropriate to the
person’s level of practice may alleviate anxiety (Forbes, 2011). The postures may be specific
Restorative Yoga postures done with the body fully supported by bolsters, blankets, and blocks,
or regular postures such as backbends, forward bends, standing poses, and inversions done in a
slow way to calm the nervous system and reduce anxiety (Forbes, 2011). Forbes (2011)
describes a Restorative Yoga practice as one that helps to quiet the nervous system and allowing
the body to be relaxed and the mind to be more reflective “with less reactivity than . . . in either a
meditation or an active yoga practice . . . allowing the body to integrate these experiences” (p.
101). Breathing practice (Ujjayi) to accompany the postures may be done with the ratio of
inhalation to exhalation 1:2; if the quality of mind is depressed when the body is anxious, the
ratio of inhalation to exhalation may be 2:1. The practitioner or client is encouraged to explore
which of the two practices one feels most beneficial for them (Forbes, 2011)
Trauma-sensitive Yoga consisting of Restorative Yoga poses and regular poses self-paced
and done gently done in a trauma-sensitive setting helps offer trauma-survivors a “medium [for
survivors] to make choices in relation to their bodies and their experience that are kind, gentle,
and caring—all of the things that were missing during the trauma” (Emerson & Hopper, 2011, p.
45).
The asana practice may also, at times, be vigorous or “discharging” to help decrease
symptoms of anger, tension, and fatigue which can be some of emotional and physiological
side-effects of prolonged anxiety (Streeter et al., 2007).
Meditation
Mindfulness meditation practices for many forms of anxiety including PTSD should
include body-oriented practices such as breathing practices or movement practices with pauses to
observe the effects on the body (Emerson & Hopper, 2011, p. 98; Forbes, 2011; Subramanya &
Telles, 2009).
Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy are both
effective meditation practices that may be taught and used in group therapy (MBSR; Kabat-Zinn,
1990) or individual therapy (MBCT; Segal, Williams, & Teasdale, 2002) and then practiced
individually at home to help reduce anxiety (Roemers, Salters-Pedneault, & Orsillo, 2006).
Mindfulness meditative practices for anxiety may include practicing three stages of a practice
that begin with a guided body scan (sitting or lying), a short sitting meditation, and a walking
meditation (Labbe, 2011). Sitting meditation may begin in therapy with a focus on mindful
breathing (e.g., simple breath awareness or diaphragmatic breathing) and after practicing this
daily for one week, the focus of the sitting meditation may be widened to “include other bodily
sensations besides breathing, as well as sounds, thoughts, and feelings” (Labbe, 2011, p. 50).
Kabat-Zinn (2005) described the practice of being able to sit quietly and watch whatever enters
one’s awareness and let it come and go as “a relaxation into stillness and peace beneath the
surface agitations of your mind” (p. 72).
The aforementioned Mindfulness Meditation techniques arise from Buddhist meditation and
breathing techniques that have become very popular in the west and have recently become
common additions in Yoga classes. A number of classical Yogic meditation techniques which,
due to lack of exposure in the west may seem more esoteric and complex can add a richness to
the therapist’s toolkit and may be offered to clients more familiar with Yoga practices.
Psychotherapists and authors Simpkins and Simpkins (2011) pointed to a variety of classical
Yoga meditations that a therapist may practice and teach to clients. These include pratyahara
(sense withdrawal) starting by noticing sounds outside, then noticing stimuli progressively more
and more close to the client, then turning attention to body sensations, then to finally focusing
simply on being calm and quiet, without being directed to anything and sustaining the quiet state
inwardly focused attention until ready to stop. Dharana (concentration) focusing on a single
point (an object, the breath, a mantra, a concept) and keeping it there is an advanced Yogic
meditative practice. Simpkins and Simpkins (2011) recommend an applied meditation practice
in the pose of savasana (corpse pose) after doing a sequence of asanas for anxiety which
includes progressive tightening and relaxing of different muscles groups (p. 148). After having
trained with the two previous practices intensively one may begin to learn the practice of dhyana
(meditation) in order to immerse one’s self into the oneness of samadhi, the state of higher
consciousness where one’s ego concerns dissolve and one becomes fully engaged in the deeper
spiritual nature of the world (Simpkins & Simpkins, 2011, p.110). This depth of progressive
Yoga meditative practice is recommended for the clients who are interested in the traditional
Yogic practices or some parts of these steps may provide useful interventions for
psychotherapists offering Yogic meditation to clients struggling with anxiety.
All three of these Yoga practices (breathing, physical postures, and meditation) are often
combined in Yoga sequences in classes or personal practice. Research has shown that they were
effective practiced separately but appeared to have an increased synergistic effectiveness for
helping reduce anxiety when combined (Harrigan, 1991; McCall, 2007; Telles et al., 2010).
Additional Suggestions that Support Best Practices for Using Yoga for Anxiety
 Depression, alcohol abuse, diabetes, and thyroid disease, among other conditions can
cause anxiety and should be ruled out or treated by a physician. If significant anger or
low level of self-esteem is part of the client’s anxiety symptoms, they may have an
underlying depression and may benefit from consulting with a physician or
psychotherapist (McCall, 2007, p. 148).
 The combination of therapy and medication or therapy and Yoga is likely to be more
effective in treating anxiety than either alone (McCall, 2007, p. 148).
 Insight and understanding, the main staples of CBT and psychodynamic therapies, “are
not enough to keep traumatized people from regularly feeling that they are traumatized
all over again” (van der Kolk, 2006, p. 282). In PTSD, an extreme form of anxiety, Yoga
may be an very useful way of regulating physical arousal “in which using breath and
body movement can help regain a physical sense of being able to defend and protect
one’s self” (van der Kolk, 2006, p. 289).
 Breathing practices are highly respected by Yoga practitioners and often considered
advanced Yoga practices and so should be kept very simple while learning them. More
advanced practices should be taught under the guidance of a qualified teacher. Trauma
survivors may be triggered by breathing more deeply and letting down the body’s
defenses, and others may feel triggered by the more rapid breathing practices. Working
with breath “is best approached cautiously and with a great deal of patience to help
people gently and slowly expand their capacity for breath” (Emerson & Hopper, 2011, p.
108-109).
 Anxiety balancing practices for those with an Anxious Body/Anxious Mind and those
with Anxious Body/Depressed Mind may feature forward-bending (face-down)
restorative poses to ground, calm and soothe the body. If the mind is anxious a 1:2 breath
(exhalation twice as long as inhalation) should be used to calm the mind and the nervous
system If the mind already feels balanced slow, 1:1 breath (inhalation and exhalation
equally long) will help keep the mind calm, yet alert (Forbes, 2011).
 Anxious clients may be encouraged to do occasional body scans to ensure that their
bodies are very relaxed and to breathe slowly without straining as they practice
pranayama as well as asana. Forcefully doing any Yoga practices may cause the body to
tense up rather than relax in an anxious person, whether doing simple or challenging
postures (Emerson & Hopper, 2011).
 Clients whose anxiety manifests mainly in mental symptoms like constant worrying may
find Hatha Yoga preferable to mindfulness meditation, whereas those whose symptoms
of anxiety tend to manifest mainly in the body may prefer an orientation to meditation
that focuses less on the body (Kabat-Zinn, Chapman-Waldrop & Salmon, 1997).
However, once the client has “learned to induce a relaxed calm state through Yoga
breathing, meditation becomes easier and can be beneficial” (Gerbarg & Brown, 2007, p.
78).
Depression – Effective Yoga Interventions
Pranayama (Breathing Practices)

The same diaphragmatic breathing mentioned above for anxiety is recommended for people
with a more depressed nervous system with either a ratio of 1:1 (in which the inhale and exhale
are equal in length) or 2:1 (in which the inhalation is twice as long as the exhalation, the opposite
of that for anxiety). One popular Yoga therapy approach to depression combines concepts found
in both Yoga and Ayurveda and categorizes depression as being either tamasic in nature or
rajasic (McCall, 2007, p. 267). A major goal of Yoga and Ayurveda is to attain a state of sattva,
which is a state of clarity, ease and emotional balance. Rajasic depression, or agitated
depression, may present symptoms of anxiety, restlessness, and impulsiveness, and the typical
breath pattern may be quick and erratic, with clients having difficulty exhaling and may benefit
from 1:2 breathing pattern. Tamasic depression is marked by lethargy, feelings of hopelessness,
and melancholia, with crying jags being commonplace and the client often having difficulty
getting out of bed in the morning, and these clients may benefit from a 1:1 breathing pattern, just
focusing on slowly lengthening both the inhalations and exhalations.
Ujjayi breathing is recommended for depression of all sorts, either as a separate pranayama
practice or as the breath used while moving into, holding, or releasing asanas (physical postures)
(Weintraub, 2004, pp. 138-139).

Nadi Shodhana (Alternate Nostril Breath) is called a purifying breath because it helps to
balance both sides of the body and mind, clearing the 72,000 tube-like channels travelling
through the body called nadis, as well as the three main conductors the run the length of the
spine, the ida, conducting energy through the left nostril, and the pingala, conducting energy
through the right nostril and the sushumna, which is the central channel. The inhalations and
exhalations should be kept at even lengths as one is learning the practice. “Nadi Shodhana may
be practiced as a way to center yourself before Yoga asanas, before meditation, or any time you
would like to enhance your feeling of equanimity” (Weintraub, 2004, p. 140).
Viloma (Three-Part Breath) may be useful for depression (McCall, 2007). This breath may
be done lying down or sitting upright, and involves inhaling to the count of three, holding then
continuing two more times until one has a full inhalation.
Kumbhaka (Breath Retention) may be introduced with any of the above pranayama
practices after clients are comfortable and steady in their practice (Weintraub, 2004, p. 140).
Telles et al. (1995) studied the effect of breath retention: their research indicated that short breath
retention (four to six counts) energizes the body, while longer holding of the breath (more than
six to maximum capacity) seems to calm the body (Telles et al. 1995).
Brahmari (Bee Breath) slows down the exhalation and has a calming effect on the nervous
system. It is practiced sitting upright. Constricting the glottis at the back of the throat, inhale
through the nostrils, then exhale slowly through the nostrils making a deep buzzing sound in the
throat like a bee buzzing. When the client feels more comfortable with the breath, they may
activate the three locks or bandhas in the body and practice holding the breath out between
rounds. The three bandhas, which conform to anatomical structure in the body, help the
practitioner hold and direct prana, the lifeforce that is in each breath, in the body during
pranayama or the asana practice. Mulabandha, corresponding to the pelvic floor, involves lifting
the perineum and holding, uddiyana bandha corresponds to the diaphragm and is activated after
mulabhanda by bringing the belly back towards the spine, jalandhara bandha corresponds to the
top of the chest and involves sliding the jaw forward and lowering the chin toward the sternum.
Kumbhaka comes from the Sanskrit word kumbha, which means ‘pot’ so holding the breath in
(kumbhaka) while activating all three of the seals (bandhas) helps the prana (lifeforce in the
breath) build to later be dispersed bringing vitality throughout the body. Doing Yoga breathing
practices as well as in activating the bandhas, has been shown to stimulate the vagus nerve and
increase heart rate variability (HRV), which are known to help heal depression, anxiety, PTSD
and aggression (Brown & Gerbarg, 2005a; 2005b; Brown & Gerbarg, 2009; Sarkar, personal
communication, September 1, 2011).
Kapalabhati (Skull Shining) is a recommended practice for waking up dormant prana (the
lifeforce contained in the breath) in depression. It may be done sitting or in some of the standing
Yoga poses with knees bent and arms raised over head (utkatasana). The practice involves
inhaling normally and passively, and exhaling forcefully through both nostrils while snapping
the belly back to the spine. One may begin with 20 repetitions, and after becoming proficient,
increase the speed and number of pumped repetitions of the exhalations. This ‘fan the fire’
breath is technically called a kriya (complete purifying action) rather than a pranayama
(breathing practice). It should not be practiced if one is pregnant, menstruating, or has
unmedicated high blood pressure. If a depressed client has had a bipolar disorder diagnosis, they
are cautioned to consult with their psychiatrists before practicing kapalabhati or bhastrika
breathing, a more vigorous version of this kriya as both of these practices may trigger a manic
episode (Weintraub, 2004, p. 142).

Asanas
Clients who experience rajasic depression, may find Restorative Yoga practices helpful
as they calm the sympathetic nervous system and relax the hypervigilant state. Sometimes the
mind may be too anxious to benefit from simple restorative poses at the beginning so some
clients may need to burn off enough excess energy through a vigorous Yoga practice to settle the
mind enough so it can respond to inversions and relaxation poses later which tend to be calming.
However, starting with a vigorous practice may not be possible for depressed people in a state of
nervous exhaustion and they “may benefit more from slow, supportive practices that rest their
minds without taxing their bodies too much” (McCall, 2007, p. 278).
Poses that synchronize breath and movement, build tapas (heat) in the body like the
simple sequence of standing in tadasana (mountain pose), basically standing upright, and
moving to urdhva hastasana (arms overhead) and repeating a few times can be very helpful for
depression (McCall, 2007, p. 278; Emerson & Hopper, 2011).
Poses, either restorative or active, that lift and open the heart and open the armpits, such
as backbends can bring a depressed client into a joyful state (Iyengar, 1997). Inversions, like
headstands or shoulderstands or dog poses with the head on support or even the gentle and
supported legs up the wall pose, have been shown to help relieve depression by increasing tone
and muscle extension in the postural muscles responsible for erect carriage against the pull of
gravity which may have a positive effect on posture and, hence, mood. Increased extensor tone
in the spine has a positive effect on the limbic cortex and frontal cortical functioning in the brain
(Brownstone, as cited in Weintraub, 2004, p. 67). Another physiological benefit from
inversions, which lead to a general relaxation response, includes the gravitational stimulation of
the carotid sinus, which causes the carotid sinus “to send messages to the medulla of the brain
and cardiac centers that ultimately lower heart rate, respiration, and resting blood pressure”
(Brownstone, as cited in Weintraub, 2004, p. 67). Increased blood flow to the brain increases
bioavailability of oxygen and glucose—the two most important metabolic substrates for the
brain. Cells bathed in a solution that is rich in factors required for the creation of
neurotransmitters (like norepinephrine, dopamine, and serotonin) are better able to produce these
chemicals. Altering the flow of cerebral spinal fluid (CSF) and compression of the caudal
(bottom) portion of the brain may also improve overall brain functions in Yoga inversions
(Koffler, as cited in Weintraub, 2004, p. 67).
Standing poses, which focus on the connection to earth or the use of gravity as a sensory
stimulus, may help trauma survivors develop grounding strategies to combat dissociation and
may help people struggling with both anxiety and depression to develop a bodily sense of
confidence along with a feeling that they have a right to be in the world.
Meditation
Mindfulness meditation may be very helpful for depression, which is often marked by
rumination. Critical thinking practices may, at times, be unhelpful in dealing with emotions
because often “we ruminate when we feel low because we believe that it will reveal a way to
solve out problems” (Williams, Teasdale, Segal & Kabat-Zinn, 2007, pp. 43-44). Research
shows that our ability to solve problems deteriorates markedly during rumination (Williams et
al., 2007, p. 44). Learning mindfulness meditation helps to cultivate awareness, which is an
alternative to critical thinking gone amok (rumination) and helps us to expand the breadth of our
being to learn how we are capable also of having direct experiences through our senses and
intuition. By cultivating heightened awareness, meditation may actually help sidestep the
cascade of mental events that draw people down into depression. Through the meditative
experience, one may gain awareness of how to live in the present moment rather than mentally
dwell in the past (as in depressed states of mind) or worry about the future (as in anxious states
of mind). The mindfulness approach to meditation teaches us that thoughts are just mental
events that come and go in the mind like clouds in the sky. Cultivating this awareness may help
the practitioner at an early stage of feeling low to respond to moods in a way that keeps them
from being pulled down further (Williams et al., 2007, p. 47).
Additional Suggestions that Support Best Practices for Using Yoga for Depression
Depression-Lifting Practices designed for those with Depressed Body/Depressed Mind
and those with Depressed Body/Anxious Mind feature back-bending (face up) restorative poses
to open, energize, and uplift the body. If the mind is sluggish or unbalanced 1:1 breathing can be
used to keep the mind calm, but alert. If the mind is anxious 1:2 breathing is recommended to
calm it and the nervous system (Forbes, 2011).
A therapist must be able to offer variations or options for the Yoga postures, including
the option of coming out of any posture and returning to mindful breathing. A therapist must be
diligent to ask for feedback from the client because a Yoga posture or breathing practice that is
calming for one person may be very upsetting for someone else. Subjective experiences are
more important than anything else when it comes to a trauma-sensitive Yoga practice (Emerson,
Sharma, Chaudry, & Turner, 2009; Emerson & Hopper, 2011).
Theories of Counselling Employed with Yoga

No specific theoretical models of counselling that support the use Yoga or Yoga
therapy interventions were found in this research. Newer CBT models including
mindfulness that are “focused less on challenging an individual’s irrational or negative
thinking and more on changing the individual’s relationship to thoughts and feelings
through acceptance and mindfulness” (Singh, Lancioni, Wahler, Winton, & Singh, 2008,
p. 660) may be considered as theoretical leads to determining a future
psychotherapy/Yoga theory. Mindfulness is a core feature of Yoga, but it has been made
much more explicit in Buddhist traditions. Mindfulness practices have been developed
for use in therapy such as Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn,
1990), which incorporates Hatha Yoga practices with meditation, along with one of its
derivatives Mindfulness-based Cognitive Therapy (MBCT; Segal, Williams &Teasdale,
2002), and others that incorporate mindfulness in their packages of treatments such as
Dialectical Behavior Therapy (DBT; Linehan, 1993).
“Support for body work is found in different theoretical models: psychodynamic
theories, including Reichian and neo-Reichian theories, humanistic and existential
psychology, transpersonal psychology, and behavior therapy” (Leijssen, 2006, p. 127).
Smith (1998) pointed out that in practice, the lines between the theoretical camps are
often more conceptual than real. The experienced usefulness of different models
“underpins our preference to integrate different therapeutic approaches on an experiential
rather than a theoretical level” (Leijssen, 2006, p. 127). Most of the theories of
psychology listed could potentially support Yoga interventions being combined with
verbal interventions in the therapy room.
The verbal interventions with which a body-oriented psychotherapist therapist
invites the experiencing body to take the lead might normally be rather short (Leijjsen,
2006). Having said that, some clients might need more guidance and practice to learn
how to let a bodily felt sense come in relation to their life experience.
Guiding an exercise in which clients systematically examine what their body
brings on take longer interventions. Breathing exercises, relaxation exercises, and

body-attunement exercises (learning to listen to the body in its natural state) can
be useful in helping clients begin to sense the body from inside and to explore
inner sensations. (Eigen, as cited in Leijjan, 2006, p. 130)
Yoga as Supplement to Psychotherapy

For clients struggling with anxiety or depression, community based Yoga classes
may be used to supplement psychotherapy (Forbes et al., 2008; Forfylow, 2011). The
psychotherapist must be well informed about Yoga practices, the types of Yoga, and
competent Yoga teachers within the community (Forfylow, 2011). Clients who are not
interested in community based Yoga classes may be referred to a Yoga therapist “as an
adjunct to psychotherapy or medication management” (Forbes et al., 2008, p. 90). A
Yoga therapist is certified in the practice of Yoga and is responsible for designing an
individual Yoga practice to treat a person’s mental and physical health (Khalsa et al.,
2009; Forflyow (2011).
Psychodynamic counsellors and writers Valente and Marotta (2011) presented a
list of questions about the Yoga experience of the client that therapists use to asses
whether the client is taking Yoga classes at an appropriate level. The questions help
increase self-awareness and encourage the client to keep them in mind during class to
reflect on their “impressions, feelings, and sensations immediately after class to bring to
the next psychotherapy session” (Valente & Marotta, 2011, p. 258). The physiological
and mental experiences of holding postures and moving through the sequences in a Yoga
class such as “letting go of gripped muscles by breathing into and accepting the tension”
could be extrapolated and applied to managing emotional distress in subsequent therapy
sessions (Valente & Marotta, 2011, p. 253). Possible questions for the first class are:
 Did the class match your expectations? If not, how was it different?
 Which postures were the most difficult and which came more naturally?
 What did you learn about your body from the process?
 What did you notice about your breath as you attempted the different postures?
 What did you notice about the tension in your body and mind before class
compared with after class? (Valente & Marotta, 2011, pp. 258-259)
As clients gain more experience with Yoga, perhaps after four or five classes, the
psychotherapist may deepen self-exploration with any of these possible questions to ask
the client:
 Did you notice any pattern of tightness as you attempted the different postures?
 What did you notice about your mind as you engaged in the class?
 What specific thoughts, emotions, or memories came up during the practice?
 How did your mind react to the discomfort experienced during the class?
(Valente & Marotta, 2011, p. 259)
Valente and Marotta (2011) posited that reflecting on these types of questions
immediately after class helps to “enhance the self-awareness and self-exploration
characteristics of the Yoga class” (p. 259). Psychotherapists, they suggested, might direct
the discussion around these questions to help connect experiences in class to everyday
lived experiences. For example, Yoga students may breathe rapidly or hold their breath
during difficult postures, and a psychotherapist may help the client connect these
experiences to the patterns of their breathing during difficult interactions or stressful
situations in their daily lives. Just as clients learn in Yoga practice to keep the breath
deep and steady during challenging postures, “they can extrapolate the experience to use
the breath to help them stay calm outside of the Yoga room” (Valente & Marotta, 2011,
p. 259).
Yoga Integrated with Psychotherapy

The field of Yoga therapy includes Yoga teachers wanting to learn how to address
emotions that come up in group or private Yoga classes, as well psychiatrists,
psychologists, and social workers who incorporate Yoga poses and meditative breathing
into their sessions. In order to do this combination therapy, Forbes (as cited in Kornfeld,
2009) warned that psychotherapists should only introduce Yoga interventions in session
if they have extensive Yoga training including “in-depth study of Yoga and a strong
background in anatomy and alignment to limit client injuries” (par.12).
Emerson and Hopper (2011) were less strict in their recommendations for
clinicians wishing to integrate Yoga-based strategies into the therapy office. They
recommended that therapists should have a personal experience of Yoga practice and
should read and practice specific exercises themselves and try them out on colleagues,
family members, and friends before introducing them in therapy. They also suggested
that therapists develop a ‘Yoga voice’ combining a slow methodical pace and vocal
quality that are calming and that therapists should participate with clients to share the
experience which may strengthen the bond between the therapist and client. After a few
Yoga interventions, Emerson and Hopper (2011) stipulated that the therapist debrief with
the client because “Yoga-based practices may bring up material that should be addressed
clinically” (Emerson & Hopper, 2011, pp. 92- 93). After the session, the therapist may
offer the client a handout with Yoga practices that they have practiced together which the
client may practice on their own at home (Emerson & Hopper, 2011).
Forflylow (2011) posited that “integrating Yoga with psychotherapy may allow
mental health professionals to work more collaboratively clients” (p. 143). Forfylow
(2011) warned that “several implications arise when combining Yoga and psychotherapy;
mental health professionals can offer a larger continuum of care, but their legal and
ethical responsibilities will also expand” (p. 144). Specifically, mental health
professionals have an increased ethical responsibility to get informed consent before
integrating any treatments with clients (British Columbia Association of Clinical
Counsellors [BCACC], 2010; Canadian Association of Social Workers [CASC], 2005;
Canadian Counselling and Psychotherapy Association [CCPA], 2007; Canadian
Psychological Association [CPA], 2000). They also have an ethical responsibility to be
accurate and honest about their areas of competence, knowledge, and the supervision they
receive before declaring competency in various treatments” (BCACC, 2010; CASW,
2005; CCPA, 2007; CPA, 2000). Forfylow (2011) stressed that
it is extremely important that mental health professionals do not recommend or
force yoga on clients who are uniformed about the risks and benefits of a yoga
practice or who are ambivalent or uncomfortable on; integrating yoga works best
for clients interested in participating in and committing to a regular yoga practice.
(p. 145)
She stressed that a mental health professional not adequately trained as a Yoga therapist
must be honest with a client, not implement Yoga practices in therapy, and refer the
client to a qualified Yoga therapist (Forfylow, 2011). She cautioned about the additional
considerations about respecting “client confidentiality when collaborating with yoga
therapists” (Forfylow, 2011, p. 145) because some clients may share the same
information with both a Yoga therapist and mental health professional, “while others may
choose to share only certain information with either professional” (p. 146).
When a therapist is dually trained in both disciplines, they must “carefully
establish appropriate boundaries as both a mental health professional and a Yoga
therapist” (Forfylow, 2011, p. 146). Most talk therapies do not involve touching the
client, while the Yoga therapist may touch the client “to adjust the posture or support a
position” (Forfylow, 2011, p. 147). Therefore, it is imperative that a mental health
professional who incorporates Yoga therapy in session “be cognizant of the differing
boundaries of the two professional roles [which] should help navigate the dual
relationship with the client” (Forfylow, 2011, p. 146).
Determinants of the Effectiveness of Yoga Interventions

In Yoga, an intuitive and individualized approach is valued and Yoga teachers aim to retain
the ability to modify methods to suit the present context, rather than follow a prescriptive
sequence based on a prior assessment and diagnosis. Many Yoga practitioners and Yoga
therapists would argue that Yoga is thousands of years older than, and more subtle than, the
scientific method, and balk at the idea of having their Yoga practices and even therapeutic
interventions extracted from the traditional context of Yoga and examined to determine “rigorous
outcome measures to capture benefits [of Yoga] in quantitative form” (Sherman, 2006, p. 10).
Laurence strongly cautioned that
Yoga therapists are no less subject than any other profession to confusing
correlation with causality, to hypothesizing untestable theories to account for
change, to focusing on short-term versus long- term gains, and to convincing
[themselves] that [they] are more effective than is true or as is perceived by our
clients. [They] need some sense of scale and a relative measure of success to
ground their focus on spontaneity, and to prevent [them] from being stuck doing
what [they] have always done “because we have always done it this way.
(Laurence, 2010, p. 48).
Many within the field of Yoga therapy, however, support calls for further research and aim to
have Yoga therapy established within the medical model in an attempt to gain professional
recognition, referrals from medical professionals, and reimbursement from managed care.
Laurence (2010) described a kind of hybrid approach that is occurring in the
current proliferation of claims that certain Yogic practices and postures are effective for
treating allopathically-defined disorders, such as depression and anxiety. Claims are
often made that the method is responsible for most or all of the change observed because
research may show that a particular method has worked. Laurence argued that we cannot
truly say that it is “because the use of this or that particular sequence of asanas or other
Yoga therapy methods leads to positive change [because there may also be] a very
significant contribution from the factors common to psychotherapy, such as hope and the
therapeutic relationship” (Laurence, 2010, p. 46). Yoga therapy recognizes the
synergistic and holistic effect of these factors. Laurence argued that attempting to reduce
treatment to a simple relationship between a diagnosable disorder and a prescribed Yogic
treatment violates the fundamental orientation of Yoga itself.
I strongly agree with Laurence who recommended that Yoga therapists, and I would say
this should include therapists who incorporate Yoga or Yoga therapy in their sessions, “focus
immediately on obtaining structured and measurable feedback within their practice and to
demonstrate that they can effect real, positive change by documenting Yoga therapy outcomes”
(Laurence, 2010, p. 48). Larger institutions can help validate simple measures against medical or
other data to ensure acceptable levels of reliability and validity (Laurence, 2010, p. 48). All
Yoga therapists must begin to back up their claims for effectiveness, not by referring to the fact
that they use a method that has been branded as “evidence-based,” “but rather by stating that,
among all available treatments, this practitioner can provide evidence from this practice collected
from these clients that demonstrates fundamental satisfaction through measurable outcomes”
(Laurence, 2010, p. 49). Laurence (2010) designed three excellent outcome rating scales which
a Yoga therapist or psychotherapist incorporating Yoga may offer the client at the end of each
session to help individualize and modify client treatment and to measure success (pp. 49-51).
These results of the outcome measures attained after therapy sessions may be added to a
comprehensive body of outcome-based research to be offered along with evidence-based
research for the future of Yoga therapy or Yoga in psychotherapy.
Many Yoga practices that were used over thousands of years in India have gained exposure
and popularity in the west over the past several years. The current widespread acceptance of
Yoga offers a rich source of body-oriented interventions for psychotherapists and clients who
wish to improve verbal psychotherapy with such effects on the client’s process as “greater
awareness, engagement in the present, deepening of experiences, opening the body memory,
cathartic release, resolving blocks, and exploring new possibilities” (Leijssen, 2006).
When practitioners of ancient Yoga meet modern medical and psychological researchers
with requirements of evidence-based research that is valid and reliable, the traditional tenets of
faithfully accepting the wisdom of the expert guru (teacher) or trusting the intuition of that
Yoga practitioner may be strongly challenged. “However, for those who enjoy the challenge of
blending two worlds together, the Yoga community can help this process by being willing to
dialogue with researchers” (Sherman, 2009, p. 9). Psychotherapists who utilize Yoga in their
sessions should obtain structured and measurable feedback within their practice and document
Yoga therapy outcomes demonstrating real and positive change for clients while respecting the
discipline of Yoga in the process.

CHAPTER 5 DISCUSSION
tada drastuh sva-rupe'vasthanam
Then the Seer (the Self) rests in its own form (True Nature). (Patanjali, Yoga Sutras, 1.4)
The purpose of this chapter is to highlight the research from the extensive review of the
literature regarding the efficacy of Yoga interventions in the amelioration of the symptoms of
anxiety and depression. Discussed first will be the ways in which Yoga and Yoga therapy is
being used in conjunction with psychotherapy. Some facts will then be shared regarding the
current trend of psychotherapy clients to use Yoga with or without their therapist’s knowledge as
self-help for anxiety and depression. The need for ongoing research into how Yoga therapies
work will then be discussed. Finally, the implications of the results of the analysis and synthesis
of the research toward recommendations of Best Practice of incorporating Yoga with
psychotherapy will be presented.
A well-documented general conclusion is that Yoga is well-suited to psychology and its
clinical practice, and the role of Yoga therapist may be compatible with the role of psychologist
or psychotherapist who engages and addresses the individual emotionally, mentally, and
relationally (Crimm, E., personal communication, September 2, 2011). Integrating Yoga with
psychotherapy “may allow mental health professionals to work more collaboratively with clients
(Forflylow, 2011, p. 143). Because most mental health professionals do not have training in
Yoga (Forfylow, 2011; Bassman & Uellendahl, 2003) “integrating Yoga with psychotherapy
encourages mental health professionals to refer clients to suitable Yoga classes, collaborate with
a Yoga therapist to co-manage clients, and/or become Yoga therapists themselves to deliver both
psychotherapy and Yoga in one session” (Forfylow, 2011, p. 140). Clients may alternate
sessions with their mental health practitioner and with the Yoga therapist who “may [then] work
together to co-manage clients and deliver a suitable mind-body treatment” (Forfylow, 2011, p.
140).
The ancient system of Yoga offers a non-verbal, experiential adjunct to talk therapy that
provides an opportunity for an integrated connection with the physical body and the inner
experience of the client (Boudette, 2006). Valente and Marotta (2011) asserted that a client’s
Yoga practice may become a valuable tool to facilitate self-exploration in psychotherapy. They
posited that, in a Yoga class, self-awareness, the core objective of Yoga, first occurs as students
are asked to evaluate the body’s positions and sensations in their different body parts
simultaneously. Progressively moving from the feeling state to the mental and emotional states,
the practitioner trains in observing his or her thinking from a position of detachment, noticing the
effects of postures on the mental states. “This internal focus and self-evaluation can cultivate
self-awareness on visual, auditory, kinesthetic, and cognitive levels” which can be built upon in
the therapy room and in all aspects of the individual’s life (Valente & Marotta, 2011, p. 258). If
one of the effects generally sought in psychotherapy is an increase in self-awareness skills, and
facilitation of the use of these skills, then Yoga is demonstrably effective in this realm.
Calls for Research

A statement by the United States federal government’s National Institute of Health (NIH)
asserted that “thousands of research studies have shown that people can learn to control
physiological parameters with yoga” (as cited in Becker, 2000, p. 109). The same report
contained concerns about a lack of studies demonstrating the efficacy of Yoga to support this
assertion. Many studies involving Yoga, as both a lifestyle and clinical practice, have been
conducted over the years. Unlike meditation research, much of the research on Yoga originated
in Indian research institutes, beginning in the early 20th century. Few of these early studies
employed research methodologies now taken for granted, but they did serve the important
function of signalling a new view of Yoga as a form of health and medical care, rather than an
exclusively spiritual practice (Khalsa, 2004; 2007; Salmon et al., 2009). Western researchers
have conducted fewer studies, but more randomized-controlled studies than Indian researchers
(Khalsa, 2004, pp. 451-452).
For every positive study lauding the apparent effectiveness of Yoga interventions for
mental wellness, a corresponding call for the need for further research support almost always
follows. Forfylow (2011) noted that the way researchers measure Yoga’s effectiveness is
complicated because of its non-specific systemic effects, as well as the diversity of yoga
practices. This sets up a fundamental research problem of defining dependent variables in
operational terms, while at the same time maintaining treatment integrity. Spencer (2003)
pointed to the lack of congruence between western quantitative research methods and the eastern
philosophy of complementary and alternative medicine; “the individualized, comprehensive, and
multidimensional nature of these interventions is difficult to measure with randomized-control
trials RCT’s” (in Forfylow, 2011, p. 142) likely due to the sacredness attributed to many
practices and the wholistic unity of all of the practices in the Yogic paradigm. Forfylow posited
that “both qualitative and quantitative methods may be useful in validating the effectiveness of
yoga” (Forfylow, 2011, p. 142). Lake (2007) distinguished quantitative evidence as that which
“shows effects that are statistically significant according to predefined criteria [but] do not
address why an intervention is effective, meaningful, or beneficial” (p. 71) whereas qualitative
data asses “the impact of a treatment on quality of life” (Lake, as cited in Forfylow, 2011, p.
142). The author identified a lack of rigorous research designs in much Indian research and like
Khalsa (2004) agrees that Indian researchers “should implement research designs that are more
rigorous to continue to validate the effectiveness of Yoga as a clinical treatment intervention” (in
Forfylow, 2011, p. 142). A proposal for the development of a standardized yoga practice manual
was recommended by Uebelacker, Epstein-Lubow, Guadiano, Tremont, Battle & Miller, 2010
and Uebelacker, Tremont, Gillette, Kalibhatseva, and Miller, (as cited in Fortylow, 2011) as “a
helpful way for effectively studying Yoga in a respectful yet rigorous way” (p. 142).
The Future of Combining Yoga with Psychotherapy

The search strategy used in this study revealed no literature on how to specifically
combine Yoga/Yoga therapy with talk therapy except in popular press. However, outside of the
scholarly data bases, a number of promising books with anecdotal reports from medical doctors,
psychologists, and Yoga experts offer suggestions for self-help as well as suggestions for how
Yoga therapists and psychotherapists may use Yoga practices as an adjunct to psychotherapy
offering case studies (Bennett, 2002; Emerson & Hopper, 2011: Forbes, 2011; McCall, 2007;
McGonigal, 2010; Simpkins & Simpkins, 2011;Weintraub, 2004).
There are two major strands in the incorporation of Yoga or Yoga therapy with
talk therapy, one of which has roots in psychology (depending on the leanings of the
therapist) and the other in wisdom traditions, chiefly Yoga. One day a new theory of
Yoga in psychotherapy may emerge as the “accumulation of new data that cannot be
accounted for by an established theory leads to the development of a new theory or the
broadening of an existing one” (Singh, Lancioni, Wahler, Winton, & Singh, 2008, p.
660). For example, Langer (1989) delineated the psychological theory of mindfulness
“and its application to human behavior” (Singh et al., 2008, p. 660) and now continuing
research on Langer’s theory is helping to elucidate how manipulating thinking with
mindfulness and awareness practices, as in the new mindful CBT streams of Mindfulness
Based Stress Reduction (MBSR; Kabat-Zinn, 1990) and Mindfulness-Based Cognitive
Therapy (MBCT; Segal et al., 2002) is helping to improve the quality of life in clients
who participate in these therapies (Singh et al. 2008).
Yogic practice, with all of its many facets, offers a full range of mindful skills,
which, when practiced regularly offer the practitioner a training process in acceptance,
physical and mental empowerment, to integrate into, help improve and maintain a high
quality of life. Just as professional psychotherapists have ethical codes, Yoga philosophy
comes with a set of moral and ethical codes called yamas (things not to do) and niyamas
(things to do) for sincere adherence throughout the daily life of the practitioner as well as
for all aspects of one’s Yoga practice, the ultimate goal of which is attainment of spiritual
enlightenment, or samadhi.
Appropriate Standards and Practices for Two Worlds Colliding

As more psychotherapists begin to incorporate Yoga into treatment regimes in
order to help their clients achieve short-term symptom relief, as well as long-term
solutions for mental wellness, guidelines for using these practices ethically with clients
are essential. Sherman (2006) declared that “it behoves the Yoga community to enter the
dialogue [with the biomedical research community] regarding what is Yoga and what are
its possible anticipated benefits” (p. 9) in order to evaluate the efficacy of Yoga and
understand the mechanisms of action in biomedical and/or psychological terms.
Psychotherapists who wish to incorporate Yoga as an adjunct to verbal therapists either in
session or referring to Yoga classes or a Yoga therapist, as well as Yoga therapists, must
immediately begin to facilitate this positive dialogue by using outcome-based standards
and practices (Laurence, 2010). The primary analysis is necessarily negative: What are
the risks of harm? Once they have been established, and contained, then research can
proceed.
Outcome-based methods are efficient, effective, and conform to both modern
medical practices and to third-party reimbursement requirements. At the same
time, outcome-based approaches maintain the spirit and identity of the Yogic
approach to change and are thus superior to strictly evidence-based therapies.
Outcome-based therapy is a middle way between a reductionist, allopathic
medical model approach and a free-wheeling, forever spontaneous philosophy
that eschews research and evidence. (Laurence, 2010, p. 42)
As research continues to develop perhaps mindfulness psychology theories will be
broadened, enabling researchers to use deductive reasoning based on current data to
develop testable research hypotheses. Or perhaps, with continued cooperative research in
the area of Yoga and its clinical applications in psychotherapy and medicine, a new or
expanded theory of Yoga in psychotherapy may emerge that may be acceptable to many
in Yoga community who wish to use Yoga interventions therapeutically, as well as to
practitioners and researchers in the western scientific community who wish to
respectfully borrow from the wisdom tradition of Yoga. The keys to this development
appear to be (a) a unified theory of somatic and psychological therapy, (b) the ability of
the research community to evaluate nonspecific systemic treatment effects, and (c) that
ability of the yoga and psychotherapy communities to standardize Yoga practice at a
level sufficient to ensure treatment integrity in comparative studies.
Salmon et al. (2009) asserted that for clinicians willing to invest the time and energy to
become immersed in Yoga practice and philosophy, the potential payoffs are substantial because
Yoga incorporates elements of traditional psychological relaxation techniques that elicit the
Relaxation Response (Benson, 1975). Yoga provides an alternative means of achieving this
state, adding flexibility to one’s clinical repertoire of relaxation practices by with its slow,
repetitive movement patterns that help entrain physiological factors (breathing synchrony, heart
rate, etc.) easily disrupted by stress, creating a satisfying sense of physical integration (Salmon et
al., 2009).
Best Practices in Integrating Yoga with Psychotherapy

Psychotherapy tends to marry our direct experiences with meaning-making, or
evaluation, and trauma research has shown that this can often be counterproductive to the
process of reducing symptoms of depression and anxiety (van der Kolk, 2006). Mental
processing, specifically our meaning making mechanisms, the foundation of verbal therapies,
often has negative bio-chemical consequences to the story teller: Research has shown that
recounting an emotionally charged negative story causes a cascade of biochemical events in the
emotional regions of the brain thus reinforcing negative samskaras (deeply ingrained memories)
(van der Kolk, 2006; Forbes, 2011). These biochemical events consequently reinforce anxiety
and depression—the very pathways clients are hoping to change (B. Forbes, personal
communication, September 4, 2011). Forbes is a clinical psychologist, and Yoga teacher whose
background includes training in biopsychology, behavioural medicine, and stress management.
As a result of these neurobiological phenomena psychiatrist and researcher van der Kolk
recently went as far as to say that “it is high time that therapy talked less and moved more” (van
der Kolk, as cited in Forbes, 2011).
Yoga offers a powerful set of tools to positively influence the biochemistry and
neuroplasticity of a person suffering from anxiety or depression by balancing the nervous

system, addressing the body’s patterns through physical postures which influence mood and visa
versa, interrupting negative meaning-making, and offering changes to create new stories through
bodily experiences in the learning lab of an integrated therapeutic process. Yoga techniques such
as gentle asana practice (physical postures), pranayama (breathing practices), and restorative
Yoga (supported physical processes) that activate the parasympathetic nervous system appear to
be relatively safe to introduce in psychotherapy (Emerson & Hopper, 2011; Forbes, 2011).
The integrated mind-body approaches of Yoga offer clients a chance to subtly progress
from mental insight to embodied insight, which research has shown leads to lasting change
(Ogden, 2006). In order to create a sustainable psychotherapeutic practice the professions of
psychology and counselling cannot ignore the powerful research that points to the inherent value
of integrated somatic practices of Yoga which may offer a direct path to optimum functioning for
our clients. The focus in therapy in the past number of years has been moving from therapist-
directed processes to more client-directed processes and the incorporation of Yoga and into
psychotherapy is fully in keeping with this movement—rather than therapists observing clients,
clients in Yoga therapies are observing themselves externally and internally and giving therapists
feedback about their own direct experiences. Forbes (personal communication, September 4,
2011) predicted that there may soon come a time when doing only verbal therapies in
psychotherapy may no longer be considered Best Practices in the profession.
If we understand clients’ therapeutic needs to be holistic, therapists are ethically
responsible to aim toward providing comprehensive integrated treatments for clients to heal
symptoms of emotional suffering inherent in anxiety and depression. Offering Yoga as an
adjunct to psychotherapy is a chance to work collaboratively with clients but it may also offer
clients something more than this. It may offer them a chance to connect to their bodies’ wisdom,
perhaps for the first time ever, and to somatically experience the interconnectedness of their
thoughts and feelings. It may offer bodily experiences and opportunities to reflect and actually
learn how to redirect the functioning of their nervous systems such as activating the
parasympathetic nervous system during times of emotional distress and gaining a sense of
mastery of their emotions. It may offer them a wholistic set of interventions to help them
mobilize their inner resources to begin to rewire old emotional patterns that confined them and
help them move toward more lasting mental, physical and spiritual health and well-being.
Combining Yoga with psychotherapy may mean truly offering our clients a curriculum for
personal transformation.
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YOGA IN PSYCHOTHERAPY

Running Head: YOGA IN PSYCHOTHERAPY

Yoga in Psychotherapy: Best Practices for Treating Anxiety and Depression

A thesis submitted in partial fulfillment of the requirements for the degree of

Master of Arts in Counselling Psychology

City University of Seattle

Glen Grigg, Ph.D., Advisor, Counselling Psychology Faculty

Monica Franz, M.A., Faculty Reader, Counselling Psychology Faculty

Division of Arts and Sciences

relates to the effectiveness and value of Yoga as an adjunct to psychotherapy in session-based

profession of psychotherapy in order to be disseminated and tested more formally.

indebted to you for helping me mature as a student and researcher.

friends and, perhaps collaborate again in the future.

kindly offering her refinements.

clients who have been my greatest teachers on this path.

tasks—you know who you are!

I extend my heartfelt gratitude to my truly gifted physiotherapist Bev Kosuljandic who

research with incredible professionalism and friendliness.

Pranayama (breathing practices):...............................................................................59

psychotherapy are a much-needed contribution to the profession.

about the effectiveness of Yoga interventions in therapy. In a search of PsycArticles, ERIC,

integration of the dual interventions of Yoga with psychotherapy.

separate mind and body ailments. Laurence (2010) wrote that

analytic, reductionist, and evidence-based focus of Western medicine. (p. 45).

explanation and theory in favor of outcome” (Laurence, 2010, p. 46).

combined with Ayurveda is increasingly utilized as a complement to western-style integrative

number of psychiatrists, psychologists, counsellors, and social workers have begun to

their deepest emotions.

Psychotherapy, for purposes of this study, is defined as “a process whereby

practitioners utilize “psychotherapeutic approaches [which] are conceived as existing on a

professionals who subscribe to theoretical orientations such as behavioural therapies or

transpersonal, humanistic, or existential psychologies (Leijssen, 2006).

Context for this Study

according to various ancient Indian physiological, psychological, and spiritual systems.

pranayama, Yogic breath practices, and/or dhyana, Yogic meditation practices.

therapy training today.

suffering physical and mental afflictions.

more modern body/mind physician when she spoke of how

healing. (Kornfeld, 2009, par.6)

empowering, preventive, and healing aspects of Yoga therapy.

1932), systematic desensitization (Benson, 1975), and biofeedback-assisted relaxation (Shearn,

validated Mindfulness Based Stress Reduction (MBSR; Kabat-Zinn, 1990) protocol.

levels caused by stress.

meditation technique decreased the body's response to norepinephrine, a hormone released in

chronic pain (Kabat-Zinn, as cited in Goleman, 1986).

cluster of symptoms related to chronic hyperarousal, as described above, as well as difficulty

Western body/mind researchers study another form of focused relaxation called

reported that this research revealed

health in general. (Siegel, 2007, par.8)

including strength and flexibility development, as well as enhancement of organ functioning,

generally not found in most psychotherapies. On a psychological level, the introspection

relaxation response with a Yogic explanation for how relaxation works:

the conscious mind. (Sausys, 2006, par.5)

cited in Brahinsky, 2006, par. 5).

Yoga in classes into practices at home and in their daily lives.

Khalsa, assistant professor of medicine at Harvard Medical School and director of

Structure of the Thesis

or other conditions in the therapy.

interviewing practitioners such as Yoga therapists, psychotherapist, counsellors, and patients or

(Mold & Gregory, 2003).

by clinicians and clients.

CHAPTER 2 LITERATURE REVIEW