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Toward an Explanatory Framework for Yoga Therapy Informed by

Philosophical and Ethical Perspectives

Article in Alternative Therapies in Health and Medicine · November 2017

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HYPOTHESES
Toward an Explanatory Framework for Yoga
Therapy Informed by Philosophical and
Ethical Perspectives
Marlysa B. Sullivan, MPT, C-IAYT; Steffany Moonaz, PhD, C-IAYT; Kristine Weber, MA, C-IAYT, ERYT-500;
Jessica Noggle Taylor, PhD, APRN, NP-C; Laura Schmalzl, PhD
ABSTRACT
Context • Yoga Therapy is an emerging complementary
and integrative health practice for which there is increasing
interest from both clinical and research perspectives.
Currently missing, however, is an explanatory framework
for the profession that provides practitioners, clients, and
the public with an understanding of how various yogic
traditions and principles can be understood in modern
health care contexts.
Objective • This study proposes an explanatory framework
for yoga therapy, informed by phenomenology,
eudaimonia, virtue ethics, and first-person ethical inquiry.
Marlysa B. Sullivan, MPT, C-IAYT , is an assistant
professor, and Steffany Moonaz, PhD, C-IAYT, is director
of clinical and academic research at Maryland University
of Integrative Health in Laurel, Maryland. Kristine
Weber, MA, C-IAYT, ERYT-500, is director at Subtle Health,
LLC, in Asheville, North Carolina. Jessica Noggle Taylor,
PhD, APRN, NP-C, is an independent scholar in Decatur,
Georgia. Laura Schmalzl, PhD, is an associate professor at
the Southern California University of Health Sciences in
Whittier, California.
Corresponding author: Marlysa B. Sullivan, MPT, C-IAYT
E-mail address: msullivan1@muih.edu
Y
oga therapy is an emerging complementary and
integrative health (CIH) practice that has recently
grown in professionalization with the development
and adoption of educational competencies, accreditation of
schools, and certification of individuals. The International
Association of Yoga Therapists defines yoga therapy as a
“process of empowering individuals to progress toward
improved health and well-being through the application of
the teachings and practices of yoga.”1
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Conclusions • These 4 philosophical perspectives—
phenomenology, eudaimonia, virtue ethics, and
first-person ethical inquiry—provide a lens through
which to understand how yogic practices support the
individual’s transformation in the experience of illness,
pain, or disability. We propose that this transformation
occurs through facilitating a reharmonization of body,
mind, and environment toward the experience of
eudaimonic well-being. (Altern Ther Health Med. [E-pub
ahead of print.])
A growing body of research supports the effectiveness of
yoga for a variety of health concerns.2-6 Furthermore, evidence
exists that the general public is turning toward yoga as a
mind-body practice to foster well-being and manage health
conditions.7-9 Although this trend toward the
professionalization of yoga therapy is promising, important
barriers need to be addressed for it to become an understood
and accepted CIH practice and for yoga therapists to become
respected and included in integrative health care teams.
High heterogeneity among yoga practices and poor
standardization and reporting of these practices in yoga
research have been identified as significant obstacles to
understanding the mechanisms underlying the effectiveness
of yoga for health conditions.2,3 Various lineages, styles, and
practices are often used in clinical and research contexts,
without a clear justification or detailed description of the
components they entail.10
Delphi studies have sought consensus on practices and
guidelines from experts in the field to address this problem.11,12
For mental health conditions, consensus has been found on
the inclusion of what was defined as the 4 main components
of yoga practice: postures, breath, relaxation, and meditation.11
In addition, practices such as the cultivation of positive
values, attitudes, and behaviors as well as a yoga lifestyle were
recommended.11 However, a Delphi study on musculoskeletal
Sullivan—Yoga Therapy Explanatory Framework
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conditions reached no consensus on the inclusion of meditation
or yoga philosophy.12 A recent article by Gard et al13 proposed
a framework for yoga’s effects on psychological health,
highlighting 4 components: ethics, postures, breath, and
meditation. Another theory article by Schmalzl et al14 described
the neurophysiological and neurocognitive mechanisms
hypothesized to underlie the effects of yoga, with a specific
focus on movement, breath, and attention techniques. Last, an
opinion article by Solomonova15 explored the implications of
yoga as an intentional practice. These studies draw attention to
the various ways in which yoga can be defined for clinical and
research purposes, and the challenges that this variety creates
for yoga therapists and researchers.
Yoga’s rich and ancient spiritual tradition provides the
context for the integrative practice of yoga therapy.16-19 Yoga
therapy, as a growing CIH profession, draws on both
traditional practice and contemporary biomedical science to
create an evidence-informed and holistic healing practice.
Traditionally, the primary aim of yoga has been to alleviate
suffering, and the practices are intended to be understood
and experienced within this theoretical and philosophical
framework. Recent work by Mallinson and Singleton20 has
endeavored to clarify misconceptions and biases in the many
ways that yoga has been understood, defined, and interpreted
historically. Despite the variability and diversity amongst the
traditions of yoga, there are essential and foundational
philosophies shared throughout the texts and teachings of
yoga that can inform the yoga therapist’s perspective and
practice. To this end, this article discusses these shared
concepts to elucidate the philosophical foundations informing
an explanatory framework that can traverse individual
lineages and create a shared language for yoga therapy in
current health care contexts. Texts, such as the Upanishads,
Bhagavad Gita, and Samkhya Karika,16,17,19 offer foundational
teachings of yoga as a path toward the alleviation of suffering.
Other texts, such as the Yoga Sutras of Patanjali and Hatha
Yoga Pradipika,18,21 lay out specific practices, including
(1) ethical principles that guide interactions with others and
inward self-disciplines, such as nonharming and truthfulness
(yama and niyama); (2) physical postures (asana);
(3) breathing practices (pranayama); and (4) meditation, all
of which can be utilized as techniques to facilitate a shift in
the practitioner’s perspective, and ultimately toward the
alleviation of suffering.
In the absence of an explanatory framework of health
and suffering adapted to modern integrative health contexts,
the practices of yoga may be chosen outside of the context in
which they evolved. When yoga practices such as ethical
principles, physical postures, breath practices, and meditation
techniques are provided within a different cultural context,
such as a biomedical explanatory framework, they may lack
a cohesive understanding of intent, potentially limiting their
effectiveness or creating a misunderstanding in application.
The development of this explanatory framework for yoga
therapy will enable the evaluation, assessment, and delivery
of yoga therapy practices to be provided with the intention of
Sullivan—Yoga Therapy Explanatory Framework
facilitating the client’s empowerment toward balance and
well-being. However, a biomedical professional who is
unfamiliar with this explanatory framework of yoga therapy
may choose a practice, such as a physical posture or a
breathing technique, without a recognition of their synergy
nor an appreciation of the possible effect of a single practice
on physical, mental, social or existential well-being.
The development and definition of an explanatory
framework of yoga therapy informed by the philosophical
foundations of yoga is necessary to refine and direct yoga
therapists’ perspectives in the application of the practice for
various populations and conditions. This work can benefit
the development of clinical-reasoning skills and assist yoga
therapists in translating their work as they become part of
health care teams. In addition, the development of an
explanatory model can benefit the growth, clarity, and
cohesion of the field to further its integration as a CIH
practice and utilization by health care consumers, researchers,
providers, and organizations. This article explores and
proposes such an explanatory framework for yoga therapy.
Philosophical concepts and practices of yoga, such as its
ethical principles (yamas and niyamas), will be highlighted
and viewed through the lens of current research, with the aim
of providing a perspective that bridges the wisdoms of
ancient traditions and of modern science. The creation and
definition of this explanatory framework for yoga therapy
and its relation to current research in phenomenology,
eudaimonia, virtue ethics, and first-person ethical inquiry
can foster a collaboration among the traditions and lineages
as well as between researchers, practitioners, the general
public, and other health professionals.
PHENOMENOLOGY AND YOGA
The theoretical and reflective approach of phenomenology
has been adapted and utilized for the development of
practical applications in health care professions, such as
nursing, psychology, and physical therapy.22-24 An in-depth
exploration of phenomenology is beyond the scope of this
article. However, certain phenomenological concepts have
potential significance for underlying themes and philosophies
within the yoga tradition that can benefit the development of
a shared language and explanatory framework for yoga
therapy. Furthermore, the understanding and articulation of
particular concepts offered by phenomenology can support
the integration and translation of yoga therapy into current
health care and research contexts. In addition, yoga therapy
may represent a methodology of application for
phenomenological inquiry into health or well-being and
disease or illness.
Phenomenology attempts to view phenomena in a
rigorous and unbiased manner to uncover unexamined or
automatic assumptions.23 In this way, the world of pure
phenomena may be explored and experienced from a fresh
and foundational perspective.22,23 Maura Dowling writes that
phenomenological reduction was devised by Husserl
“in order to hold subjective perspectives and theoretical
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constructs in abeyance and facilitate the essence of the
phenomena to emerge.”23 The mode of inquiry and
investigation offered by phenomenology calls for a
“fresh attentiveness” to the way the world appears through
experience, in what Husserl called “the epoché of the natural
attitude.”22 This “natural attitude” is understood as the naive
way of encountering the world outside of habitual patterns.
The phenomenological approach provides an exploration
and inquiry into the meaning of experience through the
study of the individual’s perspective, including perceptions,
thoughts, memory, bodily awareness, emotions, embodied
actions, and social activity.23-26 In the context of
phenomenology, an experience can be explored in so far as it
reflects the continual interplay and cocreation between the
body, mind, and environment (BME).27,28
Particularly significant to the framework of yoga therapy
is Merleau-Ponty’s “lived body” (LB) as the foundation from
which a person perceives and acts.27 The LB reflects the way
in which the world and body coconstitute and cocreate one
another as it is through the medium of the body that the
individual becomes conscious of the world, and it is through
the world that the individual becomes conscious of the
body.29 The LB concept represents the “copenetration that
exists between subject and world,” where the body is the site
of subjectivity.27 Similarly, yoga and yoga therapy hold that
the bodily experience serves as a meeting point between the
3 components of the BME, such that it becomes a conduit
through which the individual subjectively experiences
suffering or its alleviation.17,18
Although the phenomenological concepts of the LB and
“lived experience” (LB/LE) include this interplay between the
BME, they can also incorporate more abstract concepts, such
as “awareness.”23,27,28 Samkhya, a philosophical foundation
informing the thought and practices of yoga, emphasizes the
concept of awareness in relation to the BME in the experience
of suffering.17
Although the dating of yoga philosophy is difficult, the
teachings of Samkhya are incorporated within many of the
seminal yoga texts, such as the Yoga Sutras of Patanjali and
the Bhagavad Gita. As such, this philosophical tradition
represents a shared understanding across texts and traditions
informing the practice and philosophy of yoga and is
essential in the creation of a shared language and explanatory
framework for yoga therapy. Samkhya elucidates the
relationship of Prakriti (ie, material nature or the BME), with
Purusha, the awareness that enlivens Prakriti, as both the
cause of suffering and the means of its alleviation.17
Furthermore, Samkhya teaches a methodology to facilitate
realization of the difference between awareness (Purusha)
and the BME (Prakriti) for the alleviation of suffering.17,18
The tradition of yoga offers many examples to illustrate
this relationship of awareness to the BME in the creation of
the experiences that lead to health, ease, pain, or suffering.
These teachings include an illustration of the ways in which
life experiences are presented as opportunities for realization
and, thus, the potential alleviation of suffering.17,18
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The metaphor of the lame man and blind man from the
Samkhya Karika captures these connections.17 The lame man,
representing awareness, and the blind man, representing the
body-mind complex, join together on a journey, representing
the environment, toward realization. As awareness cannot move
and body-mind cannot see, they must unite to traverse the
journey of life successfully, highlighting the concept that
realization and the alleviation of suffering cannot happen
outside the relationships between awareness and the BME.17 The
emphasis on bodily and worldly experience as an imperative
that moves the individual toward the alleviation of suffering is
seen throughout yoga philosophy.17,18 In other words, release
from suffering does not happen outside of this connection
between the parts, including awareness and the BME.
Another Samkhya Karika metaphor to explain this
relationship further is that of an actor and a play.17 It says that
nature will continue to engage in life with body-and-mind
consequences just as an actor performs his or her part in a
play. This play, and nature’s assumption of roles, is for the
benefit of awareness; the play and the roles provide
opportunities for awareness to discriminate between itself,
the play, and the actor. When awareness no longer confuses
itself with the actor or the play, freedom from suffering may
arise as nature ceases the taking on of new roles to play.17
Of the philosophies informing the yoga tradition,
perhaps tantra offers the clearest emphasis on the power
of the bodily experience for the attainment of liberation
through the LB in which life is experienced and expressed.30
Although the origins of tantra may be difficult to discern,
it was popularly practiced in India from the sixth to the
19th centuries CE.20 In The Tantric Body, Gavin Flood
offers the term entextualization to describe how the body
is inscribed by tradition, wisdom, and texts in the
formation of identity and self. Knowledge becomes a lived
experience realized through the body rather than an
intellectualized endeavor.30
In sum, phenomenology and yoga offer perspectives to
explore the intricate links between awareness and the BME
for a therapeutic approach that moves beyond a dichotomous
body-mind construct. Phenomenology explores the
“trialectic” that occurs through the interplay of the BME,
where the LB is the meeting place between the BME and
cannot be reduced, separated, or isolated in the experience of
the individual.15,28,31,32 It is through the LB that meaning,
identity, formation of self, and habit are experienced and
expressed through the BME.25,28,33,34
The phenomenological framework offers a platform
through which contemplative approaches, such as yoga, can
explore a methodology to work with the intertwined
relationship between awareness and BME in well-being or
suffering. As such, this framework provides an ideal basis for
the development of an explanatory model for yoga therapy,
because it brings the focus into an awareness of the LB/LE and
movement toward an integrated expression of the BME
through the subjective experience of well-being or
suffering.23,25,27,31,32,34
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Just as phenomenology may support and inform an
explanatory framework of yoga therapy, yoga may provide a
methodology for the application of phenomenological
concepts in client or patient care. Both phenomenology and
yoga seek to suspend the habitual tendencies of the individual.
This suspension of habit can be utilized to explore the ethical
and value concerns important in the transformation of
identity for an individual’s experience of well-being or the
alleviation of suffering.17,18,24
According to yogic wisdom, suffering arises from a
misperception or misidentification with the BME.17,18 The
practices of yoga are aimed at reorienting identity to the
experience of awareness.16-19 Yoga offers practical application
through training of discriminative knowledge, inquiry into
the nature of awareness and the BME, and practices aimed
to extricate and untangle the misidentification with the
BME.16-19
Yoga therapy may be uniquely suited as a methodology
of phenomenological practice for reorienting individuals
toward a transformation in meaning and purpose as well as
facilitating an inquiry into the nature of suffering. This
practice can facilitate a process whereby the individual can
alter or change his or her relationship to the nature of
suffering and of the LB/LE in the experience of illness,
disease, or disability.
The phenomenological concept of the habitual body
from Merleau-Ponty offers insight into the assumption of
habit as arising from a synthesis of bodily understanding as
the body serves as “mediator of a world.”29 Habit includes
both motor and perceptual functions, such that action and
behavior become prereflective.29 In this context, habit is the
development of the relationship between the environment
and subject, where the body adapts in response to interaction
with the environment.27 The habitual body reflects and can be
used to explore prereflexive, kinesthetic patterns of
movement, intentions that have shaped the body and mind,
and habitual ways of engaging with the environment and
oneself molded through an individual’s lifetime in the
creation of meaning and identity.15,23,25,27,33,34
Similarly, yoga philosophy illuminates the relationships
among habit, intention, the body, and action, and their effects
on one another.16–19 The Brihadaranyaka Upanishad describes
the relationship between desire and action, where desire in
the mind shapes the body and creates action: “As a person
acts, so he becomes in life … you are what your deep driving
desire is. As your desire, so is your will. As your will, so is
your deed. As your deed is, so is your destiny. We live in
accordance with our deep, driving desire.”16
The Samkhya Karika continues this thought, indicating
that the subtle body and intellect house the “driving forces of
resources and action.”17 This text also provides the metaphor
of the potter’s wheel that continues to turn after the potter
ceases exerting a force on it; the resonance of past impulses
continues to create thought and action in the body, even after
discriminative knowledge of habitual patterns has been
realized, until they are lived through.17
Sullivan—Yoga Therapy Explanatory Framework
The Yoga Sutras offer a similar habitual body in which
subliminal intentions, or samskaras, are rooted and
propagated by misidentification with the BME.18 The
Yoga Sutras speak to these habitual actions, leaving traces
that further the misperception of identity and produce
resultant actions.18 Tantra emphasizes the role of the body in
providing the means, vehicle, and map through which
liberation from these habitual tendencies and misidentification
with mind and environment occurs.30
The path of yoga encompasses the development of
discriminative wisdom, understanding the habits of
engagement with the BME, and the creation of a path toward
freedom from these patterns; this freedom allows the
individual to stand in his or her true identity, independent of
the BME.16-19 Yoga therapy becomes the practical application,
in the context of well-being and suffering or health and
illness, for the exploration of and disentanglement from
these prereflexive, habitual patterns. New patterns are created
through the therapeutic yoga practice for engagement with
the BME toward the subjective experience of well-being and
a change in the relationship to suffering.
APPLICATIONS TO PAIN, ILLNESS, OR DISABILITY
As mentioned previously, the common concepts
underlying phenomenology and yoga can allow
phenomenology to inform an explanatory model of yoga
therapy that traverses individual lineages and, in turn,
permits yoga therapy to provide a methodological framework
for phenomenological inquiry in clinical settings. Just as
phenomenological insight into the LB/LE offers a context to
explore bodily and identity change resulting from pain or
illness, yoga offers a path for facilitating transformation in
identity and relationship to the BME.25
Given their shared focus on first-person experience, these
complementary frameworks can support current trends in
medicine toward client-centered care, such as shared decision
making, active engagement strategies, and restoration of client
agency.25,26,33 This type of care is especially important in
chronic conditions or disability, where the development of a
shared meaning of illness between the client and the
practitioner and a focus on well-being or quality of life are vital
for working with changes in self-concept.25,26,33
In phenomenology, the LB may be differentiated from
the objective body, which is of particular significance in
working with the changes in perception, self, meaning, and
purpose in chronic illness or disability.25,26 Biomedicine
concerns itself with objective findings and the objective body,
which may not correlate with improvement in the concerns
of a client with chronic conditions, such as sense of identity,
meaning, purpose, and connection to or isolation from the
individual’s body or environment.24-26,31,33
The use of patient-reported outcomes in clinical practice
and research acknowledges the distinction and importance of
measurements for both the objective body and the LB for
health and well-being.35 Changes in chronic illness can traverse
the physical, emotional, and existential layers and may become
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a transformational experience triggering a redefining of
identity, purpose, meaning, and the ways in which individuals
engage with themselves and their enviornments.24-26,31,33 To this
point, phenomenological research has demonstrated
disturbances in the LB/LE in illness and pain, whereby new
habits and a new lived experience must be cultivated in the
pursuit of well-being.25,26,33
One example seen in clients with chronic pain is the
reporting of the body as alien, powerless, or isolated, with a
rejection of or distancing from the affected body part and an
unraveling of identity.26 Another example seen in stroke
patients is the reporting of changes in self-concept and
identity, where the body becomes something to control or
overcome.24 Last, patients with operable lung cancer report
disorientation, uncertainty, a loss of familiarity with the
body, an inability to engage with the world as they had
previously, an altered sense of identity, and increased
attention to bodily function.33 In chronic conditions or
disability, the healthy LB is no longer experienced in the
background, transparent to engagement in life, with harmony
between the BME.24-26,31,33 Rather, the painful or disabled
body may become a source of betrayal, no longer understood.
As the painful body comes to the forefront of experience, the
person’s world may feel diminished, reducing all facets of life
to a constant negotiation around the pain or disability.24-26,31,33
Phenomenology offers a change in perspective in working
with a client with chronic pain, illness, or disability from a
focus on objective findings and the objective body to that of
the LB/LE of the individual. This shift creates a change in
treatment strategy and therapeutic focus to the restructuring
of identity and reorientation of the BME through an exploration
of the client’s own meaning of illness and to help develop
tolerance to or alter the relationship with the nature of
suffering in the experience of illness, pain or disability.26,31
Working with objective status has not been sufficient to
mitigate these changes in identity or to create a life of
meaning in these populations, so it is important to identify
methodologies that can facilitate a reconnection to purpose,
meaning, and identity distinct from the experience of pain or
disability.26,31 Yoga therapy exemplifies this approach because
it works to reharmonize and integrate the BME while
reconnecting to meaning and purpose. One study found that
yoga enhances the sense of embodiment and furthers the
understanding of the loss associated with disability after
breast cancer.15,36 Whereas phenomenology offers the context
to interpret and work with the narrative of clients, yoga offers
the tools to work with transformation of identity in illness.24
Working from the perspective of the LB/LE, clinicians can
assist clients in finding a more connected sense of identity
and ultimately enhance well-being.25
YOGA THERAPY AS A PATH TOWARDS
EUDAIMONIC WELL-BEING
The concept of eudaimonia, often defined as a life well-lived
or well-intentioned,37-39 can further elucidate the benefits of
cultivating a life of meaning and purpose for both subjective
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well-being and physiological health. Thus far, the problem
explored has been phenomenological, working with the LB/LE
of pain or disability. Reconciliation can be explored through
the concept of eudaimonic well-being or a well-lived life of
fulfilled meaning and purpose. Yoga therapy then becomes
the path and practice toward the ultimate aim of a life of
meaning and purpose in the realization of well-being.
The yoga tradition teaches that suffering stems from an
individual’s misperception of who he or she is and a
concomitant overidentification with a variety of phenomena,
including the mind, passions, nature, and aversion.16-19 Yoga
aims to reorient the individual toward the experience of
awareness to encounter a steadfast type of joy that is
differentiated from momentary pleasure.16,19 This foundational
principle of yoga asks the yoga therapist to move away from
a focus on the medical diagnosis or condition and toward the
facilitation of an opportunity, where the client may experience
qualities such as steadfast joy, calm, peace, or contentment
irrespective of diagnosis. This defining philosophical feature
of yoga therapy distinguishes its approach and the intention
of its practice from a biomedical one and illustrates the
importance of understanding the philosophical paradigm
from which the yoga therapist operates.
The concept of eudaimonic well-being has been explored
in research for its effects on health and well-being38,40,41 and
offers a potential parallel to the experience of steadfast joy that
lies at the core of the yoga therapy process.16,19 Understanding
the effects of eudaimonic well-being on health can further the
development of a theoretical framework, based on the
philosophical and traditional thought of yoga, which can
inform the practice and perspective of yoga therapy.
According to Aristotle, eudaimonia was the pinnacle
and goal of human life, exemplifying a state of flourishing
and optimal happiness.42 Similar to the differentiation found
in yoga between steadfast joy and momentary pleasure,
Aristotle pointed to 2 types of happiness.37 Eudaimonia is
defined as an enduring form of happiness and is differentiated
from a more transient and passionate hedonic happiness.37
During Aristotle’s time, health, virtue, and medicine were
interconnected; health was seen as the “telos of medicine” and
eudaimonia as the “telos of human action,” where the former
created an analogy for the latter.43 Current research has defined
eudaimonic well-being as self-actualization, optimal
functioning, and meaning and purpose in life.37-39,41,42
Eudaimonic well-being is said to occur when people live in
alignment with their true, authentic natures and in congruence
with their values.39 Comparably, the Bhagavad Gita illuminates
a path toward self-actualization and the individual’s experience
of steadfast joy through living life in alignment with his or her
distinct and unique dharma.19 Dharma is a difficult and
complex concept to define; it is used to mean duty, law, virtue,
and rightness or merit and implies action that must be taken
for the benefit and sustenance of the individual and society.44
The Bhagavad Gita delineates 3 qualities, or gunas—rajas,
tamas, and sattva—that are said to underlie everything in
nature, including food, action, knowledge, and joy.17,19 Sattva,
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which is closest to eudaimonia, gives rise to such qualities as
tranquility, harmony, and equilibrium.17,19 Rajas gives rise to
such qualities as turbulence and anger, whereas tamas gives
rise to delusion and ignorance.17,19 These 3 qualities are said to
coexist and comingle in the creation of material nature and to
be part of all experience.17
In the movement toward well-being, for example, sattva
can predominate as clarity and lucidity but the other 2 qualities
can provide important characteristics, such as creativity and
motivation (rajas) and groundedness and stability (tamas).17
Sattvic happiness is said to stem from self-understanding and
from developing and cultivating the good within ourselves,
leading to steadfast joy, offering an interesting parallel to
eudaimonic well-being.19,42 Applying the yoga practices
through the lens of these foundational principles—such as
cultivating sattva and facilitating a process where the individual
may find his or her unique dharma, or path, toward eudaimonic
well-being, or steadfast joy—has significant implications in
forming the unique perspective of the yoga therapist in
working with various client populations.
From a physiological and mental health standpoint,
eudaimonic well-being has been linked to many positive
health outcomes, including improved immune function and
decreased allostatic load and all-cause mortality, independent
of age, gender, physical inactivity, and the presence of
disease.38,39 Whereas perceived social isolation has been
associated with conditions such as heart disease,
neurodegenerative disease, and some cancers, all involving
upregulation of proinflammatory genes and decreased
expression of antiviral and antibody-related genes,
eudaimonic well-being has been found to downregulate
these same adverse gene expressions, thereby mitigating the
effects of perceived social isolation.40,45
Approaches that promote eudaimonic well-being can be
a powerful way to diminish the effects of perceived social
isolation on gene expression and on associated disease
states.40 A recent study demonstrated that yoga practice is
correlated with increasing the presence of meaning in life as
a measure of eudaimonic well-being and, therefore, can help
improve health and well-being.41
The focus of yoga therapy on cultivating the connection
to steadfast joy, eudaimonic well-being, meaning, and
purpose highlights an important place for yoga therapy in
caring for the ill client. When the practices of exercise,
breathing, meditation, and ethical principles are rooted in
yoga’s philosophical underpinnings and given within the
currently proposed explanatory framework, they form a path
toward meaning, purpose, and eudaimonic well-being. Smith
et al46 found that an integrated yoga practice, including the
ethical practices of yoga (yamas and niyamas), had a greater
effect on anxiety-related symptoms and salivary cortisol than
physical postures (asana) alone. Additional work to define and
find consensus on the philosophical framework through which
yoga aims to facilitate a process of eudaimonic well-being will be
essential to further the field of yoga therapy as a unique part of
integrative health and as a phenomenological methodology.
Sullivan—Yoga Therapy Explanatory Framework
TOWARDS EUDAIMONIC WELL-BEING: DEFINING
VIRTUE ETHICS AND RELATIONSHIP TO YOGA
Aristotle’s virtue ethics were specific virtues, moral
qualities, and attitudes which, when practiced consistently,
would help a person to achieve eudaimonic well-being,
human flourishing, and a life well-lived.39,43,47-49 The virtue
ethics, such as generosity, truth, and humility, were meant to
be developed and practiced over a person’s lifetime until they
became a part of the individual’s character.42,47
Cultivation of virtues required practical action and
helped to mold the individual’s behavior to live better in the
pursuit of eudaimonic well-being.42,47,48 The practice of ethical
investigation reflects an exploration of how the individual
holds a system of values or beliefs about right or wrong and
good or bad, informing his or her decisions and actions
toward a well-intentioned life.24
The individual’s ethical framework forms the context for
inquiry into life’s experiences, such as illness, and serves as
the foundation from which action and meaning are created.24
Ethical practice, according to Aristotle’s teachings, was not
meant as a cognitive exercise but as a plan for action; the
quality of the individual’s life was reflected in the quality of
his or her actions as a result of these virtues’ guidance.43 Right
action was said to emerge from this development and
practice of virtues and ethics in the aspiration to benefit the
person and society.42,43,48
The ethical practices of yoga, such as virtue ethics, are
meant to be a consistent and disciplined practice to overcome
the obstacles of the mind and emotions for the alleviation of
suffering and connection to the experience of awareness.17-19,42
Both the Bhagavad Gita19 and Aristotle37 emphasize the
importance of discrimination, intellect, wisdom, and practical
reasoning in the development of habits to live an ethical,
purposeful life.19,42 To that end, the Bhagavad Gita defines yoga
as excellence in action and as a means of living a harmonious,
virtuous, and ethical life that reflects right action.19,42
The concept of dharma as the path toward a
well-intentioned life highlights each individual’s duty to live
in alignment with his or her path for the benefit of the
individual and society. Yogic texts offer many ethical
practices, such as nonviolence, truth, humility, forgiveness,
and compassion, with some yoga lineages focusing on these
principles before the practice of asana, pranayama, or
meditation can be initiated.18,19,21,42
Terminology, such as dharma and the yamas and niyamas,
would benefit from continued clarification regarding their
contextualization into modern practice and, as essential
components of the explanatory framework of yoga therapy, in
their application to the exploration of the nature of suffering
and eudaimonic well-being in pain, illness, or disability.
This work to clarify the framework and terminology
from which the practices arise can inform the yoga therapist’s
unique perspective in working with a client and assist in
clarification, utilization, and translation of the explanatory
framework of yoga therapy, both within the field and for the
public. As the yoga therapist works to bring these concepts to
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the individual in pain or illness, a shared meaning or
definition is needed so that the practices can effectively
facilitate the client’s path toward eudaimonic well-being.
FIRST-PERSON ETHICS AND YOGA IN ILLNESS
First-person ethics represents a phenomenological
approach to exploring the subjective and intentional
experience of ethics that helps to align the individual’s
thoughts, feelings, and actions rather than the study of ethics
as an outer moral judgment or set of rules to follow.26,50 This
view describes the body of ethics that the individual holds as
a representation of an intention toward a well-lived life and a
way to understand meaning ascribed to events, thoughts, and
emotions.24,26,50 The intentions that are held by the individual,
consciously or subconsciously, inform how the phenomena
of the BME are related to and experienced as either increasing
or decreasing suffering.51
First-person ethical inquiry advances the idea of
phenomenological exploration into a subjectively defined
ethical, well-lived life dependent on individual context and
needs.42,47,49 In line with phenomenology, first-person ethics
is interested in the movement from an externally driven,
rule-oriented understanding of ethics to an intrinsically
driven, internally motivated one.47,49 Intention, in the
context of first-person ethics, can help the individual to
understand how ethics shapes his or her sense of identity
and agency and how the 3 components of the BME come
together in the well-lived life.26
This phenomenological approach to ethics is of particular
interest in understanding the transformative nature of
disability or disease and the ethical concerns that arise in
living with or adjusting to a disability or illness, including a
reorientation of identity.24 Chronic illness, pain, or disability
bring changes in an individual’s values, ethics, and meaning,
signaling a transformation between who he or she was and
who he or she is.24
A methodology that can investigate the LB/LE and values
important to a client with a chronic condition, including the
particular ethical and moral concerns that arise, is important
in the cultivation of eudaimonic well-being and the restoration
of the sense of identity.24 First-person ethical inquiry with the
chronically ill or symptomatic client can support an active
engagement in care and encourage the client to redefine his or
her relationship to the illness, including identity, agency,
meaning, and values.24,26 This re-evaluation can assist the client
in addressing the complexity of pain or disability, including
existential concerns to cultivate a life well-lived.24,49
Yoga’s practices of yama and niyama—the ethical
principles and observances—are well-suited for this
first-person, phenomenological, ethical inquiry toward the
meaningful life. The setting of intention and its embodiment
is a fundamental part of the yoga practice.15 Intention in yoga
can be seen in the practice of yama and niyama as well as in
other philosophical principles such as dharma. The meditative
components of yoga, which can take different forms
depending on the specific practice, can also incorporate
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intention.15 The many tools through which the yoga therapist
can apply these intentional and ethical practices to facilitate
a client’s well-being highlight the need for defining and
clarifying both the framework in which they are used and the
terms themselves to ensure their inclusion in clinical practice
and research. In addition, the integration of this explanatory
framework and ethical practices with concepts from
biomedical ethics can help to further the understanding of
the practical applications of the yamas and niyamas and
translate them for research and use.
SUMMARY AND NEXT STEPS
This discussion begins the development of a clearly
defined, explanatory model of yoga therapy, rooted in the
philosophical and ethical components of yoga, from which
the practices are applied. The aim for such a model is to allow
the lineages and traditions of yoga to share language and to
assist the yoga therapist in the development of clinical
reasoning skills. In addition, a clear, operationalized,
explanatory model and a definition of yoga ethics can
support the use of yoga therapy by the public, scientists,
health care providers, and organizations.
This article proposes the following explanatory
framework for yoga therapy. Illness, pain, or disability can
create physical, mental, and existential changes in the BME,
which can trigger a redefining of identity, meaning, and
purpose in the LB/LE of an individual, potentially leading to
an experience of suffering.
Likewise, suffering can also facilitate changes in the
BME and in the LB/LE, which can affect disease states and
the experience of pain.
Yoga therapy is utilized to explore the nature of and the
individual’s relationship to suffering through the LB/LE and
the BME to facilitate movement toward eudaimonic
well-being. Ethical inquiry through yama and niyama and
discriminative knowledge can facilitate an intentional
reorientation of the BME and LB/LE toward the individual’s
dharma and eudaimonic well-being. Asana, pranayama, and
meditation are given in this context to align the BME with the
individual’s dharma and eudaimonic well-being. Through
their effects on each of the 3 components of the BME, yoga
practices can create a transformation of the LB/LE of the
individual. As a result of this process, a reharmonization of the
BME can occur, creating a shift in meaning and purpose and
in the individual’s experience of illness, disability, or pain.
Through this transformation, the individual may
experience the state of eudaimonic well-being, or steadfast
joy, and thus the potential alleviation of or change in
relationship to the nature of suffering. This experience of
eudaimonic well-being may also facilitate changes in the
LB/LE and the BME and effect the disease state or the
experience of pain (Figure 1).
Next steps include developing consensus on the explanatory
model for yoga therapy, including the definition of specific
philosophical and ethical practices—such as dharma, gunas, and
specific yamas and niyamas—that inform the application of
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Figure 1: Explanatory Framework for Yoga Therapya

a
The left side of the chart illustrates a process whereby illness, pain, and disability can create changes in an individual’s
subjective experience of the BME, thereby shifting the LB and LE of that individual toward the experience of suffering.
Likewise, suffering can facilitate changes in the LB and LE of the individual and, thus, in the subjective experience of the BME,
which can affect disease states and the experience of pain. Yoga therapy can foster an alteration in the BME of an individual
suffering from illness, pain, or disability, such that the LB and LE move toward the alleviation of that suffering and eudaimonic
well-being. The yoga therapeutic process uses first-person ethical inquiry through yama, niyama, and discriminative
knowledge to facilitate an intentional reorientation of identity and a reconnection to meaning, purpose, and an individual’s
dharma. Asana, pranayama, and meditation are given in this context to cultivate a reharmonization of the BME, which shifts
the LB and LE of the individual toward alignment with eudaimonic well-being. This experience of eudaimonic well-being can
also facilitate changes in the LB, LE, and BME of the individual and affect the disease state and experience of pain.

Abbreviations: BME, body, mind, and environment; LB, lived body; LE, lived experience.

yoga practices for yoga therapy. This evolving framework of
yoga therapy, including the emphasis on the ethical principles as
a foundation, would benefit from integration with concepts
from biomedical ethics for practical applications as well as for
translation and integration into research and to foster use by the
public and health care providers.
In addition, understanding potential neurophysiological
frameworks that correlate to the application of these
philosophical principles can support the development of the
professional practice of yoga therapy. The utilization of
phenomenological methodologies for yoga therapy research
can provide important insights into the effects of yoga
practice, including the (1) ways in which yoga practice, based
on the previously described explanatory framework, might
create a change in the individual’s relationship to pain,
illness, and disability and to eudaimonic well-being;
(2) development of a shared understanding of yoga
terminology, such as dharma and gunas, for health care and
research contexts; and (3) effects of practicing yama and
niyama as an embodied intentional practice for creating this
shift in the BME, the LB/LE, and the person’s relationship to
pain, illness, disability, and eudaimonic well-being.
ACKNOWLEDGEMENTS
The authors would like to thank Laurie Robertson and Matt Erb for their comments on
an earlier version of the manuscript.
AUTHOR DISCLOSURE STATEMENT
This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors. The authors have no conflicts of interest related
to the study.
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