For those unfamiliar with yoga therapy, or medical yoga, the first step is to understand that a yoga therapy session is different from a studio yoga class. While it is fair to say that in its ideal form, all yoga is therapeutic, there is a difference between taking a typical studio or gym yoga class, which focuses on physical postures to promote exercise, social connection, self-awareness, strength, flexibility, and relaxation, and engaging in yoga therapy, which is an individualized, evidence-based therapeutic intervention using movements, breath work, mindfulness, yoga philosophy, neuroscience, anatomy and physiology,, psychological/therapeutic principles, and somatic awareness to reduce the pain and suffering of mental and physical health conditions. They both have their place within the larger universe of yoga.
Yoga therapy draws from a number of traditions to ease suffering and promote healing for those with a variety of conditions. Even though sessions are aimed at particular symptoms and issues a person might be having, yoga therapy works by looking at those issues within the context of one’s own body, own mind, own experiences, own life.
Let’s take a person suffering from depression, for example, a common, often debilitating heterogeneous condition, meaning that its origins may exist along the biopsychosocial spectrum but end up in the same place, with some gender and cultural variations. Imagine the person has been diagnosed by a medical or mental health professional using the DSM or equivalent. Perhaps the person is taking an antidepressant or is engaging in talk therapy, both standard treatments for depression. The most commonly used antidepressant, an SSRI, is thought to work by changing the body’s chemistry, specifically in the serotonergic network, and the talk therapy works to change negative thought and belief patterns through reframing. Research shows that both of these methods work for 40-60% of people. Medications tend to work faster at first and can be invaluable as a first line of treatment of severe depression but lose effectiveness over time, come with side effects, and are correlated with a substantial risk of relapse. Talk therapy tends to take longer to work but the benefits are longer lasting. Often people take medication to reduce symptoms first then use talk therapy to make lasting changes in their mental health, which provides better outcomes than doing one or the other alone, especially for severe depression.
In treating depression, yoga therapy, like medication, is primarily a bottom-up therapy, meaning that we work with the body initially rather than directly addressing entrenched negative thought patterns like talk therapy does. However, the mindfulness component of yoga therapy, which we bring in gradually as capacity increases, is more like cognitive therapy: It’s top down, as the person examines thought patterns through meditation and learns to practice non-attachment and non-reactivity to thoughts and beliefs. In this way, yoga therapy can be seen as a bottom -up therapy that adds a top-down modality as well, through mindfulness.
Recent research has begun to identify the mechanisms through which yoga therapy for depression is effective. Here are just a few ways:
- Biochemicals, ANS, and Neuroplasticity The combination of breath practice, movement, and mindful attention can change the body’s chemistry, particularly by increasing GABA, an inhibitory neurotransmitter that supports well being, and by reducing stress hormones, particularly cortisol. By inhibiting the stress response, yoga therapy promotes better function of the prefrontal cortex, whose capacity has been hijacked by the sympathetic nervous system. Most people with mental health issues have some dysregulation in the autonomic nervous system, which can not function well under the allostatic load. Reducing the stress response through breath and movement allows us to help the PFC to come back “online,” and the subsequent improvement in executive function allows the person to better evaluate the difference between perceived threat and actual threat. Engaging in practices that safely challenge the autonomic nervous system within the client’s own window of tolerance builds resilience and flexibility in the person’s response to stress. For those suffering from depression, this means using movement and breathwork to gently move the person out of hypoarousal, a state characterized by low energy, minimal movement, and anhedonia (loss of interest), while for those with comorbid anxiety, this means nurturing a physiological state between hypo and hyperarousal. Operating on the principle that story follows state, yoga therapy can trigger a response in the body that opens possibilities for change that the person could not see when in hypoarousal or hyperarousal. There is also evidence that yoga promotes brain plasticity, which means that yoga makes it more likely that growth and learning will stick, as new patterns become solidified in the form of neural networks. This is a key feature of yoga therapy for depression, as the brains of depressed people are resistant to change, with neural networks hijacked by the stress response, stagnant schemas, lower PFC function, a decrease in globalization, and a decrease in gray matter in the hippocampus. Researchers such as Dr Patricia Brown, Dr Richard Gerburg, and Dr Chris Streeter, among others, have published many papers in medical journals detailing yoga’s ability to change physiology. Every year, new research is published identifying the specific brain substrates through which yoga therapy creates positive change.
- Polyvagal Theory Yoga therapy’s effectiveness can also be explained using the principles of Stephen Porges’ polyvagal theory. Breath practice, singing/chanting, and mindful movement promote the ventral vagal state, a calm but alert awareness associated with learning, growth, and human connection. People suffering from depression have a predominant dorsal vagal state of hypoarousal or, when anxiety is comorbid, chronic sympathetic state or hyperarousal. Stimulating the vagus nerve, which yogis have done through chanting and humming breath for millenia, improves vagal tone, which has a. number of positive effects on our system, including increased heart rate variablity, an indicator of good health and an important target in working with depression. Bessel van der Kolk, Peter Levine, and others have long championed the importance of bodywork to help those with various mental health concerns, including depression, anxiety, and PTSD. They work to create a safe space of embodied awareness, through which the person can explore their challenges. Polyvagal theory is particularly applicable for those whose depression is intertwined with trauma.
- Anatomy and Health Yoga therapy also works on the assumption that our physical anatomy (particularly posture, muscles, and fascia) is in a dialectical relationship with our physical, emotional, and mental health. Posture, mood, and illness are interrelated.The postural habits of those with depression, for example, often reveal slumping shoulders, a sunken chest, and contraction of hip flexors, which seems to be a result of their depressed state but can also sustain the depressed state. In gently working with posture, along with breath and movement, we can alter physiology, particularly the function of the ANS, lung efficiency, and heart rate coherence, reducing SNS activation and promoting better mental health and feelings of agency. Better posture is associated with feelings of stability and self-efficacy. Working with posture and movement has positive knock on effects that increase quality of life, including better sleep, better digestion, better lung capacity, and increased energy, all of which can help people with depression, as well as those with other health conditions, feel like engaging in activities and treatments that will help them heal. Researchers in medicine and physiotherapy, as well as fascia researchers like Joanne Avison, have validated this link between our posture and our health.
- Breath Physiology One of yoga therapy’s most potent tools is breathwork, or pranayama. Using calming breaths like ujjayi and dirga breath, stimulating breaths like kapalabhati, and equalizing breaths such as coherent breathing and alternate nostril breathing, a skilled yoga therapist can alter physiology, especially ANS function, through breath, promoting healing. People with depression are often exhausted but can’t truly rest. Working with stimulating and calming breaths, we gradually expand the client’s window of tolerance so that they can rest deeply without fear of entrenched hypoarousal or hyperarousal/panic. More importantly, once the client learns these breathing techniques, along with somatic awareness, they can self-regulate, gaining the agency they need to manage their condition. Researchers, including cardio-great Dr Herbert Benson, have long espoused the potential in the power of breath work with mindful focus to promote health.
- Holistic Healing Yoga therapy looks beyond the physical symptoms of depression. Yoga therapists use the kosha model, a lens that allows us to examine the client’s environment, their energy levels, and their thoughts and mood, much as medical and clinical professionals do. But yoga’s roots in spiritual traditions add an additional layer, as we cultivate the person’s innate wisdom and capacity for joy, powerful dimensions of a human being that we can recruit in healing. This means that we often don’t move directly into the area where the person’s complaints lie. If thoughts are ruminative and negative, we will work with another “kosha” rather than directly examining those thoughts. We may ask the person to consider what they are taking in from their environment (quality and quantity of food, alcohol, drugs, media, conversations, pollution, touch, exercise, work) and to make changes in their physical world that lead to more connection and a sense of purpose and belonging; we may work with breath and movement to change energy levels that lead the person to make other positive changes in their life and remind them what feeling good feels like; we may do meditation or movement practices that lead to feelings of connection and joy that remind the depressed person how positive emotion feels in their body. We initiate awareness and change in one area and this sparks awareness and change in other areas. We use yoga philosophy and ancient stories to spark imagination, to initiate awareness of possibilities, and promote self-reflection. And this process will be different in each client. This is what is meant by yoga therapy being a holistic healing modality. We work on the principle that healing can be initiated in a number of ways. This is especially true of a heterogeneous condition like depression. So while the therapist knows that the aim is to reduce the suffering of depression or another condition, how we get there will follow a path unique to each client. Perhaps we can say that well being is an emergent property–that it arises from the collaboration of many systems rather than belonging to a single aspect of the human mind and body.
These are some of the ways in which yoga therapy approaches depression, which is only used here as an illustrative example. We also use the kosha lens for other mental health conditions, from anxiety to PTSD/trauma to eating disorders, as well as other health issues such as Parkinson’s, IBD and IBS, cancer, and diabetes.
It’s important to remember that yoga therapy does not claim or intend to replace appropriate medical and mental health care. People with mild to moderate forms of conditions like anxiety, depression, and burn out may find the relief and tools they need to manage their depression through yoga therapy alone, whereas people with active PTSD or eating disorders would see a yoga therapist in conjunction with other providers. Even people with mild symptoms may also wish to take medication and/or see a cognitive therapist in conjunction with yoga therapy. Yoga therapists are trained to work together with those in other professions to offer each person their best chance at healing. A good yoga therapist knows the limitations of their scope of practice and will always refer a client to a competent professional when the client’s issues are outside their scope. In this way yoga therapy works as a stand alone or complementary therapy. In some cases, such as in mild depression/anxiety or persistent pain, yoga therapy may be the only modality the person seeks, whereas with a condition such as Parkinson’s or cancer, yoga therapy takes a supportive role in lessening the suffering of some symptoms and improving quality of life. But in each case we leverage the person’s own innate capacity for healing to promote well being within the context of that person’s health and circumstances.
Amy Hunt Yoga 