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Canadian Journal of Counselling and Psychotherapy /Revue canadienne de counseling et de psychothérapie
ISSN 0826-3893 Vol. 45 No. 2 © 2011 Pages 132–150

Integrating Yoga with Psychotherapy: A Complementary
Treatment for Anxiety and Depression
Intégrer le yoga avec la psychotherapie : Un traitement
complémentaire pour l’anxiété et la dépression
Andrea L. Forfylow

Campus Alberta Applied Psychology Consortium

abstract
This article addresses the empirical research on yoga as an effective, complementary, clinical intervention for anxiety and depression based on an examination of studies publishedfrom 2003 to 2010. There is a discussion of study findings and research limitations andsuggestions for researchers and future research. Yoga appears to be an effective clinicalintervention for anxiety and depression. However, more rigorous research needs to becompleted to further support using yoga in mental health treatment planning. This article
concludes with practical suggestions and implications for mental health professionals
interested in using yoga.

résumé
Cet article traite la recherche empirique sur le yoga comme intervention clinique complémentaire effective pour l’anxiété et la dépression fondée sur une enquête des études
publiées de 2003 à 2010. Une discussion des résultats des études et des limites de larecherche ainsi que des suggestions pour les chercheurs et les recherches futures sontprésentées. Le yoga semble être une intervention clinique effective pour l’anxiété et ladépression. Cependant, la recherche plus rigoureuse doit être effectuée afin de soutenirl’usage du yoga dans la planification du traitement de la santé mentale. Cet article termine avec des suggestions pratiques et des implications de l’utilisation du yoga pour lesprofessionnels de la santé mentale.

Approximately 50% of American adults suffer from a mental health disorderat some point in their lives, the most prevalent being depressive and anxiety disorders (Kessler et al., 2005). Intriguingly, people with mental health disorders,such as depression, often engage in self-help treatments before seeking treatment
from a medical or mental health professional (Oliphant, 2009). Conceivably, they
may choose to engage in self-help treatments in an effort to maximize financial
savings, to refrain from consuming synthetic medications, or avoid negative stigmatization. People may also desire a more holistic treatment than allopathic careor psychotherapy can offer; perhaps this is why the use of complementary andalternative medicine (CAM) has surged. CAM is perceived as more wholesome,with fewer negative side effects than conventional treatments (Oliphant, 2009).

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Thus, individuals are using CAM to manage chronic pain, to improve health or
prevent negative health issues (Faass, 2006), and to treat mental health issues(Barnes, Bloom, & Nahin, 2008).
CAM is “a group of diverse medical and health care systems, practices, andproducts that are not generally considered part of conventional medicine” (National Center for Complementary and Alternative Medicine [NCCAM], 2010,
para. 2). Approximately two out of every five adults in the United States has
utilized CAM (Barnes et al., 2008). Specifically, anxiety and depression are twoof the mental health issues most commonly treated with CAM (Barnes et al.,2008; Pilkington, Kirkwood, Rampes, & Richardson, 2005). In fact, those with
anxiety, depression, or a comorbidity of these disorders are twice as likely to use
complementary and alternative treatments when compared to others with mental
health disorders and four times as likely when compared to those without any
mental health disorders (Wahlstrom et al., 2008).
One of the five domain categories of CAM treatments is mind-body interventions, defined as “interactions among the brain, mind, body, and behavior,
with the intent to use the mind to affect physical functioning and promotehealth” (NCCAM, 2010, para. 9). The use of CAM mind-body interventions
has increased, with yoga ranking as a commonly used CAM mind-body intervention (Barnes et al., 2008). Saper, Eisenberg, Davis, Culpepper, and Phillips(2004) found that yoga is commonly used to treat anxiety and depression.
Perhaps people are attracted to yoga because they desire to integrate the bodyand the mind in healing. 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). However, finding
mental health professionals who integrate mind-body dualism in their practice
can be difficult; psychotherapeutic approaches are conceived as existing on acontinuum of verbal interactions and an integration of awareness of the body
(Leijssen, 2006).
Yoga is meant to supplement conventional treatments for clients with various
mental health disorders, including anxiety and depression (Gerbarg & Brown,2007). The practice of yoga alone cannot correct mental illness (Douglass, 2009);
professional help is necessary to treat the primary cause of the disorder (Torkos,
2008). Interestingly, as Douglass (2009) found in her research, mental healthprofessionals recognize that yoga may be a beneficial therapeutic supplement topsychotherapy, but they are not entirely informed about why or how yoga is effective. Thus, mental health professionals may benefit from learning what makes
yoga effective and why and how to incorporate their learning into their practicewith clients. By understanding the relationship between yoga and physiological
functioning, mental health professionals will likely appreciate the benefits ofyoga and, therefore, possibly offer a more comprehensive and desired mind-bodytherapeutic treatment.

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philosophical tenets of yoga
Definition
Yoga is an approximately 5,000-year-old ancient “science, art, and philosophy”
derived from East Indian culture (Austin & Laeng, 2003, p. 282). The father ofyoga, Patanjali, devised yoga to be one of six philosophy systems to unite the bodyand mind and to also unite the personal spirit with the Universal spirit (Iyengar,
1966). To fully educate the reader about yoga within the scope of this article would
be impossible. People can study and practice yoga for a lifetime yet still remainin the infancy stages of understanding yoga (Austin & Laeng, 2003). Thus, myintention in writing this article is to provide an introductory understanding of
yoga and its relevance for mental health professionals.
The word yoga translates from Sanskrit to English as “‘to yoke,’ reflecting its
purpose in joining the mind and body in harmonious relaxation” (Dey, Barrett,& Yuan, 2003, p. 172). Since yoga first began to be practiced in North America,
most people practicing yoga place less emphasis on the philosophical practiceand more emphasis on the physical postures, breathing techniques, and forms of
meditation (Austin & Laeng, 2003).
Hatha yoga is the most commonly practiced style of yoga in North America.
It is intended to create physical and emotional balance between body and mind
(Dey et al., 2003). Iyengar is known for developing Iyengar yoga, a popular typeof Hatha yoga that focuses on “technical alignment” of the body (Riley, 2004,
p. 21). He is also revered for promoting the practice of yoga “as a form of healthcare throughout the world” (Austin & Laeng, 2003, p. 284). Ashtanga and Vini­
yoga are also popular types of Hatha yoga and focus on movement between the
postures (Riley, 2004). Regardless of the style of Hatha yoga, a contemporary
practice involves concentrated breath work through a variety of standing, seated,and balancing postures followed by forms of twists and backbends or inversions,and ends with a relaxation or meditation posture (Austin & Laeng, 2003).
Breath work. The Sanskrit word prana signifies the spirit and has various English
meanings including “breath … life … [or] energy” (Iyengar, 1966, p. 44). Yogic
breathing techniques may be stimulating and create energy, such as Ujjayi breathing, while other techniques may be calming and create balance, such as Bhastrika
breathing (Gerbarg & Brown, 2007). Accordingly, the ability to rhythmicallycontrol the breath through inhalation, exhalation, and retention in an effort toreach a pure mind is important; mastering the breath squelches cravings anddistractions in the mind and fosters control over the senses, leading to a state ofconcentration (Iyengar, 1966). A mind that is clear and free from thoughts andcravings may be considered pure: carefree, motionless, and mindless; this mind
is ready for concentration, meditation, and self-examination (Iyengar, 1966).
Reaching this state is important because concentration restores tranquility in themind (Iyengar, 1966).
Physical postures. The physical postures, known in Sanskrit as asanas, positively
alter “flexibility, strength, coordination, balance, and circulation” of the musculo­Integrating Yoga with Psychotherapy

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skeletal system (Austin & Laeng, 2003, p. 285). Each posture was created to servea purpose: exercise of a distinct body part (Iyengar, 1966). Other physical training
tools (e.g., weights) are unnecessary, as the body and its limbs provide the required
tools (Iyengar, 1966). As a result, postures can be weight-bearing, stabilizing, ormobilizing (Austin & Laeng, 2003).
While the postures benefit the body physically, they also benefit the mind
(Iyengar, 2002). For example, physical postures can stimulate psychologicaland emotional responses and can change energy levels (Austin & Laeng, 2003).
Postures “can be sequenced to … induce a variety of effects, such as to ground,soothe, stimulate, or revitalize one’s energy level” (Austin & Laeng, 2003, p. 287).
Specifically, forward bends have a calming or soothing effect (Austin & Laeng,2003); backbends and inversions are invigorating (Austin & Laeng, 2003); andbalancing postures “help develop psychoemotional poise and strength” (Austin& Laeng, 2003, p. 288).
Meditation. Once the body, the mind, and the senses have been stilled throughthe physical postures and the concentrated breath work, meditation can begin (Iyengar, 1966). Meditation is an advanced state of contemplation reached throughsustained concentration over a period of time (Iyengar, 1966). In the deepest stateof meditation, the body and the senses are relaxed, and the mind is alert but notdistracted (Iyengar, 1966).
literature review
There have been an abundance of studies examining yoga as an effective clinical treatment intervention for psychological and physiological concerns. Khalsa(2004) completed an extensive review of the literature examining all of the clinicalstudies published that used yoga as a therapeutic intervention for psychologicaland physiological concerns. He found that there is some evidence to support theuse of yoga as a treatment intervention for popular physical health concerns, suchas cardiovascular and respiratory conditions, as well as for mental health conditions such as depression, anxiety, and addiction (Khalsa, 2004). Since Khalsa’s
review, additional researchers have found similar results; yoga has shown to be aneffective physical intervention for the management of cardiovascular conditions(Donesky-Cuenco, Nguyen, Paul, & Carrieri-Kohlman, 2009), respiratory conditions (Vempati, Bijlani, & Deepak, 2009), chronic pain (Kolasinski et al., 2005),
neurological conditions (John, Sharma, Sharma, & Kankane, 2007), as well as
mental health disorders such as depression (Butler et al., 2008; Chen et al., 2009;
Franzblau, Echevarria, Smith, & Van Cantfort, 2008; Krishnamurthy & Telles,
2007; Shapiro et al., 2007; Woolery, Myers, Sternlieb, & Zeltzer, 2004), anxiety (Descilo et al., 2010; Javnbakht, Kenari, & Ghasemi, 2009; Khalsa, Shorter,
Cope, Wyshak, & Sklar, 2009; Kozasa et al., 2008; Lavey et al., 2005; Smith,Hancock, Blake-Mortimer, & Eckert, 2007; Subramanya & Telles, 2009; Telles,
Guar, & Balkrishna, 2009; Telles, Naveen, & Dash, 2007; Telles, Singh, Joshi,& Balkrishna, 2010), and addiction (Khalsa, Khalsa, Khalsa, & Khalsa, 2008).

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To fully review the efficacy of yoga as a treatment intervention for all physicaland mental health disorders is outside the scope of this article. Given that anxiety
and depression are the two most common mental health disorders being treatedwith CAM (particularly yoga), a review of the research findings for these two specific mental health disorders and plausible psychophysiological reasons to explain
the research findings will be given. Below is a discussion of the relevant researchstudies conducted on yoga and anxiety, as well as yoga and depression, from 2003
to 2010. The discussion is organized for both anxiety and depression using thethree major components of yoga: breath work, physical postures, and meditation.
Clinical Findings: Anxiety
breath work
Researchers speculated that devoting a large portion of time to focusing on
the concentrated breath work aspects of a yoga practice would substantially aid
in the reduction of symptoms of anxiety (Descilo et al., 2010; Khalsa et al., 2009;
Kozasa et al., 2008; Telles et al., 2010). Kozasa et al. (2008) concluded that after
one month of practicing breath work and meditation, both state and trait anxiety
scores significantly reduced. After practicing yoga for 2 months, participants in
the Khalsa et al. (2009) study reported an increase in self-confidence and clarity,
as well as a reduction in fatigue and musical performance tension and anxiety. The
physical and cognitive symptoms related to musical performance anxiety decreased
due to the practice of yoga, particularly the breathing techniques (Khalsa et al.,2009). Telles et al. (2010) concluded in their study on the effects of yoga breathing practices on anxiety that there was an increase in feelings of anxiety in thoseparticipants who did not participate in the yoga practice. In the same year, Descilo
et al. (2010) found that yoga breath work was effective in reducing symptoms ofdepression and anxiety, particularly posttraumatic stress disorder (PTSD).
physical postures
Khalsa et al. (2009) found that practicing yoga over a 2-month period improved
physical strength, increased flexibility, and reduced physical tension in young
musicians with performance anxiety. Attending three classes a week for 8 weeks,regardless of the physical intensity of the practice, created these physical changes
in the participants (Khalsa et al., 2009). In the study conducted by Javnbakht etal. (2009), state and trait anxiety scores decreased significantly in women 30 to
40 years old after practicing yoga twice a week for 2 months. These researchers
credited the decrease in anxiety scores to yoga’s ability to increase body awareness(including body tension) and foster a sense of confidence and control over the
body (Javnbakht et al., 2009).
meditation
Subramanya and Telles (2009) compared the effects of cyclic meditation (yogapostures followed by supine rest) and supine rest (a relaxing yoga posture such as

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shavasana) on levels of anxiety and memory scores. A short yoga practice of cyclic
meditation (22:30 minutes) was significantly more effective in increasing memory
scores and almost four times as effective in decreasing anxiety as the same amountof supine rest (Subramanya & Telles, 2009).
yoga theory and philosophy
Researchers concluded that both practicing yoga and learning yoga theory are
effective in reducing stress and symptoms of anxiety (Khalsa et al., 2009; Telles
et al., 2009). For example, Khalsa et al.’s (2009) study contained two groups:
one only practiced yoga and the other practiced and learned yoga theory. Bothgroups experienced decreased stress and performance anxiety (Khalsa et al.,2009). Telles et al. (2009) also found similar results in their study with twogroups: one group practiced yoga and the other group watched a video to learn
yoga theory. All participants reported a decrease in anxiety; however, participants who completed the 2-hour yoga practice reported a more significant decrease in anxiety symptoms (14.7%) than those participants who watched thevideo (3.4%; Telles et al., 2009).
Interestingly, when yoga was compared to conventional relaxation techniquesdesigned to aid in stress management and decreasing anxiety (e.g., progressive
muscle relaxation), yoga was found to be equally “as effective as relaxation with
reducing stress and anxiety” (Smith et al., 2007, p. 81). Smith et al. (2007) concluded that yoga might be a safe way for people to assist themselves in managing
symptoms related to anxiety and stress.
Clinical Findings: Depression
breath work
Practicing yoga breathing techniques for 45 minutes for 4 days was helpful
in decreasing battered women’s feelings of depression (Franzblau et al., 2008).
Franzblau et al. (2008) found a significant decrease in depression scores in participants who received training in yoga breath work; specifically, participants wholearned yoga breath work practices and also gave testimony experienced the mostsignificant decrease in depression scores.
physical postures
Woolery et al. (2004) studied the effects of yoga on reducing symptoms of depression in young adults with mild depression. Researchers over a 5-week period
examined a 1-hour Iyengar yoga class that focused on physical postures that “aresupposed to alleviate depression, particularly back bends, [vigorous] standing
poses, and inversions” (Woolery et al., 2004, p. 61). As expected, the inversions,standing physical postures of Iyengar yoga, as well as those postures that open
and lift the chest, were effective in reducing depression scores by almost one-thirdand significantly improving mood (Woolery et al., 2004). Woolery et al. (2004)
proposed that the backbends, inversions, and standing postures “enhanced feelings

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of mastery … [and] may have countered the slumped body posture associatedwith depression” (p. 62).
Shapiro et al. (2007) also examined Iyengar yoga postures as an additional treatment for people experiencing symptoms of remission but taking antidepressant
medications for unipolar major depression (Shapiro et al., 2007). After the study
participants took 20 sessions of yoga practice three times weekly, Shapiro et al.
found that an Iyengar yoga practice with inversions, standing postures, and postures that expand the chest were helpful in diminishing mood-related symptoms
of depression. The physical postures positively increased mood state experiencesof people with depression and also positively reduced other mental health areas
such as anxiety; participants 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)(Shapiro et al., 2007). Interestingly, researchers concluded that improvements inmood after a yoga practice are not dependent on gender or having a mood disorderdiagnosis (Lavey et al., 2005).
meditation
Krishnamurthy and Telles (2007) studied changes in depression scores inseverely depressed seniors after practicing yoga versus receiving ayurveda medicine (herbal preparations). After 6 months of practicing yoga 6 days a week for
75 minutes a day, only the participants who practiced yoga showed significant
decreases in depression (Krishnamurthy & Telles, 2007). Krishnamurthy andTelles reported that participants most enjoyed the last 15 minutes of the practicespent on devotional spiritual meditation songs; the songs “may have been able
to give participants a group experience of expressing emotions, as well as a better
acceptance of themselves” (2007, p. 22). Butler et al. (2008) also examined theeffects of yoga, including meditation, on symptoms of chronic mild depression.
Participants who received yoga and meditation training experienced the largest
remission rate at 77% and did not develop any new depressive episodes regardless of using medications or receiving psychotherapy (Butler et al., 2008). Butler
et al. concluded that meditation in yoga “may be used to let go of thoughts thatmaintain the depressive affect” (p. 816).
yoga theory and philosophy
No published studies were found in this exhaustive literature review on depression and how learning yoga theory and philosophy affects levels of depression.
Explanations of Yoga’s Potency
After practicing yoga, people often report many “beneficial emotional, psychological, behavioral, and biological effects” (Shapiro et al., 2007, p. 501); an
increased feeling of well-being is one important example (Dey et al., 2003). People
experience beneficial changes to both the mind and body because “yoga createschange in the neurophysiology of the body” (Douglass, 2009, p. 127). The con-

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nection between yoga and psychophysiology is gaining interest from researchers,
and several hypotheses have been put forth to explain why yoga creates cognitiveand 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 ofyoga on several neurotransmitters known to be involved with anxiety and depression; cortisol, gamma-aminobutyric acid (GABA), serotonin, and melatonin arestrongly related to the regulation of stress and mood (Douglass, 2009).
breath work
Researchers examined ANS functioning and noted that yoga, especially thebreath work, increases heart rate variability (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) can 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 to counteract the ANS
causes the sympathetic and the parasympathetic nervous system to function effectively in response to stress instead of “becoming hypo-reactive or hyper-reactive”(Brown & Gerbarg, 2005a, p. 195).
physical postures
People anecdotally report feeling more at ease after a yoga practice (Douglass, 2009). 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). A stress response is a physical or cognitive reaction “resulting
from various disturbing physical, emotional, or chemical factors” (Sarbadhikari& Saha, 2006, Background, para. 2). Interestingly, Granath, Ingvarsson, vonThiele, and Lundberg (2006) found that after 10 sessions of a yoga practicefocused on physical postures, an increased level in cortisol occurred in participants. Woolery et al. (2004) also found that after 10 yoga classes emphasizing
Iyengar style postures, those who completed a regular 1-hour practice, twice a
week, had higher levels of morning cortisol by the end of the 5 weeks than thecontrol group who did not participate in yoga activities. Higher levels of cortisol are usually associated with a response to stress. However, in those people
who experience above-average levels of a stress response, normal homeostasis ofneurobiological systems may be disrupted (Lydiard, 2003). Thus, researchers

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suggested that finding increased levels of morning cortisol may 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 ofneurobiology.
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 1-hour session of yoga postures,
Streeter et al. (2007) indeed found that GABA levels increased by approximately
one-quarter when compared with baseline measurements, regardless of the typeof yoga practiced.
Serotonin is also believed to improve mood states (Douglass, 2009). Davies etal. (2006) found that serotonin regulates both psychological and cardiovascularresponses to stress in people with anxiety. To this author’s knowledge, there havebeen no studies published on yoga’s effect on serotonin levels. However, Young(2007) noted that there are many non-pharmacological methods for increasing
serotonin, including exercise. Interestingly, Netz and Lidor (2003) examined theeffects of mindful exercise (e.g., yoga) versus aerobic exercise (e.g., swimming)on anxiety and depressive mood. These researchers concluded that after just one
session, mindful exercise more effectively reduced anxiety and increased positivemood than aerobic exercise (Netz & Lidor, 2003). Netz and Lidor proposed that
this finding may be due to the cognitive focus found in mindful activities.
meditation
Melatonin is believed to regulate mood and sleep patterns (Douglass, 2009). In
Harinath et al.’s (2004) study, researchers found that participants had increased
melatonin levels after practicing yoga, particularly meditation. Additionally, researchers found that people with depression who practiced yoga reported feelingmore positive about themselves and their health and also reported sleeping better(Chen et al., 2009). Harinath et al. (2004) hypothesize that the participants’ positive reports may be due to increased levels of melatonin.
Summary
Yoga reduced anxiety for people with state, trait, and performance anxiety as
well as for people with PTSD. The breath work practice, meditation practice, andlearning about yoga practices decreased feelings of anxiety, whereas the physicalpostures decreased the physical symptoms of tension and anxiety. Given that yoga
was found to be as effective as conventional relaxation techniques in reducing stressand 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 conven-Integrating Yoga with Psychotherapy

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tional psychotherapy. Particularly, the physical postures of Iyengar yoga had many
physical and cognitive benefits for people with depression. Focusing on posturesthat 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. Thus, yoga may be an appropriate non-pharmacological clinical intervention
for treating anxiety and depression (Javnbakht et al., 2009).
Research Critique
Several issues with the methodology of the studies reviewed may limit the validity of the results supporting the use of yoga as a clinical intervention for anxiety
and depression. The methodological issues preventing researchers from concluding that yoga is an effective treatment intervention for anxiety or depression are
fourfold. First, more rigorous research needs to be done, especially randomized,
controlled trials (RCTs). Approximately half of the studies reviewed were RCTs.
While the aforementioned studies show promising results, researchers are in theinfant stages of drawing conclusions about the efficacy of yoga as a treatment
intervention for anxiety and depression.
A second methodological concern is that 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. Researchers used a rangeof yoga interventions from gentle practices such as Hatha yoga to invigorating
practices such as Ashtanga yoga, which altered the types of breathing techniques,
physical postures, and forms of meditation. Also, the length of time, the amountof time, and the intensity of the yoga intervention varied; some participants inthe studies received one yoga intervention while other participants received days,
weeks, or months of practice. Thus, researchers may wish to focus on a style of yoga
and an aspect of yoga to narrow the scope of research. Additionally, researchers
could examine the benefits derived from a regular yoga practice over a substantial
period of time.
A third concern is that it is difficult to generalize the findings regarding yoga’s
potential effectiveness to all people with anxiety or depression because the participants in each study varied in ethnicity, age, sex, yoga experience, motivation,and severity of anxious or depressive symptoms. Participants in some studies were
East Indian while participants in other studies were not, which may potentiallyhave created biases in the results, given that yoga may be a familiar form of healthpractice in East Indian culture (Descilo et al., 2010).

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Some studies had participants similar in age while others had a range of ages.
Additionally, some studies included both male and female participants but others
included either female or male participants. Further, participants in some of thestudies were unfamiliar with yoga or yoga techniques while others were familiar
and were current yoga practitioners. The participants’ motivation and interest in
participating in yoga practice were also incongruent between studies. Finally, theseverity of anxious or depressive symptoms ranged from anticipated symptoms toformal diagnoses of disorders. As well, there was no consistency in the assessment
tools used to evaluate the anxiety and depression. Thus, it will be important for
researchers to conduct studies that have a larger sample size, as well as a representative sample population, in order to generalize findings.
Fourth, there is a paucity of information on safety or contraindications withrespect to yoga. Information on any adverse effects related to the practice of
yoga was not explored in any of the studies reviewed. However, it is importantthat people understand the techniques of yoga to avoid incorrect practices
leading to harmful consequences. For example, people with a pre-existing
medical condition such as pregnancy should avoid practicing certain breathing techniques (Sharma, 2007). Thus, it will be important for researchers to
examine any contraindications and determine which type of yoga is appropriate for people who do have pre-existing health conditions or comorbid healthconditions.
Implications for Researchers
How researchers measure the effectiveness of yoga is complicated. There is alack 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 tomeasure quantitatively with RCTs (Spencer, 2003). Applying Western scientificscrutiny to the holistic practice of yoga may jeopardize the sacredness and holistic
unity of yoga. Conceivably, both qualitative and quantitative methods may be
useful in validating the effectiveness of yoga. Quantitative evidence “shows effects
that are statistically significant according to predefined criteria [but] do not address why an intervention is effective, meaningful, or beneficial” (Lake, 2007, p.
71) whereas qualitative data assess “the impact of a treatment on quality of life”(Lake, 2007, p. 71).
Interestingly, Indian researchers have conducted most of the research on theeffectiveness of yoga (Khalsa, 2004). In comparison, Western researchers havepublished fewer studies, but they have conducted more RCTs than Indian researchers (Khalsa, 2004). Khalsa (2004) posited that researchers, particularly
Indian researchers, should implement research designs that are more rigorous tocontinue to validate the effectiveness of yoga as a clinical treatment intervention.
The development of a standardized yoga practice manual may be helpful for effectively studying yoga in a respectful yet rigorous way (Uebelacker, Epstein-Lubow,
et al., 2010; Uebelacker, Tremont, et al., 2010).

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143suggestions for practice for mental health professionals
Despite the lack of conclusive research evidence to support integrating yoga
as an effective clinical treatment, yoga continues to be a popular complementary
and alternative treatment. Integrating yoga with psychotherapy may allow mental
health professionals to work more collaboratively with clients. Uebelacker, Tremont, et al. (2010) argued that yoga and psychotherapy can be easily married, as
there “are many similarities between psychotherapy and yoga” (p. 259), both are
multidimensional, and each can be implemented uniquely (Uebelacker, Tremont,
et al., 2010). However, most mental health professionals do not have training
in CAM (Bassman & Uellendahl, 2003). Consequently, integrating yoga withpsychotherapy encourages mental health professionals to refer clients to suitableyoga classes, collaborate with a yoga therapist to co-manage clients, and/or becomeyoga therapists themselves to deliver both psychotherapy and yoga in one session.
For clients with anxiety or depression who are willing to participate in community-based yoga classes, yoga may be used as a supplement to psychotherapy.
Accordingly, it is important that clients be accurately matched to a suitable type of
yoga (Boudette, 2006). Thus, a large onus is placed on the mental health professional to be sufficiently informed about the practice of yoga and about suitabletypes of yoga to help the client select an appropriate class. Additionally, a large
onus is placed on the client to be willing to participate in a community-basedyoga class; clients need to feel safe doing yoga in order to benefit from the practice.
For clients who may resist joining a community-based yoga class, mental
health professionals may alternatively refer clients with a diagnosis of anxiety and/or depression 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 aperson’s mental and physical health (Khalsa et al., 2009). In such a scenario, theclient may complete a session with the mental health professional and then join
the yoga therapist for a private, supervised, and uniquely designed yoga practice.
Both the referring mental health professional and the yoga therapist may work
together to co-manage clients and deliver a suitable mind-body treatment.
Given that the licensing procedures greatly vary for CAM practitioners (White,
2000), it is helpful for mental health professionals to be aware of competent CAM
practitioners to guide the referral process for the client. If clients are left on theirown to find a CAM practitioner, they may find a practitioner who is licensed
but “less than fully competent and trustworthy” (Bassman & Uellendahl, 2003,
p. 267). Currently, there is a lack of national standards regulating the licensing
process for yoga therapists (Douglass, 2009). Thus, it would be beneficial for mental health professionals interested in using yoga with psychotherapy to familiarize
themselves with local yoga therapists suitably qualified to co-manage clients with
anxiety and depression.
For mental health professionals who wish to offer yoga and psychotherapy asa mind-body treatment in a single cohesive session, seeking dual accreditation

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to also become a licensed yoga therapist is necessary. Interestingly, White (2000)
pioneered the idea of an integrative medical psychology that combines psychology
with CAM interventions to provide more holistic care. White is a dually trained
practitioner: she is a psychologist, and she is also a CAM practitioner trained “inOriental medicine and homeopathy” (p. 678). White acknowledged that being adually trained practitioner does create many questions about boundaries and may
elicit uncertainty for clients. However, she noted that in many CAM practices, theoffering of a “body-mind treatment” by one practitioner is extremely beneficial(White, 2000, p. 679).
Implications for Practice
Several implications arise when combining yoga and psychotherapy; mental
health professionals can offer a larger continuum of care, but their legal and ethicalresponsibilities will also expand.
continuum of care
For mental health professionals, integrating yoga with psychotherapy enables
them to offer an expanded continuum of care beyond psychotherapeutic andpharmacological interventions. Therapy can be individualized for the needs ofeach client, rather than making all clients fit one psychotherapeutic approach(Strozier, 2008). Expanding the continuum of care to include yoga may help
mental health professionals consider new ways of understanding mental health,illness, and healing. It is possible that mental health professionals have failed to
notice the value in providing wholesome solutions “in addition to or in lieu of
psychotherapy and prescription medications” to address mental health concerns(White, 2009, p. 633).
legal responsibilities
Mental health professionals assume a far greater burden of liability, including greater legal accountability for malpractice, by incorporating CAM withpsychotherapy even when they co-manage clients with CAM practitioners or use
CAM themselves within psychotherapeutic sessions (Cohen & Schouten, 2007).
Therefore, mental health professionals providing CAM mind-body treatments
could collect clients’ detailed medical history to avoid recommending a complementary and alternative treatment that may negatively harm pre-existing medical
conditions (Cohen & Schouten, 2007). For example, mental health practitioners
should avoid recommending certain yoga breath work techniques to clients who
hyperventilate, faint, or have high blood pressure because it may exacerbate clients’anxiety (Sharma, 2007).
Additionally, mental health professionals should provide treatment that has
research evidence to support its effectiveness (Cohen & Schouten, 2007). Cohen
and Schouten (2007) recommended that conventional treatments should be theinitial form of care, especially if the client’s “condition can be readily cured byconventional care” (p. 24). Lake (2007) maintained that it is safe to combine

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conventional treatments with CAM when there is sufficient evidence from RCTs
regarding the efficacy of each treatment; case studies may be considered for CAM
when few RCTs have been completed. Thus, for people with anxiety or depression
who are interested in combining yoga with treatment, it may be advantageous formental health professionals to recommend conventional psychotherapeutic andpharmacological treatments first before the incorporation of yoga is considered.
However, given that the conventional treatment for anxiety and depression is notalways effective, that people may not want to take medications, that people may
desire a more holistic treatment, and that there are minimal risks associated withan informed yoga practice, yoga is a viable treatment option to consider alongsideconventional treatments in the decision-making process.
ethical responsibilities
Mental health professionals have an increased ethical responsibility to get informed consent before integrating any treatments with clients (Canadian Association of Social Workers [CASW], 2005; Canadian Counselling and Psychotherapy
Association [CCPA], 2007; Canadian Psychological Association [CPA], 2000).
Ensuring that clients are sufficiently educated about treatment options in decisionmaking is necessary. It is optimal to collaborate with clients to assess and examine
the risks and the benefits of combining treatment options, including the safetyof combining conventional and complementary treatments (Lake, 2007). Mental
health professionals also have an increased ethical responsibility to be accurate andhonest about their areas of competence, knowledge, and practice, and need toreceive adequate training and supervision before declaring competency in various
treatments (CASW, 2005; CCPA, 2007; CPA, 2000). White (2009) recommended
15 hours of training as the minimum for psychologists to sufficiently learn about
CAM. Additionally, mental health professionals have an increased ethical responsibility to adhere to ethical principles of confidentiality, especially when referring
and/or co-managing clients with other professionals (CASW, 2005; CCPA, 2007;
CPA, 2000). Finally, mental health professionals have an increased responsibility to manage boundaries (CASW, 2005) and dual relationships (CCPA, 2007;
CPA, 2000), especially if they are accredited as both mental health professionals
and CAM practitioners (they will also have to manage two sets of codes of ethics,
scopes of practice, and licensing procedures).
Thus, it is extremely important that mental health professionals do notrecommend or force yoga on clients who are uninformed about the risks andbenefits of a yoga practice or who are ambivalent or uncomfortable with theintervention; integrating yoga works best for clients interested in participating
in and committing to a regular yoga practice. If a mental health professional
is not adequately trained as a yoga therapist, the professional should be honest about his or her lack of training and competency with the client and not
implement yoga practices within sessions but should instead refer the client toa qualified yoga therapist. Mental health professionals should also respect client
confidentiality when collaborating with yoga therapists. Some clients may share

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the same information with both a yoga therapist and a mental health professional, while others may choose to share only certain information with either
professional.
Finally, if trained in both disciplines, the professional has to carefully establish
appropriate boundaries as both a mental health professional and a yoga therapist
in the relationship with the client. For example, in most talk therapies, the mental
health professional does not touch the client, whereas in a yoga session, the yoga
therapist may touch the client to adjust the posture or support a position. Being
cognizant of the differing boundaries of the two professional roles should help
navigate the dual relationship with the client.
conclusion
People often seek alternative ways to manage their anxiety and depression;
self-help treatments such as yoga seem to offer desirable physical and mental
benefits, especially when conventional treatments for anxiety and depression
may not always be desirable or effective. Thus, addressing anxiety and depression
through the concentrated breath work practices, physical postures, and meditationof yoga may be an additional way for mental health professionals to treat anxiety and depression. Accordingly, it is important that mental health professionals
encourage more rigorous research to further support the efficacy of yoga as aclinical treatment intervention for anxiety and depression, as there is a paucity inthe current research. Those mental health professionals who choose to use yoga as
a complementary treatment with psychotherapy may work more collaboratively
with clients, deliver a more individualized therapeutic treatment, and implementa more holistic therapy.
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About the Author
Andrea L. Forfylow is a graduate of the Campus Alberta Applied Psychology Consortium, Masterof Counselling program. She is a Canadian Certified Counsellor. Her research and specializationinterests include addiction, adolescent identity development, complementary and alternative
medicine (yoga), and multicultural counselling (First Nations).
Address correspondence to Andrea Forfylow; e-mail andreaforfylow@hotmail.com