Integrating yoga into psychotherapy: The ethics of moving from the mind to the mat

Abstract

Given the rise in attention to client preferences in medical treatment and the shift in focus toward health promotion, it is not surprising that the use of complementary health approaches have increased in the past several years. Yoga is among the most prominent complementary health approaches. Recently, both qualitative and quantitative work has emerged supporting its use for a variety of medical and psychological disorders. However, there is a critical gap in knowledge regarding how to most optimally and ethically integrate complementary therapies (i.e., yoga) into current psychology practices. Moreover, it remains unclear which clients are the best candidates for receiving such complementary treatments and which therapists should provide them. The purpose of this paper is to provide an overview of the history of yoga, the scientific evidence in support of its use for mental health issues, and an ethical framework to guide psychologists interested in integrating yoga into psychotherapy.

Modern medical treatment now highlights the importance of maintaining mental and physical well-being in addition to mitigating ongoing disease and psychopathology [3]. Moreover, awareness of client-centered care, in particular taking consideration of client preferences of treatment, has increased [11]. Importantly, complementary and alternative approaches to treatment have increased in parallel with this [23]. Additionally, 65% of people in psychotherapy reported using at least one form of complementary and alternative medicine (CAM) in the prior year [9]. It is therefore becoming increasingly more relevant to understand how complementary treatments, such as yoga, may benefit individuals with mental health problems and how psychotherapists may go about ethically integrating such practices.

1. Shifting medical paradigms

Biomedical to biopsychosocial

Previous conceptualizations of health care in the United States emphasized the biomedical model, which proposed disease was a derangement in an underlying physical mechanism [19]. Specifically, mental and physical health were largely treated separately, with physical complaints usually given priority over mental health issues. Because of the higher value placed upon physical problems, fewer resources were devoted to mental health care, leaving many mental/behavioral problems untreated. Despite much success of the biomedical approach to treating disease, including increased life expectancy [19], from 1996 to 2006, diagnoses of psychological disorders increased by 60% among adults aged 18–64 [12]. Rates of psychotropic medication also increased similarly during this time [12]. Therefore, there was a lack of treatment available other than psychopharmaceuticals, which led to a failure to adequately address mental health issues, and thus, to the emergence of a paradigm shift from authoritative to more collaborative. From this, resulted the biopsychosocial model [10], a more comprehensive, multi-factorial, holistic approach to treating pathology, with an awareness that both mental and physical health interact. With this shift from conventional medicine to mind-body medicine, came the mindfulness meditation movement, positive psychology, and yoga as feasible and available ways to treat and maintain health.

Integration of CAM

In both previous and recent models of disease and health, evidence based practice has been a critical component in influencing and disseminating the most effective treatment strategies. Psychotherapists build off of this by combining empirical evidence and clinical judgment to determine best treatment avenues for individual client needs. It is striking, and encouraging to consider how far mental health care has come since the initiation of the biomedical approach. For example, health professionals, including psychotherapists are in an unprecedented era where not only do they have the traditional, well-known and standard tools to treat clients, but also a number of complementary and alternative methods that have been established as potential treatments. Because of this, psychotherapists are in a unique position to educate clients about the use of CAM and integrate specific CAM modalities into treatment when appropriate.

2. Yoga: brief history, benefits, and significance to psychotherapists

Brief history of yoga

Over the past ten years, there has been a three-fold increase in the number of publications on yoga research, with mental health disorders among the top three disorders addressed in these yoga intervention studies [18]. Yoga, an ancient practice with its roots in India, originated as a discipline to help relieve suffering and disease [17]. Under the umbrella term of “mind-body practice”, yoga includes physical movement (asana), meditation (dhyana), and breathing (pranayama). While initially a practice of the Eastern world, yoga has increasingly become more popular in the West (i.e., United States) and has been proposed as a prominent holistic wellness approach [18]. According to the National Health Interview Survey (NHIS) yoga is one of the most commonly used complementary health practices among adults, with more than 15 million adults practicing yoga in the United States [24]. Numbers of those practicing are on the rise, with an increase of approximately three million people between 2002 and 2007 [5]. The National Center for Complementary and Integrative Health (NCCIH) has determined many reasons why people practice yoga, including for musculoskeletal conditions, to treat specific medical conditions, and to maintain health and well-being [7].

Benefits of yoga

Moreover, current scientific research has confirmed what ancient yogis have thought for centuries: practicing yoga may reduce certain forms of pain, improve quality of life, reduce stress, and relieve symptoms of a number of psychological disorders [15,26]. Specifically, previous work has suggested that yoga is an effective method for reducing muscular tension, which may precipitate pain, and therefore, may have important therapeutic implications for a variety of issues such as chronic pain and headaches [14]. Additionally, research had found that yoga’s potential for reducing stress-related symptoms is so well-established that the National Institute of Health recommended meditation over prescription drugs as the preferred treatment for mild hypertension in 1984 [4]. In particular, regular yoga practitioners were found to have lower levels of the stress hormone, cortisol, in their saliva [30]. Finally, yoga appears to have benefits in treating internalizing disorders, such as anxiety and depression, such that among young adults with mild depression, practicing yoga was found to decrease self-reported symptoms of depression, improve acute mood (decreasing levels of negative mood and fatigue immediately after yoga class), and improve morning cortisol levels [31]. Additionally, yoga has been shown to be effective for reducing anxiety symptoms in specific populations, including the elderly [2], AIDS and HIV patients [8], individuals with asthma [13], organ-transplant recipients [21], psychiatric patients [22], individuals with irritable bowel syndrome [29], children with Attention-Deficit Hyperactivity Disorder (ADHD) [16], and individuals with Obsessive-Compulsive Disorder (OCD) [20]. Other work has highlighted that yoga reduces examination anxiety, and it may be effective in reducing anxiety because of its capacity to lower excitability and increase concentration and self-control [25]. Findings also suggested that a 60-minute yoga session in experienced practitioners is acutely associated with a 27% increase in GABA levels, an inhibitory neurotransmitter that induces relaxation and reduces stress and anxiety [27]. Anxiety and depression are marked by low GABA levels, so this suggests yoga should be explored as a possible treatment for such issues.

Significance to psychotherapists

In light of continued interest in and evidence for the therapeutic benefits of yoga to promote health and alleviate psychological symptoms, this practice is of particular relevance for psychotherapists. Importantly, psychotherapists can expand their continuum of care by integrating yoga into their interventions and tailoring therapy to each individual, targeting the needs of each client [28]. Moreover, psychotherapists can teach clients yoga skills (e.g., breath work) that they can practically and safely use outside of the therapy session, which may lead to gains in psychological improvement [16,25]. However, there is a critical need to aid clinicians (e.g., psychotherapists) in ethically integrating yoga into their work with clients.

3. Ethical considerations to setting up an integrative practice

Important standards to consider

Notably, there are several ethical standards to consider when integrating yoga into a psychotherapy practice. Providing the highest standard of care to clients takes several forms. First, from the stance that the psychotherapist will be the one providing yoga to the client, it is important for the psychotherapist to have sufficient competence in this area. Alternatively, if the psychotherapist is not providing the yoga, they will instead need to be adequately informed to make appropriate referrals for their clients. This falls under Standard 2, Competence, of the American Psychological Association’s ethical standards, which requires that psychologists provide services within the boundaries of their competence [1]. Additionally, they are required to maintain their competence through continuing education in order to stay informed about emerging developments in the field. Psychologists are required to base their work upon scientific and professional knowledge of the discipline. Given that many psychotherapists may not have formal training in yoga, it would become relevant in this circumstance to obtain such training. The appropriate training for psychologists interested in providing yoga to clients remains an open question. According to the APA ethical standards, when an area is still emerging (e.g., integration of CAM techniques) and preparatory training does not yet exist, the psychologist is required to take the appropriate and reasonable steps to ensure the competence of their work and to protect their clients.

Second, Standard 3, Human Relations, and specifically, Avoiding Harm (3.04) informs psychologists to take reasonable steps to avoid causing harm to their clients and to minimize harm where it is avoidable. Again, while it is unclear at this time what the most optimal training would be for a psychologist interested in using yoga, it may be that a psychologist with a certificate in yoga is best suited to lead such training. Moreover, the aforementioned training may include how psychological principles connect with yogic philosophy, as well as provide practical tools and guidelines for clinicians to begin using this in their practice.

Third, and relatedly, psychotherapists will need to turn a keen eye to Standard 3, Multiple Relationships (3.05). It will be important for psychologists to maintain their professional role with the client, given they will now have two roles that could be perceived by the client: therapist and yoga teacher. Importantly, under this standard, the psychologist is required to consider if entering into a multiple relationship could be expected to impair their objectivity, competence, or effectiveness. Again, given that both roles (psychotherapist and yoga teacher) should be treated with a similar level of professionalism in this context, the psychologist will likely not be in danger of this; however, as the standard states, the psychologist should take steps to resolve any issue that may result. For example, the psychologist could have a conversation with the client prior to beginning treatment to learn about the client’s preference regarding unexpected contact outside of the therapy setting.

Fourth, once a psychologist makes a decision to move forward with their practice, such that they have determined they can competently do so, without harm, and without negative consequences of engaging in multiple relationships, they must appropriately set up their practice to include providing sufficient information to their client at the outset of the professional relationship. This will enable the client to decide whether or not to participate in this treatment. This informed consent process applies both to the yoga end of their practice (3.10), as well the general therapy side (10.01). Specifically, it will be important to include the risk and benefits of yoga, and also the nature of therapy, potentially integrating the theoretical orientation of the psychotherapist and how this orientation might connect with yogic philosophy.

Finally, some additional, and important ethical standards to consider include Cooperation with Other Professionals (3.09), as some clients may need their primary care physician to clear certain physical activity used in yoga. Psychologists should be also cognizant of their expectations related to record keeping and fees (Standard 6), as in yoga it may be common for the student/teacher to trade services if the services seem fundamentally similar in nature (e.g., massage therapy for yoga classes). However, because therapy will also be a part of the service, the psychologist should determine up front how to handle potential bartering with clients.

4. Ethical decision making in addressing potential conflicts: a clinical vignette

Dilemma: Boundaries on physical contact

Typically, in therapy, the psychotherapist has little to no physical contact with the client (which may differ based on cultural considerations), however in yoga, it is common for the practitioner to use touch to help a client be more comfortable in a pose, avoid injury, and move more deeply into a posture. Therefore, a particular ethical dilemma that arises in the context of a psychotherapist integrating yoga with their client is one of boundaries: to touch or not to touch? Specifically, the remainder of this paper will consider a client with a traumatic history, as an example of how to approach ethically integrating the use of yoga into traditional psychotherapy, with a lens toward boundary implications.

Clinical Vignette

Consider a client with whom you’ve been working for several sessions, a young woman presenting with symptoms of post-traumatic stress disorder (PTSD) following a sexual assault. Your client is interested in using yogic techniques to reduce her symptoms, especially in hopes of reducing the negative physiological symptoms she has been experiencing, and you also see the value in doing so. In your first session, the client has consented to both the use of yoga and psychotherapy, and included in that consent form, was a description that touch is sometimes used in yoga for the following reasons: increase comfort, avoid injury, and deepen a pose. As you begin to guide her in the physical practice of yoga, you notice she seems to be uncomfortable in certain poses; in particular it appears she’s compromising integrity of the pose which could result in injury. Given this client’s traumatic history, which involved crossing of physical boundaries, you question the appropriateness of using touch.

Decision-making model applied

Behnke’s four bin approach is a useful ethical decision-making model that involves considering four issues (legal, clinical, ethical, and risk-management) and may be especially helpful in considering how to address this dilemma. According to Behnke’s decision-making model, differentiation and integration is key to this approach [6]. Particularly, the four bins are not interchangeable, and integrating them is important to achieve a coherent response to the dilemma. First, a therapist should consider the dilemma from a legal perspective to determine if there are any federal or state laws pertinent to this issue. Because the client has already consented to the use of yoga, it is likely that there will be no legal issues that arise. However, “informed” consent explicitly implies that the client has a comprehensive understanding of all aspects of the treatment in which they will engage, and in this case, the therapist may choose to reiterate and confirm that the client indeed is comfortable with the use of touch. Second, in line with Behnke’s model, a psychotherapist should seek supervision by asking others in practice for their input about potentially using touch in the yoga portion of psychotherapy. Supervision is critical component of training as a psychologist and serves as a method by which the psychologist can gain perspective from other mental health professionals on complex issues. Third, under this approach, if collegial consultation has proven insufficient, a psychotherapist may also choose to contact an ethics office of the American Psychological Association to identify areas of the ethical code to consider. However, this step is only necessary if the issue seems critical enough and if it could not be resolved in the other ways previously mentioned. Fourth, the psychotherapist will also want to consider questions related to how a certain course of action will increase or decrease their exposure to liability (risk-management). Finally, the psychologist should remember the principles of beneficence and non-maleficence that remind us to choose interventions that are most likely to benefit clients and to also do no harm to clients. The use of physical contact can be powerful and trigger positive or negative feelings in the client, so always considering if the touch is beneficial to the client remains key. Moreover, a comprehensive understanding of the client’s psychological history may be useful in aiding the therapist to make decisions over whether or not to use touch. Further, communication and consent from the client around this issue is vital, and creating a comfortable atmosphere where clients can make informed decisions about their treatment, including the use of touch is important.

With a growing interest in the use of complementary and integrative health approaches for treating mental health problems, it has become increasingly more relevant for mental health providers to gain a better understanding of how CAM modalities may affect their clients. Importantly, yoga has emerged as one of the most commonly used CAM modalities in particular, and psychologists interested in integrating this modality will need to have an understanding of the current research, as well as the ethical implications of such an integrative practice. Future directions may include establishing a standardized protocol for training psychotherapists how to integrate yoga with their clients, with an eye toward setting up one’s practice ethically and suggestions for ethical decision-making when it comes to the most common conflicts that could arise (e.g., physical contact). The present research adds to a growing body of literature that suggests CAM approaches, such as yoga, can be ethically used in psychotherapy to meet individual client needs, while alleviating psychopathological symptoms and promoting well-being.