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Integrating Yoga Into Psychotherapy

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.

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.

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.

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.

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