Available online at www.sciencedirect.com Cognitive and ScienceDirect Behavioral Practice ELSEVIER Cognitive and Behavioral Practice 16(2009)59-72 www.elsevier.com/locate/cabp Yoga and Mindfulness:Clinical Aspects of an Ancient Mind/Body Practice Paul Salmon,Elizabeth Lush,Megan Jablonski,and Sandra E.Sephton Department of Psychological and Brain Sciences,University of Louisville,Louisville,KY 40292 The use of Yoga and other complementary healthcare interventions for both clinical and non-clinical populations has increased substantially in recent years.In this context,we describe the implementation of Hatha Yoga in the Mindfulness-Based Stress Reduction (MBSR)program of Kabat-Zinn and colleagues.This is embedded in a more general consideration of Yoga's place in complementary healthcare.In providing this overview,we comment on the nature and quality of current research on Yoga,summarize current physiological and psychological explanations of its effects,and discuss practical issues related to teacher training and experience. A.Introduction and Overview about the implementation of these practices-particularly There is a long-standing interest in the health benefits Yoga-in either clinical or research contexts.Concerning of Yoga in India and other non-Western cultures.Yoga is clinical research,studies generally provide little detailed currently experiencing a marked increase in popularity in information about specific intervention elements in terms the West,primarily in health clubs and wellness centers. of either content or process factors,and instead focus One program which has advanced the status of Yoga in attention primarily on outcome measures. clinical settings is the mindfulness-based stress reduction Yoga as discussed here refers to an integrative physical/ (MBSR)program developed by Kabat-Zinn (1990)and spiritual practice which developed in ancient India.We colleagues.This work has stimulated extensive clinical capitalize the word Yoga'throughout in recognition of its practice and research in acceptance-based psychological historical stature as a highly evolved cultural system of interventions in recent years (Germer.2004:Haves and beliefs and practices,even though clinical applications Feldman,2004).Outcome studies reviewed elsewhere tend to 'de-contextualize'it from its cultural and spiritual (Baer,2003;Salmon,Sephton,Weissbecker,Hoover, roots.The word Yoga'means 'yoke'or 'union'and Ulmer,Studts,2004)attest to its promise as a clinical connotes the interconnection of mind,body,and spirit. intervention.A meta-analysis of health benefits associated Yoga practice in Western contexts involves sequences of with MBSR (Grossman.Niemann,Schmidt.Walach. postures,called asanas,that incorporate regulated breath- 2004)reached a similar conclusion,but noted a relative ing and focused attention.Ongoing practice is reported absence of methodologically rigorous studies,and a lack by practitioners to promote psychological well-being and of detail concerning intervention specifics. a variety of physical benefits.Although the focus in Indeed,much of the writing about mindfulness Western Yoga practices is usually on the asanas,they interventions to date has focused on conceptual defini- comprise only the most basic of what are characterized as tions and broadly-defined outcome measures,to the the 'Eight Limbs of Yoga,'a cumulative series of stages relative neglect of the program's content and structure, embodying ethical principles of behavior and meditative particularly with respect to Yoga.Kabat-Zinn has written states compiled by the Indian sage Patanjali in a collection extensively about the nature of the original MBSR of aphorism known as sutras (Desikachar,1999).There program (Kabat-Zinn,1996,2003b)and described three are different paths that Yoga practitioners may follow,the key components -sitting meditation,Hatha Yoga,and most widely practiced being Hatha Yoga (physical devel- body scan (a sustained mindfulness practice in which opment);Gnyana Yoga (developing the intellect);Bhakti attention is sequentially directed throughout the body)- Yoga (spiritual devotion);and Karma Yoga (practical at great length.However,little has been written elsewhere action;Patel,1993).The form practiced in the MBSR program,and indeed in most Western healthcare 1077-7229/08/59-72$1.00/0 contexts,is Hatha Yoga. 2008 Association for Behavioral and Cognitive Therapies. The inclusion of Yoga in the MBSR program is Published by Elsevier Ltd.All rights reserved. interesting and warrants detailed consideration.Aside
Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice Paul Salmon, Elizabeth Lush, Megan Jablonski, and Sandra E. Sephton Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY 40292 The use of Yoga and other complementary healthcare interventions for both clinical and non-clinical populations has increased substantially in recent years. In this context, we describe the implementation of Hatha Yoga in the Mindfulness-Based Stress Reduction (MBSR) program of Kabat-Zinn and colleagues. This is embedded in a more general consideration of Yoga’s place in complementary healthcare. In providing this overview, we comment on the nature and quality of current research on Yoga, summarize current physiological and psychological explanations of its effects, and discuss practical issues related to teacher training and experience. A. Introduction and Overview There is a long-standing interest in the health benefits of Yoga in India and other non-Western cultures. Yoga is currently experiencing a marked increase in popularity in the West, primarily in health clubs and wellness centers. One program which has advanced the status of Yoga in clinical settings is the mindfulness-based stress reduction (MBSR) program developed by Kabat-Zinn (1990) and colleagues. This work has stimulated extensive clinical practice and research in acceptance-based psychological interventions in recent years (Germer, 2004; Hayes and Feldman, 2004). Outcome studies reviewed elsewhere (Baer, 2003; Salmon, Sephton, Weissbecker, Hoover, Ulmer, & Studts, 2004) attest to its promise as a clinical intervention. A meta-analysis of health benefits associated with MBSR (Grossman, Niemann, Schmidt, & Walach, 2004) reached a similar conclusion, but noted a relative absence of methodologically rigorous studies, and a lack of detail concerning intervention specifics. Indeed, much of the writing about mindfulness interventions to date has focused on conceptual definitions and broadly-defined outcome measures, to the relative neglect of the program’s content and structure, particularly with respect to Yoga. Kabat-Zinn has written extensively about the nature of the original MBSR program (Kabat-Zinn, 1996, 2003b) and described three key components – sitting meditation, Hatha Yoga, and body scan (a sustained mindfulness practice in which attention is sequentially directed throughout the body) – at great length. However, little has been written elsewhere about the implementation of these practices – particularly Yoga – in either clinical or research contexts. Concerning clinical research, studies generally provide little detailed information about specific intervention elements in terms of either content or process factors, and instead focus attention primarily on outcome measures. Yoga as discussed here refers to an integrative physical/ spiritual practice which developed in ancient India. We capitalize the word ‘Yoga’ throughout in recognition of its historical stature as a highly evolved cultural system of beliefs and practices, even though clinical applications tend to ‘de-contextualize’ it from its cultural and spiritual roots. The word ‘Yoga’ means ‘yoke’ or ‘union’ and connotes the interconnection of mind, body, and spirit. Yoga practice in Western contexts involves sequences of postures, called asanas, that incorporate regulated breathing and focused attention. Ongoing practice is reported by practitioners to promote psychological well-being and a variety of physical benefits. Although the focus in Western Yoga practices is usually on the asanas, they comprise only the most basic of what are characterized as the ‘Eight Limbs of Yoga,’ a cumulative series of stages embodying ethical principles of behavior and meditative states compiled by the Indian sage Patanjali in a collection of aphorism known as sutras (Desikachar, 1999). There are different paths that Yoga practitioners may follow, the most widely practiced being Hatha Yoga (physical development); Gnyana Yoga (developing the intellect); Bhakti Yoga (spiritual devotion); and Karma Yoga (practical action; Patel, 1993). The form practiced in the MBSR program, and indeed in most Western healthcare contexts, is Hatha Yoga. The inclusion of Yoga in the MBSR program is interesting and warrants detailed consideration. Aside 1077-7229/08/59–72$1.00/0 © 2008 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved. Available online at www.sciencedirect.com Cognitive and Behavioral Practice 16 (2009) 59–72 www.elsevier.com/locate/cabp
60 Salmon et al. from a mindfulness-based program for depression (Wil- Gong (Ospina et al.,2007).Our intention is to highlight liams,Teasdale,Segal,Kabat-Zinn,2007),Yoga has recent findings from methodologically rigorous studies, received little attention in clinical psychology,despite an which until recently have been relatively few in number. extensive research literature documenting its benefits in As is the case with meditation research as recently noted stress reduction and other contexts (Khalsa,2007).One by Walsh and Shapiro(2006)many studies involving Yoga obvious reason for this omission is that few psychologists as both a lifestyle and clinical practice have been have much experience or training in Yoga and other conducted over the years.Unlike meditation research. physical disciplines.A second possible reason for a lack of however,much of the research on Yoga originated in attention in clinical contexts is that Yoga is associated by Indian research institutes,beginning in the early 20th many more with fitness and health than as a treatment for century.Few of these early studies employed research illness,despite its historical roots in Indian Ayurvedic methodologies now taken for granted,but they did serve medicine. the important function of signaling a new view of Yoga as a Yoga has generated considerable empirical research in form of health and medical care,rather than an other contexts,especially Indian medical practice,which exclusively spiritual practice (Khalsa,2007). we comment on below.Its comparative exclusion from Currently Yoga is among the 10 most widely practiced clinical psychology is something of an anomaly,and this forms of complementary healthcare in the U.S.(Barnes, article is an attempt to rectify this oversight.In discussing Powell-Griner,McFann,Nahin,2004).Yoga practice is the program which he formulated,Kabat-Zinn (1990) linked to demographic variables including gender notes that Yoga was originally included for the practical (female),education level (high),age (post-WWII birth), purpose of helping medical patients overcome disuse and lifestyle (urban;Saper,Eisenberg,Davis,Culpepper, atmophy -deterioration of muscle tissue due to lack of &Phillips,2004).As a result of its growing popularity,Yoga activity-that frequently accompanies illness.In addition, is becoming a focus of increasing clinical research in this however,and perhaps of even greater importance,Yoga country. provides an opportunity to practice mindfulness.Yoga is Results of well-designed recent randomized trials introduced in the program once participants have been employing Yoga as a clinical intervention report promis- exposed to the Body Scan,a physically static exercise in ing results.For example,Yoga has been shown to improve which attention is systematically directed toward internal management of Type II diabetes mellitus (Innes and sensations emanating from different regions of the body, Vincent,2006),relieve chronic low back pain (Sherman, beginning with the feet and progressing to the head.The Cherkin,Erro,Miglioretti,Deyo,2005),improve quality Yoga movement sequences have been formulated with the of life in patients with chronic pancreatitis (Sareen, intention of encouraging mindful awareness:they are Kumari,Gajebasia,Gajebasia,2007),reduce gastro- done slowly and gently and are not overly physically taxing. intestinal symptoms in irritable bowel syndrome(Kuttner, Much of the attention directed at the MBSR program Chambers,Hardial,Israel,Jacobson,Evans,2006),and focuses on sitting meditation,a predominantly cognitive improve the physical capabilities of healthy senior adults practice that has its roots in Buddhist meditation practices. (Oken et al.,2006).A recent article reviewing the impact Hatha Yoga,on the other hand,draws on related but of Yoga interventions on risk factors for chronic disease somewhat distinct cultural and philosophical traditions found evidence that Yoga elicits favorable changes in body that employ physical activity in the context of meditation weight,blood pressure,cholesterol,and blood glucose practice.That the two elements have been juxtaposed in levels (Yang,2007).Studies have also shown that Yoga the same program,along with the body scan,is something interventions are beneficial to emotional wellness,with of an anomaly,reflecting the particular experiences and improvements demonstrated in stress management training of those who originated the program. (Granath,Ingvarsson,von Thiele,Lundberg,2006) and depressive symptoms(Pilkington,Kirkwood,Rampes, B.Clinical Research Richardson,2005).Research studies vary in the degree In recent years,a substantial body of clinical research to which the Yoga practice is described in detail,and it is has accumulated attesting to the health benefits of Yoga.It quite evident from those that provide detailed informa- is not the purpose of this article to review the extant tion that there is considerable variation in how it is research literature;a recent comprehensive analysis of implemented. published studies by Khalsa(2004),and more selective Two recent research studies employing randomized reviews by Innes and Vincent(2006),Innes,Bourgignon, control designs are especially noteworthy in terms of and Taylor (2005),and Raub (2002)do this admirably. methodological rigor and detailed descriptions of the More recently,Yoga is included in an exhaustive review Yoga practice.In one study,38 patients with lymphoma and critique of health-oriented meditation studies invol- were randomly assigned to a seven week Tibetan-based ving mantra and mindfulness meditation,Tai Chi,and Qi Yoga program or a wait-list control group (Cohen
from a mindfulness-based program for depression (Williams, Teasdale, Segal, & Kabat-Zinn, 2007), Yoga has received little attention in clinical psychology, despite an extensive research literature documenting its benefits in stress reduction and other contexts (Khalsa, 2007). One obvious reason for this omission is that few psychologists have much experience or training in Yoga and other physical disciplines. A second possible reason for a lack of attention in clinical contexts is that Yoga is associated by many more with fitness and health than as a treatment for illness, despite its historical roots in Indian Ayurvedic medicine. Yoga has generated considerable empirical research in other contexts, especially Indian medical practice, which we comment on below. Its comparative exclusion from clinical psychology is something of an anomaly, and this article is an attempt to rectify this oversight. In discussing the program which he formulated, Kabat-Zinn (1990) notes that Yoga was originally included for the practical purpose of helping medical patients overcome disuse atrophy – deterioration of muscle tissue due to lack of activity – that frequently accompanies illness. In addition, however, and perhaps of even greater importance, Yoga provides an opportunity to practice mindfulness. Yoga is introduced in the program once participants have been exposed to the Body Scan, a physically static exercise in which attention is systematically directed toward internal sensations emanating from different regions of the body, beginning with the feet and progressing to the head. The Yoga movement sequences have been formulated with the intention of encouraging mindful awareness: they are done slowly and gently and are not overly physically taxing. Much of the attention directed at the MBSR program focuses on sitting meditation, a predominantly cognitive practice that has its roots in Buddhist meditation practices. Hatha Yoga, on the other hand, draws on related but somewhat distinct cultural and philosophical traditions that employ physical activity in the context of meditation practice. That the two elements have been juxtaposed in the same program, along with the body scan, is something of an anomaly, reflecting the particular experiences and training of those who originated the program. B. Clinical Research In recent years, a substantial body of clinical research has accumulated attesting to the health benefits of Yoga. It is not the purpose of this article to review the extant research literature; a recent comprehensive analysis of published studies by Khalsa (2004), and more selective reviews by Innes and Vincent (2006), Innes, Bourgignon, and Taylor (2005), and Raub (2002) do this admirably. More recently, Yoga is included in an exhaustive review and critique of health-oriented meditation studies involving mantra and mindfulness meditation, Tai Chi, and Qi Gong (Ospina et al., 2007). Our intention is to highlight recent findings from methodologically rigorous studies, which until recently have been relatively few in number. As is the case with meditation research as recently noted by Walsh and Shapiro (2006) many studies involving Yoga as both a lifestyle and clinical practice have been conducted over the years. Unlike meditation research, however, much of the research on Yoga originated in Indian research institutes, beginning in the early 20th century. Few of these early studies employed research methodologies now taken for granted, but they did serve the important function of signaling a new view of Yoga as a form of health and medical care, rather than an exclusively spiritual practice (Khalsa, 2007). Currently Yoga is among the 10 most widely practiced forms of complementary healthcare in the U.S. (Barnes, Powell-Griner, McFann, & Nahin, 2004). Yoga practice is linked to demographic variables including gender (female), education level (high), age (post-WWII birth), and lifestyle (urban; Saper, Eisenberg, Davis, Culpepper, & Phillips, 2004). As a result of its growing popularity, Yoga is becoming a focus of increasing clinical research in this country. Results of well-designed recent randomized trials employing Yoga as a clinical intervention report promising results. For example, Yoga has been shown to improve management of Type II diabetes mellitus (Innes and Vincent, 2006), relieve chronic low back pain (Sherman, Cherkin, Erro, Miglioretti, & Deyo, 2005), improve quality of life in patients with chronic pancreatitis (Sareen, Kumari, Gajebasia, & Gajebasia, 2007), reduce gastrointestinal symptoms in irritable bowel syndrome (Kuttner, Chambers, Hardial, Israel, Jacobson, & Evans, 2006), and improve the physical capabilities of healthy senior adults (Oken et al., 2006). A recent article reviewing the impact of Yoga interventions on risk factors for chronic disease found evidence that Yoga elicits favorable changes in body weight, blood pressure, cholesterol, and blood glucose levels (Yang, 2007). Studies have also shown that Yoga interventions are beneficial to emotional wellness, with improvements demonstrated in stress management (Granath, Ingvarsson, von Thiele, & Lundberg, 2006) and depressive symptoms (Pilkington, Kirkwood, Rampes, & Richardson, 2005). Research studies vary in the degree to which the Yoga practice is described in detail, and it is quite evident from those that provide detailed information that there is considerable variation in how it is implemented. Two recent research studies employing randomized control designs are especially noteworthy in terms of methodological rigor and detailed descriptions of the Yoga practice. In one study, 38 patients with lymphoma were randomly assigned to a seven week Tibetan-based Yoga program or a wait-list control group (Cohen, 60 Salmon et al
Yoga and Mindfulness:Clinical Aspects of an Ancient Mind/Body Practice 61 Warneke,Fouladi,Rodriguez.Chaoul-Reich,2004). although voluminous,much of this early research on Yoga The Yoga intervention incorporated regulated breathing was hampered by a range of methodological problems and imagery,mindfulness practice,and sequences of that detract from its empirical foundation and conse- postures (asanas)appropriate for individuals receiving quently limit its clinical utility (Khalsa,2007).For cancer treatment.The sole area of improvement con- example,a recent systematic review by Innes and Vincent cerned sleep quality;changes were noted in depression, (2006)evaluated the methodological rigor of 70 studies anxiety,or fatigue.The significance of this study lies in its published between 1970 and 2004 assessing the effect of robust experimental design,clear description of the Yoga on insulin resistance and cardiovascular disease.In intervention,and demonstration that Yoga can fruitfully terms of experimental design,the majority were observa- be practiced by medical patients receiving taxing treat- tional (1),non-controlled (26),or controlled but non- ment regimens.Yoga was employed in another rando- randomized (21);in contrast,only twenty-two studies mized controlled study (Moadel et al.,2007)involving a (31%)employed a randomized controlled design. multi-ethnic sample of breast cancer patients.The Methodological problems enumerated by these and intervention consisted of twelve weekly 90-minute sessions other authors have included:lack of statistical power, incorporating sequences of poses (asanas),meditation, small sample sizes,substantial variations in Yoga interven- and regulated breathing.This study was especially notable tion protocols,failure to control for possible explanatory for the positive outcomes reported (improved quality of confounds,questionable statistical analyses,and lack of life and emotional well-being,reduced distress),and specificity concerning randomization procedures.They acceptance by ethnically diverse participants. also pointed out that many of these studies were More generally,the therapeutic significance of move- conducted in non-Western clinical research contexts, ment-based interventions including Yoga,Tai Chi,and primarily in India,where Yoga is widely accepted within others was recently emphasized by van der Kolk(2006)in a the prevailing culture.Of the shortcomings noted above, discussion of neuro-cognitive aspects of PTSD.He pre- the most problematic from a research standpoint is the sented compelling evidence that regulation of physical current lack of specificity or standardization with respect movement is a fundamental priority of the nervous system, to the Yoga practice itself.Yang (2007)recently under- perhaps from an evolutionary standpoint even more scored the difficulties inherent in evaluating and replicat- important than regulation of emotional functions.Physical ing interventions without having detailed descriptions of therapies may benefit from'pre-wiring'that augments their the Yoga postures and their sequence,urging the impact on patterns of behavioral reactivity commonly development of a more standardized intervention that associated with various clinical conditions.In addition. could be replicated for research purposes.These meth- physical activity provides a rich source of present-moment odological concerns and contextual factors need to be interoceptive cues that can serve as a focal point for mindful addressed in designing future Yoga-based intervention attention that is comparatively well tolerated by trauma research and clinical practice.In general,the entire field victims,who may otherwise feel overwhelmed by inner of meditation-oriented research is in need of much grea- sensations.Van der Kolk notes however,that aside from ter methodological rigor and consistency (Ospina et al, mindfulness-oriented intervention models such as those of 2007).The fact that a relatively standardized approach to Kabat-Zinn (1990)and Linehan (1993).few Western Yoga practice has already been developed in the MBSR psychological models -even those that ascribe to a program is a promising development in this regard. mind/body perspective -make systematic use of body- centered or movement-based interventions. C.Underlying Physlological Processes The absence of movement therapies in Western Yoga-Hatha Yoga to be specific-involves physical psychotherapy and clinical practice is notable but activity,and in general both physical activity and exercise certainly understandable,given that what Freud termed have been linked to a variety of neurophysiological effects the 'talking cure'has historically placed more emphasis including B-endorphin release and altered brain neuro- on cognitive factors than on physical aspects of transmitter levels,especially dopamine and serotonin, behavior.It also reflects in part the mind/body which have emotion-enhancing effects (Buckworth and dichotomy that has traditionally characterized Western Dishman,2003).However,many of these changes occur health and medical care.In addition,relatively few in the context of relatively high intensity activity,which somatically-based practices have been thoroughly involves heightened activation of the sympathetic nervous empirically validated,despite their broad popularity. system (SNS).In contrast,most forms of Yoga (excluding This is the case,for example,with methods such as high intensity,aerobic variants such as Ashtanga Yoga) those developed by Feldenkrias,Alexander,and Pilates. elicit the 'relaxation response'described by Benson In contrast,Yoga attracted considerable research (1975),a state of physiological de-activation reflecting interest,beginning early in the 20th century.However, dominance of the parasympathetic nervous system(PNS)
Warneke, Fouladi, Rodriguez, & Chaoul-Reich, 2004). The Yoga intervention incorporated regulated breathing and imagery, mindfulness practice, and sequences of postures (asanas) appropriate for individuals receiving cancer treatment. The sole area of improvement concerned sleep quality; changes were noted in depression, anxiety, or fatigue. The significance of this study lies in its robust experimental design, clear description of the intervention, and demonstration that Yoga can fruitfully be practiced by medical patients receiving taxing treatment regimens. Yoga was employed in another randomized controlled study (Moadel et al., 2007) involving a multi-ethnic sample of breast cancer patients. The intervention consisted of twelve weekly 90-minute sessions incorporating sequences of poses (asanas), meditation, and regulated breathing. This study was especially notable for the positive outcomes reported (improved quality of life and emotional well-being, reduced distress), and acceptance by ethnically diverse participants. More generally, the therapeutic significance of movement-based interventions including Yoga, Tai Chi, and others was recently emphasized by van der Kolk (2006) in a discussion of neuro-cognitive aspects of PTSD. He presented compelling evidence that regulation of physical movement is a fundamental priority of the nervous system, perhaps from an evolutionary standpoint even more important than regulation of emotional functions. Physical therapies may benefit from ‘pre-wiring’ that augments their impact on patterns of behavioral reactivity commonly associated with various clinical conditions. In addition, physical activity provides a rich source of present-moment interoceptive cues that can serve as a focal point for mindful attention that is comparatively well tolerated by trauma victims, who may otherwise feel overwhelmed by inner sensations. Van der Kolk notes however, that aside from mindfulness-oriented intervention models such as those of Kabat-Zinn (1990) and Linehan (1993), few Western psychological models – even those that ascribe to a mind/body perspective – make systematic use of bodycentered or movement-based interventions. The absence of movement therapies in Western psychotherapy and clinical practice is notable but certainly understandable, given that what Freud termed the ‘talking cure’ has historically placed more emphasis on cognitive factors than on physical aspects of behavior. It also reflects in part the mind/body dichotomy that has traditionally characterized Western health and medical care. In addition, relatively few somatically-based practices have been thoroughly empirically validated, despite their broad popularity. This is the case, for example, with methods such as those developed by Feldenkrias, Alexander, and Pilates. In contrast, Yoga attracted considerable research interest, beginning early in the 20th century. However, although voluminous, much of this early research on Yoga was hampered by a range of methodological problems that detract from its empirical foundation and consequently limit its clinical utility (Khalsa, 2007). For example, a recent systematic review by Innes and Vincent (2006) evaluated the methodological rigor of 70 studies published between 1970 and 2004 assessing the effect of Yoga on insulin resistance and cardiovascular disease. In terms of experimental design, the majority were observational (1), non-controlled (26), or controlled but nonrandomized (21); in contrast, only twenty-two studies (31%) employed a randomized controlled design. Methodological problems enumerated by these and other authors have included: lack of statistical power, small sample sizes, substantial variations in Yoga intervention protocols, failure to control for possible explanatory confounds, questionable statistical analyses, and lack of specificity concerning randomization procedures. They also pointed out that many of these studies were conducted in non-Western clinical research contexts, primarily in India, where Yoga is widely accepted within the prevailing culture. Of the shortcomings noted above, the most problematic from a research standpoint is the current lack of specificity or standardization with respect to the Yoga practice itself. Yang (2007) recently underscored the difficulties inherent in evaluating and replicating interventions without having detailed descriptions of the Yoga postures and their sequence, urging the development of a more standardized intervention that could be replicated for research purposes. These methodological concerns and contextual factors need to be addressed in designing future Yoga-based intervention research and clinical practice. In general, the entire field of meditation-oriented research is in need of much greater methodological rigor and consistency (Ospina et al, 2007). The fact that a relatively standardized approach to Yoga practice has already been developed in the MBSR program is a promising development in this regard. C. Underlying Physiological Processes Yoga – Hatha Yoga to be specific – involves physical activity, and in general both physical activity and exercise have been linked to a variety of neurophysiological effects including β-endorphin release and altered brain neurotransmitter levels, especially dopamine and serotonin, which have emotion-enhancing effects (Buckworth and Dishman, 2003). However, many of these changes occur in the context of relatively high intensity activity, which involves heightened activation of the sympathetic nervous system (SNS). In contrast, most forms of Yoga (excluding high intensity, aerobic variants such as Ashtanga Yoga) elicit the ‘relaxation response’ described by Benson (1975), a state of physiological de-activation reflecting dominance of the parasympathetic nervous system (PNS). Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice 61
62 Salmon et al. Yoga is commonly practiced in a focused,yet relaxed respiration and neuromuscular function:and altered manner.It shares in common with meditative/contem- cognitive and neurophysiological status.It is also possible plative practices an emphasis on focused attention, that Yoga has direct beneficial effects on health that are reduced extraneous external stimulation,controlled mediated through other pathways related to neurological breathing,and relaxation;thus,it has much in common approach rather than avoidance (stress)mechanisms.It with stress reduction practices eliciting the relaxation may be fruitful for research to explore effects of Yoga on response.Such practices have been found to have serotonergic,dopaminergic,and endogenous opioid measurable effects on brain function assessed by imaging pathways. techniques (Lazar,Bush,Gollub,Fricchione,Khalsa, The physiological effects of relaxation have been Benson,2000),attention-related cognitive processing thoroughly documented in broad-based,clinical research, (Galvin,Benson,Deckro,Fricchione,Dusek,2006) beginning with the work of Benson (1975).However, and cardiorespiratory function (Danucalov,Simoes, comparatively few recent studies have examined the Kozasa,Leite,2008;Dusek et al.,2006),although the physiological effects of Yoga practice per se,and more strength of such effects varies depending on the specific methodologically rigorous studies are needed.Among the practice (Peng et al.,2004).A growing body of research handful of studies that have been conducted,one study of on biological and psychological correlates of movement is 35 male volunteers showed that heart rate and skin revealing new ways in which simple behavior patterns,for conductance decreased after a guided relaxation based example walking,interact reciprocally with cognitive and on Yoga (Vempati and Telles,2002),and another emotional states(Acevdeo and Ekkekakis,2006).Walking, demonstrated reductions in heart rate and blood pressure Yoga,and other repetitive motion patterns appear to among Type II diabetics after 40 days (Singh,Malhotra, restore and entrain the rhythmicity of biological functions Singh,Madhu,Tandon,2004).Benefits in autonomic that are often disrupted during periods of stress. function have been noted among samples of refractory A two-part physiological model has recently been epilepsy patients (increased parasympathetic function; proposed (Innes,Bourguignon,Taylor,2005)to Sathyaprabha et al.,2007)and in Type II diabetic patients account for the relaxation-inducing effects of Yoga.First, (reduced allostatic load parameters of glycemic load and it may help balance the reactivity of endocrine stress cardiac activity;Singh,Malhotra,Singh,Madhu, responses,perhaps ameliorating hyper-or hypoactivation Tandon,2004).To the extent that Yoga is linked to of the SNS and the hypothalamic-pituitary-adrenal(HPA) attention-focusing mindfulness,it is likely to reduce axis.Frequent stress-related activation and/or chronic sympathetic over-activation associated with PTSD symp- suppression of the SNS and HPA results in altered toms.Yoga may also be effective in reducing physiological catecholamine (epinephrine and norepinephrine)and symptoms of PTSD,particularly when pronounced cortisol secretion.Both SNS and HPA activation are autonomic hyperarousal is involved either directly associated with heightened arousal and reactivity states (Gupta,Lanius,Van der Kolk,2005),or in the context that are normally balanced by parasympathetic activation, of attention-focusing mindfulness (van der Kolk,2006). which exerts a restorative,energy-conservative effect. Despite these promising findings,more research on the Chronic stress may lead to imbalances in stress-related effects of Yoga on autonomic balance,HPA,metabolic, versus restorative neural responses,with damaging effects neuromuscular and neurocognitive functions is needed on other body systems including regulatory mechanisms before its specific effects can fully understood. (McEwen,1997;McEwen Lasley,2003:McEwen Seeman,1999).Yoga may curtail chronic stress-related D.Clinical Implementation activation,and potentially reduce allostatic load,the One of the most obvious challenges facing greater cumulative impact of chronic HPA and SNS activation acceptance of Yoga within mainstream Western health- (McEwen.1997). care has to do with its cultural,spiritual and social origins The second part of the hypothesis suggests that Yoga in India,where it flourished for centuries without the level enhances PNS activation through relaxation-inducing slow of empirical validation and scientific verification required movement patterns that reduce heart rate and blood for widespread acceptance in contemporary biomedical pressure via stimulation of the vagus nerve,which settings.As is the case with meditation,another connects cardiac control centers located in the brain 'imported'complementary health care practice,Yoga stem with the heart's intrinsic pacemaker,the sino-atrial has in recent years been transplanted into Western node (Powers and Howley,2006).In addition to altered culture and healthcare,where the enthusiasm of its autonomic and HPA function,Khalsa (2007)recently practitioners has been countered by the skepticism of the highlighted additional physiological mechanisms by biomedical community due to the lack of strong valida- which Yoga may exert its effects.These include:reduced tion data.Validation studies are needed oriented toward metabolic rate and lower oxygen consumption;improved the pragmatics of Western healthcare that value
Yoga is commonly practiced in a focused, yet relaxed manner. It shares in common with meditative/contemplative practices an emphasis on focused attention, reduced extraneous external stimulation, controlled breathing, and relaxation; thus, it has much in common with stress reduction practices eliciting the relaxation response. Such practices have been found to have measurable effects on brain function assessed by imaging techniques (Lazar, Bush, Gollub, Fricchione, Khalsa, & Benson, 2000), attention-related cognitive processing (Galvin, Benson, Deckro, Fricchione, & Dusek, 2006) and cardiorespiratory function (Danucalov, Simoes, Kozasa, & Leite, 2008; Dusek et al., 2006), although the strength of such effects varies depending on the specific practice (Peng et al., 2004). A growing body of research on biological and psychological correlates of movement is revealing new ways in which simple behavior patterns, for example walking, interact reciprocally with cognitive and emotional states (Acevdeo and Ekkekakis, 2006). Walking, Yoga, and other repetitive motion patterns appear to restore and entrain the rhythmicity of biological functions that are often disrupted during periods of stress. A two-part physiological model has recently been proposed (Innes, Bourguignon, & Taylor, 2005) to account for the relaxation-inducing effects of Yoga. First, it may help balance the reactivity of endocrine stress responses, perhaps ameliorating hyper- or hypoactivation of the SNS and the hypothalamic-pituitary-adrenal (HPA) axis. Frequent stress-related activation and/or chronic suppression of the SNS and HPA results in altered catecholamine (epinephrine and norepinephrine) and cortisol secretion. Both SNS and HPA activation are associated with heightened arousal and reactivity states that are normally balanced by parasympathetic activation, which exerts a restorative, energy-conservative effect. Chronic stress may lead to imbalances in stress-related versus restorative neural responses, with damaging effects on other body systems including regulatory mechanisms (McEwen, 1997; McEwen & Lasley, 2003; McEwen & Seeman, 1999). Yoga may curtail chronic stress-related activation, and potentially reduce allostatic load, the cumulative impact of chronic HPA and SNS activation (McEwen, 1997). The second part of the hypothesis suggests that Yoga enhances PNS activation through relaxation-inducing slow movement patterns that reduce heart rate and blood pressure via stimulation of the vagus nerve, which connects cardiac control centers located in the brain stem with the heart’s intrinsic pacemaker, the sino-atrial node (Powers and Howley, 2006). In addition to altered autonomic and HPA function, Khalsa (2007) recently highlighted additional physiological mechanisms by which Yoga may exert its effects. These include: reduced metabolic rate and lower oxygen consumption; improved respiration and neuromuscular function; and altered cognitive and neurophysiological status. It is also possible that Yoga has direct beneficial effects on health that are mediated through other pathways related to neurological approach rather than avoidance (stress) mechanisms. It may be fruitful for research to explore effects of Yoga on serotonergic, dopaminergic, and endogenous opioid pathways. The physiological effects of relaxation have been thoroughly documented in broad-based, clinical research, beginning with the work of Benson (1975). However, comparatively few recent studies have examined the physiological effects of Yoga practice per se, and more methodologically rigorous studies are needed. Among the handful of studies that have been conducted, one study of 35 male volunteers showed that heart rate and skin conductance decreased after a guided relaxation based on Yoga (Vempati and Telles, 2002), and another demonstrated reductions in heart rate and blood pressure among Type II diabetics after 40 days (Singh, Malhotra, Singh, Madhu, & Tandon, 2004). Benefits in autonomic function have been noted among samples of refractory epilepsy patients (increased parasympathetic function; Sathyaprabha et al., 2007) and in Type II diabetic patients (reduced allostatic load parameters of glycemic load and cardiac activity; Singh, Malhotra, Singh, Madhu, & Tandon, 2004). To the extent that Yoga is linked to attention-focusing mindfulness, it is likely to reduce sympathetic over-activation associated with PTSD symptoms. Yoga may also be effective in reducing physiological symptoms of PTSD, particularly when pronounced autonomic hyperarousal is involved either directly (Gupta, Lanius, & Van der Kolk, 2005), or in the context of attention-focusing mindfulness (van der Kolk, 2006). Despite these promising findings, more research on the effects of Yoga on autonomic balance, HPA, metabolic, neuromuscular and neurocognitive functions is needed before its specific effects can fully understood. D. Clinical Implementation One of the most obvious challenges facing greater acceptance of Yoga within mainstream Western healthcare has to do with its cultural, spiritual and social origins in India, where it flourished for centuries without the level of empirical validation and scientific verification required for widespread acceptance in contemporary biomedical settings. As is the case with meditation, another ‘imported’ complementary health care practice, Yoga has in recent years been transplanted into Western culture and healthcare, where the enthusiasm of its practitioners has been countered by the skepticism of the biomedical community due to the lack of strong validation data. Validation studies are needed oriented toward the pragmatics of Western healthcare that value 62 Salmon et al
Yoga and Mindfulness:Clinical Aspects of an Ancient Mind/Body Practice 63 interventions primarily to the extent that they reduce practices that form the core of the MSBR program,along pain and suffering associated with illness.Clearly,there is with sitting meditation and the body scan.Each of these a need to develop more systematic means of specifying practices,described in greater detail below,is taught the nature of Yoga-based interventions in clinical research during program sessions and then done at home using and practice.This is especially important owing to the narratives on tape or CD for guidance.To date,more than popularity of Yoga and the degree to which it is making 15,000 patients and participants from a variety of referral significant inroads into clinical healthcare.Establishing sources have taken the program.The evolution of a research guidelines for study design,intervention speci- consistent sequence of asanas in the MBSR program, fication,and teacher training are among the most practiced by thousands of medical patients,provides a pressing needs,all of which would contribute substantially relatively standardized,field-tested intervention that is to controlling confounding variables that detract from the worth consideration by anyone contemplating research rigor of most extant research.Complete and accurate on the clinical benefits of Hatha Yoga. intervention descriptions could allow researchers to further uphold the standards necessary for maintaining E.MBSR-based Yoga accuracy,reporting and corroborating results across In the context of the MBSR program,Yoga provides a studies.Providing the critical information necessary for means of practicing 'mindfulness in motion.'Practically accurate replication and implementing stricter protocol speaking,it also addresses the problem of'disuse atrophy' control across clinical trials may further substantiate the common in medical patients as a result of reduced physical use of Yoga as a treatment option among clinical activity.The structure and underlying philosophy of the populations.In this context,it is important to be able to MBSR program are described in detail by Kabat-Zinn evaluate both positive and negative outcomes and other (1990).The basic premise underlying mindfulness practice manifestations of individual differences. is that living 'in the present'can be an effective antidote to To date,there does not appear to be widespread the myriad stressors people experience as a result of agreement in this regard.There are several possible cognitively-based projections into the past or future often reasons for this.First,the term Yoga'encompasses many marked by regret,fear,or apprehension.The Yoga practice different forms of practice,of which perhaps the most consists of two separate sequences of asanas,performed in a widely practiced is Hatha Yoga,which as noted emphasizes state of focused,yet relaxed,awareness.Each sequence lasts physical development.But even within the domain of approximately 45 minutes,and is practiced using an Hatha Yoga there are variations,including Bikram, accompanying audio tape/CD for guidance.Participants lyengar,and Ashtanga Yoga.Second,Yoga has been are expected to devote between 45 and 60 minutes most implemented primarily in private studios and health clubs days of the week to various combinations of Yoga,the Body which do not share in common standards of practice. Scan and Sitting Meditation. Third,virtually all schools of Yoga emphasize the A recent study by Carmody and Baer (2008)attests to importance of individualized instruction and personal the impact of this component of the MBSR program. adaptation,a perspective that runs somewhat counter to These authors reported results from a large (n =172) the idea of standardization.An exception to this is Bikram within-subjects MBSR trial conducted among patients Yoga,which consists of an invariant sequence of asanas with varied medical conditions at the University of that has been patented by its founder,and which is taught Massachusetts Medical School.Because they carefully by certified teachers specifically trained to conduct the gathered patient home practice logs and assessed mind- classes.A practical problem with Bikram Yoga,however,is fulness skills before and after the intervention,the that it is taught in a very hot environment that limits its authors were able to document the importance of home application,especially with respect to medical patients.In practice in cultivating mindfulness skills and the con- addition,several of the poses themselves are quite sequent decrease in psychological symptoms.Signifi- challenging from a physical standpoint,and not well cantly,the Yoga practice (vs.Body Scan and Sitting suited to beginning practitioners unless they are carefully Meditation)was clearly most strongly associated with and individually supervised. improvements in psychological well-being,and reduction The MBSR-based Yoga sequences comprise one of the of both perceived stress and psychological symptoms.It is few relatively replicable models in this regard.Hatha Yoga especially noteworthy that Yoga-involving movement is practiced as part of an eight-week meditation-based and physical activity -was most effective in reducing program comprised of weekly 2.5-hour sessions con- psychological symptoms,a finding consistent with a ducted in a group format.Historically,most participants previous study by Kabat-Zinn,Chapman-Waldrop,and were referred to the program by physicians at the medical Salmon (1997). center,but self-referrals have increased significantly in Given the apparent impact of Yoga on MBSR out- recent years.As already noted,Yoga is one of three comes,a more detailed analysis of this aspect of the
interventions primarily to the extent that they reduce pain and suffering associated with illness. Clearly, there is a need to develop more systematic means of specifying the nature of Yoga-based interventions in clinical research and practice. This is especially important owing to the popularity of Yoga and the degree to which it is making significant inroads into clinical healthcare. Establishing research guidelines for study design, intervention specification, and teacher training are among the most pressing needs, all of which would contribute substantially to controlling confounding variables that detract from the rigor of most extant research. Complete and accurate intervention descriptions could allow researchers to further uphold the standards necessary for maintaining accuracy, reporting and corroborating results across studies. Providing the critical information necessary for accurate replication and implementing stricter protocol control across clinical trials may further substantiate the use of Yoga as a treatment option among clinical populations. In this context, it is important to be able to evaluate both positive and negative outcomes and other manifestations of individual differences. To date, there does not appear to be widespread agreement in this regard. There are several possible reasons for this. First, the term 'Yoga' encompasses many different forms of practice, of which perhaps the most widely practiced is Hatha Yoga, which as noted emphasizes physical development. But even within the domain of Hatha Yoga there are variations, including Bikram, Iyengar, and Ashtanga Yoga. Second, Yoga has been implemented primarily in private studios and health clubs which do not share in common standards of practice. Third, virtually all schools of Yoga emphasize the importance of individualized instruction and personal adaptation, a perspective that runs somewhat counter to the idea of standardization. An exception to this is Bikram Yoga, which consists of an invariant sequence of asanas that has been patented by its founder, and which is taught by certified teachers specifically trained to conduct the classes. A practical problem with Bikram Yoga, however, is that it is taught in a very hot environment that limits its application, especially with respect to medical patients. In addition, several of the poses themselves are quite challenging from a physical standpoint, and not well suited to beginning practitioners unless they are carefully and individually supervised. The MBSR-based Yoga sequences comprise one of the few relatively replicable models in this regard. Hatha Yoga is practiced as part of an eight-week meditation-based program comprised of weekly 2.5-hour sessions conducted in a group format. Historically, most participants were referred to the program by physicians at the medical center, but self-referrals have increased significantly in recent years. As already noted, Yoga is one of three practices that form the core of the MSBR program, along with sitting meditation and the body scan. Each of these practices, described in greater detail below, is taught during program sessions and then done at home using narratives on tape or CD for guidance. To date, more than 15,000 patients and participants from a variety of referral sources have taken the program. The evolution of a consistent sequence of asanas in the MBSR program, practiced by thousands of medical patients, provides a relatively standardized, field-tested intervention that is worth consideration by anyone contemplating research on the clinical benefits of Hatha Yoga. E. MBSR-based Yoga In the context of the MBSR program, Yoga provides a means of practicing 'mindfulness in motion.' Practically speaking, it also addresses the problem of ‘disuse atrophy’ common in medical patients as a result of reduced physical activity. The structure and underlying philosophy of the MBSR program are described in detail by Kabat-Zinn (1990). The basic premise underlying mindfulness practice is that living 'in the present' can be an effective antidote to the myriad stressors people experience as a result of cognitively-based projections into the past or future often marked by regret, fear, or apprehension. The Yoga practice consists of two separate sequences of asanas, performed in a state of focused, yet relaxed, awareness. Each sequence lasts approximately 45 minutes, and is practiced using an accompanying audio tape/CD for guidance. Participants are expected to devote between 45 and 60 minutes most days of the week to various combinations of Yoga, the Body Scan and Sitting Meditation. A recent study by Carmody and Baer (2008) attests to the impact of this component of the MBSR program. These authors reported results from a large (n = 172) within-subjects MBSR trial conducted among patients with varied medical conditions at the University of Massachusetts Medical School. Because they carefully gathered patient home practice logs and assessed mindfulness skills before and after the intervention, the authors were able to document the importance of home practice in cultivating mindfulness skills and the consequent decrease in psychological symptoms. Significantly, the Yoga practice (vs. Body Scan and Sitting Meditation) was clearly most strongly associated with improvements in psychological well-being, and reduction of both perceived stress and psychological symptoms. It is especially noteworthy that Yoga – involving movement and physical activity – was most effective in reducing psychological symptoms, a finding consistent with a previous study by Kabat-Zinn, Chapman-Waldrop, and Salmon (1997). Given the apparent impact of Yoga on MBSR outcomes, a more detailed analysis of this aspect of the Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice 63
64 Salmon et al. program is warranted.To date,however,neither of the (lengthening the spine;Coulter,2001).All of these two asana sequences have been systematically analyzed movements involve the spine,the key component of the either descriptively (i.e.in terms of the movements axial skeleton.Yoga sequences typically consist of asanas involved)or functionally,in terms of possible reasons incorporating all of these movement patterns throughout for their positive impact.Since physical inactivity is a a full range of spatial planes and physical orientations. common problem,both within the medical and general Focused attention and controlled breathing are essential population,it would be helpful from both a clinical and to proper practice.Attention-mindfulness-helps keep research standpoint to know more about the potential one anchored in the here and now'and also enhances benefits and possible liabilities of this intervention processing internal (proprioceptive,kinesthetic)and element.However,relatively few clinicians with tradi- external(visual,auditory/vestibular)cues that contribute tional academic programs have any experience from Yoga to physical alignment and posture.Controlled breathing is practice,and fewer still have pursued formal study and/or important for several reasons.First,it provides an anchor certification.And even for those who have such back- point for attention,as is also true in sitting meditation. grounds,working with diverse patient groups comprises a Second,it helps regulate the pacing of asana movements particular challenge.And yet,simply as a form of physical to keep them from becoming either too fast or slow.Third, activity,Yoga offers sufficient benefits to those with both conscious regulation of breathing helps control the physical and psychological health problems to warrant balance of sympathetic and parasympathetic activation, taking time to acquire firsthand knowledge and experi- the latter increasing in prominence as the breath deepens ence with it.As summarized by Buckworth and Dishman and slows.Finally,learning to 'breathe into'asanas (2003),physical activity is low in cost and can be done just especially physically challenging ones-often enables one about anywhere;is essentially devoid of adverse side to move deeply into physical configurations that are effects and negative social stigmata;and has well- inaccessible when breathing is shallow and tense.These documented effects on health and disease risk reduction. general principles are embedded within the MBSR Our discussion of the MBSR Yoga sequences is program,within the broader context of mindfulness. conducted with these issues in mind.We address the Hatha Yoga is introduced at two points in the MBSR following questions:First,how does the Yoga component program:During the third of eight weekly sessions,then correspond to generally accepted practice standards? again two sessions later.The first sequence is intended not Second,are these sequences designed in such a way that only to encourage physical activity for its own sake,but they can be practiced safely by patients with a wide range also to promote 'mindfulness in motion,'the idea of of medical conditions?Third.what would be the bringing focused attention to slow deliberate movements. minimum amount of training and experience needed Participants are encouraged to do each sequence in a by clinicians who want to incorporate Yoga into mind- deliberate manner,focusing on physical sensations fulness-based interventions? associated with moving into,through,and out of each Several excellent texts are available as background re- asana.This is potentially helpful for several reasons:it ferences,among them works by Desikachar (1999), provides a focal point for one's attention,and it allows Coulter (2001),and Iyengar (1997).Although differing moment-by-moment exploration of integrated movement considerably in detail and teaching approaches,the views patterns involving many different muscle groups impor- of these tend to converge on several key points.First, tant in everyday activities such as walking,lifting, focused attention is a key aspect of effective Yoga practice. balancing,and turning. Second,beneficial effects of Yoga depend on careful, The first sequence involves a series of prone and deliberate,and persistent practice,emphasizing correct supine positions beginning and ending with participants form and breathing,and attention to moment-by-moment lying on their backs in savasana,the 'corpse'pose.(Yoga sensations as they arise in the course of sequences of poses have descriptive and often highly evocative Sanskrit postures.Third,Yoga has more to do with exploring capa- names.Entering into a pose,one is encouraged to bilities and limits in a non-judgmental way than perfor- embody characteristics of the object represented by the mance of physically challenging poses.In fact,a guiding name.The second sequence is a series of poses that principle articulated by Desikachar (1999)is to "start begins with a fundamental standing pose,tadasana where you are,"which is intended to convey the import- ('mountain'pose)and ends with savasana.Each ance of working within existing physical boundaries,which sequence is approximately 45 minutes in length.In both tend to broaden and become less confining over time. sessions,the poses are demonstrated by the instructor Yoga is generally practiced in systematic sequences of while participants do them as best they can,making asanas based on five 'families'of physical movements. allowances for whatever physical limitations may interfere These include a)forward bends;b)backward bends;c) with range of motion,balance,strength,or mobility. side twists:d)lateral (side)flexion:and e)axial extensions Given that the average class size of some MBSR programs
program is warranted. To date, however, neither of the two asana sequences have been systematically analyzed either descriptively (i.e. in terms of the movements involved) or functionally, in terms of possible reasons for their positive impact. Since physical inactivity is a common problem, both within the medical and general population, it would be helpful from both a clinical and research standpoint to know more about the potential benefits and possible liabilities of this intervention element. However, relatively few clinicians with traditional academic programs have any experience from Yoga practice, and fewer still have pursued formal study and/or certification. And even for those who have such backgrounds, working with diverse patient groups comprises a particular challenge. And yet, simply as a form of physical activity, Yoga offers sufficient benefits to those with both physical and psychological health problems to warrant taking time to acquire firsthand knowledge and experience with it. As summarized by Buckworth and Dishman (2003), physical activity is low in cost and can be done just about anywhere; is essentially devoid of adverse side effects and negative social stigmata; and has welldocumented effects on health and disease risk reduction. Our discussion of the MBSR Yoga sequences is conducted with these issues in mind. We address the following questions: First, how does the Yoga component correspond to generally accepted practice standards? Second, are these sequences designed in such a way that they can be practiced safely by patients with a wide range of medical conditions? Third, what would be the minimum amount of training and experience needed by clinicians who want to incorporate Yoga into mindfulness-based interventions? Several excellent texts are available as background references, among them works by Desikachar (1999), Coulter (2001), and Iyengar (1997). Although differing considerably in detail and teaching approaches, the views of these tend to converge on several key points. First, focused attention is a key aspect of effective Yoga practice. Second, beneficial effects of Yoga depend on careful, deliberate, and persistent practice, emphasizing correct form and breathing, and attention to moment-by-moment sensations as they arise in the course of sequences of postures. Third, Yoga has more to do with exploring capabilities and limits in a non-judgmental way than performance of physically challenging poses. In fact, a guiding principle articulated by Desikachar (1999) is to qstart where you are,q which is intended to convey the importance of working within existing physical boundaries, which tend to broaden and become less confining over time. Yoga is generally practiced in systematic sequences of asanas based on five 'families' of physical movements. These include a) forward bends; b) backward bends; c) side twists; d) lateral (side) flexion; and e) axial extensions (lengthening the spine; Coulter, 2001). All of these movements involve the spine, the key component of the axial skeleton. Yoga sequences typically consist of asanas incorporating all of these movement patterns throughout a full range of spatial planes and physical orientations. Focused attention and controlled breathing are essential to proper practice. Attention – mindfulness – helps keep one anchored in the ‘here and now’ and also enhances processing internal (proprioceptive, kinesthetic) and external (visual, auditory/vestibular) cues that contribute to physical alignment and posture. Controlled breathing is important for several reasons. First, it provides an anchor point for attention, as is also true in sitting meditation. Second, it helps regulate the pacing of asana movements to keep them from becoming either too fast or slow. Third, conscious regulation of breathing helps control the balance of sympathetic and parasympathetic activation, the latter increasing in prominence as the breath deepens and slows. Finally, learning to ‘breathe into’ asanas – especially physically challenging ones – often enables one to move deeply into physical configurations that are inaccessible when breathing is shallow and tense. These general principles are embedded within the MBSR program, within the broader context of mindfulness. Hatha Yoga is introduced at two points in the MBSR program: During the third of eight weekly sessions, then again two sessions later. The first sequence is intended not only to encourage physical activity for its own sake, but also to promote 'mindfulness in motion,' the idea of bringing focused attention to slow deliberate movements. Participants are encouraged to do each sequence in a deliberate manner, focusing on physical sensations associated with moving into, through, and out of each asana. This is potentially helpful for several reasons: it provides a focal point for one's attention, and it allows moment-by-moment exploration of integrated movement patterns involving many different muscle groups important in everyday activities such as walking, lifting, balancing, and turning. The first sequence involves a series of prone and supine positions beginning and ending with participants lying on their backs in savasana, the ‘corpse’ pose. (Yoga poses have descriptive and often highly evocative Sanskrit names. Entering into a pose, one is encouraged to embody characteristics of the object represented by the name.) The second sequence is a series of poses that begins with a fundamental standing pose, tadasana (‘mountain’ pose) and ends with savasana. Each sequence is approximately 45 minutes in length. In both sessions, the poses are demonstrated by the instructor while participants do them as best they can, making allowances for whatever physical limitations may interfere with range of motion, balance, strength, or mobility. Given that the average class size of some MBSR programs 64 Salmon et al
Yoga and Mindfulness:Clinical Aspects of an Ancient Mind/Body Practice 65 is between 25 and 40 participants,it is not possible for Following the instruction session during the third class, instructors to provide individualized feedback to partici- participants are asked to do the Yoga on days that pants.Instead,program instructors consistently empha- alternate with the body scan,using an audio tape or CD size the importance of working within one's particular which provides guided instructions.Unlike some Yoga physical capabilities and limitations,using the experience practices (Iyengar Yoga in particular),MBSR-based Yoga as an opportunity for mindfulness practice.This tends to does not make use of any special props or ancillary defuse any tendencies to treat the Yoga as a purely equipment.It is recommended that home practice be physical practice or as an offshoot of the unfortunately done in a safe area on a soft,non-slip surface (for which a prevalent“no pain,no gain”school of thought. Yoga mat would be ideal).The poses themselves have The instructor provides an ongoing commentary been selected so as to minimize inordinate physical throughout the duration of the session,describing the demands.The rationale behind such a 'minimalist' movement into and out of each asana in detail,and approach is threefold:first,it helps avoid establishing commenting frequently on the importance of moment- perceived barriers to practice by emphasizing simplicity. by-moment attention.In general,the poses are not Second,it characterizes the Yoga as an opportunity for especially challenging from a physical standpoint,and mindfulness practice,where perceptual clarity is of have much in common with what one might expect to greater importance than physical activity itself.Third,it find in a very basic Yoga class.In fact,the asanas which minimizes physical demands in order to create a safe comprise MBSR Yoga are in some ways preparatory to a environment for program participants and instructors regular class,since they consist primarily of extremely alike. basic standing,sitting,prone,and supine postures. The second Yoga sequence is traditionally introduced Nonetheless,even such apparently simple postures can during the fifth week of the program.Doing so provides an pose extreme physical challenges for certain individuals, expanded repertoire of asanas,providing participants with and it is important to keep in mind that they were selected an alternative sequence that can subsequently be incor- to begin with as being relatively accessible to a wide range porated into one's personal mindfulness practice. of medical patients in a hospital setting. Although there is some overlap between the two Participants are encouraged to 'work at their own sequences,they are sufficiently distinct to expand the level,'relying essentially on internal proprioceptive feed- range of stretches to incorporate a wide range of physical back to gauge the suitability and safety of doing the capabilities and inclinations.As is true with the first various poses.They are also encouraged to notice,and be sequence,the emphasis is on doing the practice in a respectful of,physical 'boundaries'or limits that arise in focused,deliberate,mindful manner.Each sequence ends the course of doing the asanas as a result of one's with a quiet rest period-savasana,the 'corpse'pose- particular degree of flexibility and mobility.The idea that done in a supine position,with the focus of one's attention is conveyed is to work within safe boundaries,but at the on the breath.The Yoga sequences are illustrated in Kabat- same time allow oneself to 'move up to'and explore Zinn (1990),and we recommend that they be studied in sensations denoting a level of physical intensity that may detail by anyone considering incorporating them into an signify a beneficial degree of stretching or movement that MBSR-based intervention.Our purpose in describing the goes somewhat beyond one's habitual level.This emphasis two sequences here is to point out general characteristics on inner-directed attention is in fact a powerful and and qualitative aspects of the practice.For readers who important aspect of the practice because it helps may be interested,we have prepared an analysis of both participants become increasingly familiar with their own sequences in tabular form that lists the common asana physical capabilities and limitations. names and types of movement involved (see p.9). Although instructors are expected to provide general oversight as to correct and incorrect ways to do each Yoga Sequence I sequence,participants are actively encouraged to work The first sequence begins and ends in a quiet resting within personal limits to minimize risk of over-stretching. pose known as savasana,the 'corpse'pose.This is It should be pointed out in this context that instructors intended to encourage focused attention and relaxed make a point of saying that doing the Yoga poses entails a awareness prior to and following active movement.Both personal decision that takes into account one's knowledge MBSR Yoga sequences end with a period of sustained rest of the potential risks and benefits of doing so.It is in savasana.Beginning the Yoga practice this way links it to recommended as part of the pre-program screening that the preceding body scan,which involves selectively participants confer with a physician or physical therapist directing attention throughout the body while in a about any back or neck problems prior to starting the prone position,assisted by a guided narrative that practice and medical authorization is a required pre- encourages both awareness and acceptance of any condition for participation in the program. physical sensations as they arise
is between 25 and 40 participants, it is not possible for instructors to provide individualized feedback to participants. Instead, program instructors consistently emphasize the importance of working within one’s particular physical capabilities and limitations, using the experience as an opportunity for mindfulness practice. This tends to defuse any tendencies to treat the Yoga as a purely physical practice or as an offshoot of the unfortunately prevalent “no pain, no gain” school of thought. The instructor provides an ongoing commentary throughout the duration of the session, describing the movement into and out of each asana in detail, and commenting frequently on the importance of momentby-moment attention. In general, the poses are not especially challenging from a physical standpoint, and have much in common with what one might expect to find in a very basic Yoga class. In fact, the asanas which comprise MBSR Yoga are in some ways preparatory to a regular class, since they consist primarily of extremely basic standing, sitting, prone, and supine postures. Nonetheless, even such apparently simple postures can pose extreme physical challenges for certain individuals, and it is important to keep in mind that they were selected to begin with as being relatively accessible to a wide range of medical patients in a hospital setting. Participants are encouraged to 'work at their own level,' relying essentially on internal proprioceptive feedback to gauge the suitability and safety of doing the various poses. They are also encouraged to notice, and be respectful of, physical 'boundaries' or limits that arise in the course of doing the asanas as a result of one's particular degree of flexibility and mobility. The idea that is conveyed is to work within safe boundaries, but at the same time allow oneself to 'move up to' and explore sensations denoting a level of physical intensity that may signify a beneficial degree of stretching or movement that goes somewhat beyond one's habitual level. This emphasis on inner-directed attention is in fact a powerful and important aspect of the practice because it helps participants become increasingly familiar with their own physical capabilities and limitations. Although instructors are expected to provide general oversight as to correct and incorrect ways to do each Yoga sequence, participants are actively encouraged to work within personal limits to minimize risk of over-stretching. It should be pointed out in this context that instructors make a point of saying that doing the Yoga poses entails a personal decision that takes into account one's knowledge of the potential risks and benefits of doing so. It is recommended as part of the pre-program screening that participants confer with a physician or physical therapist about any back or neck problems prior to starting the practice and medical authorization is a required precondition for participation in the program. Following the instruction session during the third class, participants are asked to do the Yoga on days that alternate with the body scan, using an audio tape or CD which provides guided instructions. Unlike some Yoga practices (Iyengar Yoga in particular), MBSR-based Yoga does not make use of any special props or ancillary equipment. It is recommended that home practice be done in a safe area on a soft, non-slip surface (for which a Yoga mat would be ideal). The poses themselves have been selected so as to minimize inordinate physical demands. The rationale behind such a 'minimalist' approach is threefold: first, it helps avoid establishing perceived barriers to practice by emphasizing simplicity. Second, it characterizes the Yoga as an opportunity for mindfulness practice, where perceptual clarity is of greater importance than physical activity itself. Third, it minimizes physical demands in order to create a safe environment for program participants and instructors alike. The second Yoga sequence is traditionally introduced during the fifth week of the program. Doing so provides an expanded repertoire of asanas, providing participants with an alternative sequence that can subsequently be incorporated into one's personal mindfulness practice. Although there is some overlap between the two sequences, they are sufficiently distinct to expand the range of stretches to incorporate a wide range of physical capabilities and inclinations. As is true with the first sequence, the emphasis is on doing the practice in a focused, deliberate, mindful manner. Each sequence ends with a quiet rest period – savasana, the 'corpse' pose – done in a supine position, with the focus of one's attention on the breath. The Yoga sequences are illustrated in KabatZinn (1990), and we recommend that they be studied in detail by anyone considering incorporating them into an MBSR-based intervention. Our purpose in describing the two sequences here is to point out general characteristics and qualitative aspects of the practice. For readers who may be interested, we have prepared an analysis of both sequences in tabular form that lists the common asana names and types of movement involved (see p. 9). Sequence I The first sequence begins and ends in a quiet resting pose known as savasana, the ‘corpse’ pose. This is intended to encourage focused attention and relaxed awareness prior to and following active movement. Both MBSR Yoga sequences end with a period of sustained rest in savasana. Beginning the Yoga practice this way links it to the preceding body scan, which involves selectively directing attention throughout the body while in a prone position, assisted by a guided narrative that encourages both awareness and acceptance of any physical sensations as they arise. Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice 65
66 Salmon et al. From savasana the sequence evolves into a sequence of because it provides a solid foundation for the second Yoga asanas that is smooth and well integrated,in the sense that sequence which emphasizes standing(upright)positions. there is no need for major postural shifts when moving In keeping with the underlying theme of the MBSR from one position to another.The fact that all are done program,this Yoga sequence is done slowly and mindfully, on the floor,in either a prone (lying on the belly)or with emphasis on noticing sensations that arise and supine (lying on one's back)position avoids radical diminish throughout the sequence of movements. postural changes.Moreover,since in either orientation much of the body's weight is supported by the floor, SequenceⅡ physical exertion is comparatively minimal.A number of Much of what has been said about the first MBSR Yoga the poses in sequence I involve bending forward by sequence applies to the sequel,except that many of the hinging at the hips while lying on one's back.We refer to poses are done while standing,emphasizing extension of these as 'forward bends,'even though posturally these the spine and upright posture.Assuming an upright movements are quite different from bending forward posture places added demands on abdominal muscula- while standing erect,the usual way to teach forward ture in terms of both postural stability and weight bearing, bends.Perhaps the term 'upward bends'would be a more so it makes sense that this sequence follows the first,which apt description,since the direction of movement in either emphasizes asanas that help develop the core area. upper or lower body is away from the floor and against Moving from a horizontal to vertical orientation provides gravity.This is an excellent way to build both strength and new opportunities to practice mindfulness in motion- flexibility in core (mid-section)musculature,in prepara- noticing,for example,the sensations associated with tion for doing standing forward bends,which are standing upright and maintaining one's balance while introduced in the second Yoga sequence. moving in a deliberate manner.This sequence ends with a If there is any major obstacle to doing this sequence,it progressive series of asanas that culminate in lying on primarily involves the ability to safely get down on and up one's back in savasana,which,like its predecessor,is from floor level,something that many people are followed by a period of quiet rest and mindful breathing. physically unaccustomed to.Shifting from an upright to Both Yoga sequences emphasize movement in and out a horizontal position can also cause a sudden alteration in of each pose done in a slow,deliberate,and continuous blood pressure,resulting in dizziness or light-headedness, manner,establishing a constant smooth 'flow'that if the transition is too sudden. promotes effective blood circulation and minimizes risk This Yoga sequence incorporates all five of the of over-exertion that can develop when poses are held standard families of Yoga poses:forward bends,back for an extended period of time (i.e.,'static'poses). bends,axial extension,lateral bends,and side twists.In Although there is no clear demarcation between a 'warm keeping with good Yoga practice,it makes systematic use up'phase and the remainder of the session,the most of 'counter poses'-asanas involving movement in a challenging poses occur toward the end of the sequence, complementary,often opposing direction to a primary preceded by preparatory asanas that engage the neces- pose.For example,forward bends are generally coun- sary musculoskeletal structures.The continuity achieved tered with back bends,whereas back bends (as well as by this pacing is somewhat attenuated by frequent axial extension,lateral bends,and side twists)are instructions to rest between postures,either by lying on normally countered with forward bends.The purpose of one's back or in another comfortable position.and focus including counter poses is to achieve balance and on movement of the breath.On balance,the fact that symmetry in movement,strength,flexibility,and range this sequence is taught to medical patients who may be of movement.Sequence I is most heavily weighted with severely limited not only posturally but also in terms of poses that involve flexing at the hips,(as in standing endurance,to some extent overrides concerns about forward bends).followed by axial extensions,back bends. sequencing‘flow.' and twists and lateral bends (one each).Since flexing at Overall,our experience teaching this program to the hips is a standard counterpose for the other categories medical patients is that it provides a useful introduction to of asanas,it is not surprising that movements of this Yoga that is generally safe and satisfying.Participants are nature are most prominent.This sequence helps foster encouraged to practice mindfully,carefully observing how strength,flexibility,and range of motion in the central their bodies respond to moving and stretching.However, core area of the body.where weak low back and when teaching these sequences in a group setting,it is abdominal musculature create postural and musculoske- important to know that there are marked individual letal problems for medical patients and non-patients variations in strength,balance,posture,flexibility,and alike.Emphasizing these areas to begin with,in a way that range of motion that need to be taken into account. utilizes the floor to provide supportive stability and reduce Experienced teachers frequently suggest'release valves'- weight bearing,is an important feature of this sequence, less demanding but related postural variations of specific
From savasana the sequence evolves into a sequence of asanas that is smooth and well integrated, in the sense that there is no need for major postural shifts when moving from one position to another. The fact that all are done on the floor, in either a prone (lying on the belly) or supine (lying on one’s back) position avoids radical postural changes. Moreover, since in either orientation much of the body’s weight is supported by the floor, physical exertion is comparatively minimal. A number of the poses in sequence I involve bending forward by hinging at the hips while lying on one’s back. We refer to these as ‘forward bends,’ even though posturally these movements are quite different from bending forward while standing erect, the usual way to teach forward bends. Perhaps the term ‘upward bends’ would be a more apt description, since the direction of movement in either upper or lower body is away from the floor and against gravity. This is an excellent way to build both strength and flexibility in core (mid-section) musculature, in preparation for doing standing forward bends, which are introduced in the second Yoga sequence. If there is any major obstacle to doing this sequence, it primarily involves the ability to safely get down on and up from floor level, something that many people are physically unaccustomed to. Shifting from an upright to a horizontal position can also cause a sudden alteration in blood pressure, resulting in dizziness or light-headedness, if the transition is too sudden. This Yoga sequence incorporates all five of the standard families of Yoga poses: forward bends, back bends, axial extension, lateral bends, and side twists. In keeping with good Yoga practice, it makes systematic use of ‘counter poses’ – asanas involving movement in a complementary, often opposing direction to a primary pose. For example, forward bends are generally countered with back bends, whereas back bends (as well as axial extension, lateral bends, and side twists) are normally countered with forward bends. The purpose of including counter poses is to achieve balance and symmetry in movement, strength, flexibility, and range of movement. Sequence I is most heavily weighted with poses that involve flexing at the hips, (as in standing forward bends), followed by axial extensions, back bends, and twists and lateral bends (one each). Since flexing at the hips is a standard counterpose for the other categories of asanas, it is not surprising that movements of this nature are most prominent. This sequence helps foster strength, flexibility, and range of motion in the central core area of the body, where weak low back and abdominal musculature create postural and musculoskeletal problems for medical patients and non-patients alike. Emphasizing these areas to begin with, in a way that utilizes the floor to provide supportive stability and reduce weight bearing, is an important feature of this sequence, because it provides a solid foundation for the second Yoga sequence which emphasizes standing (upright) positions. In keeping with the underlying theme of the MBSR program, this Yoga sequence is done slowly and mindfully, with emphasis on noticing sensations that arise and diminish throughout the sequence of movements. Sequence II Much of what has been said about the first MBSR Yoga sequence applies to the sequel, except that many of the poses are done while standing, emphasizing extension of the spine and upright posture. Assuming an upright posture places added demands on abdominal musculature in terms of both postural stability and weight bearing, so it makes sense that this sequence follows the first, which emphasizes asanas that help develop the core area. Moving from a horizontal to vertical orientation provides new opportunities to practice mindfulness in motion – noticing, for example, the sensations associated with standing upright and maintaining one’s balance while moving in a deliberate manner. This sequence ends with a progressive series of asanas that culminate in lying on one’s back in savasana, which, like its predecessor, is followed by a period of quiet rest and mindful breathing. Both Yoga sequences emphasize movement in and out of each pose done in a slow, deliberate, and continuous manner, establishing a constant smooth ‘flow’ that promotes effective blood circulation and minimizes risk of over-exertion that can develop when poses are held for an extended period of time (i.e., ‘static’ poses). Although there is no clear demarcation between a ‘warm up’ phase and the remainder of the session, the most challenging poses occur toward the end of the sequence, preceded by preparatory asanas that engage the necessary musculoskeletal structures. The continuity achieved by this pacing is somewhat attenuated by frequent instructions to rest between postures, either by lying on one's back or in another comfortable position, and focus on movement of the breath. On balance, the fact that this sequence is taught to medical patients who may be severely limited not only posturally but also in terms of endurance, to some extent overrides concerns about sequencing ‘flow.’ Overall, our experience teaching this program to medical patients is that it provides a useful introduction to Yoga that is generally safe and satisfying. Participants are encouraged to practice mindfully, carefully observing how their bodies respond to moving and stretching. However, when teaching these sequences in a group setting, it is important to know that there are marked individual variations in strength, balance, posture, flexibility, and range of motion that need to be taken into account. Experienced teachers frequently suggest ‘release valves’ – less demanding but related postural variations of specific 66 Salmon et al
Yoga and Mindfulness:Clinical Aspects of an Ancient Mind/Body Practice 67 poses-as alternatives for individuals who find the regular 1.'Start where you are'(vinyasa krama):Program poses unduly challenging.Severely deconditioned indivi- participants are encouraged to be accepting of their duals often require additional preparation with respect to current mind/body state and to work patiently range of motion,strength,and balance before under- within whatever limitations they experience.Both taking this sequence,which can be daunting to someone in-class and home practice sessions are treated as who has never done Yoga before,despite the overall mild opportunities to "be where you are,"which further intensity of the poses that comprise the sequence. implies the importance of present-moment,focused Perhaps the most important principle with respect to attention when doing Yoga. teaching either sequence is taking nothing for granted in 2.Begin by 'loosening'the body:Virtually all forms of terms of the physical capabilities of program participants Yoga practice begin with preparatory,or 'warm up', to perform even very basic asanas. asanas that prepare body and mind for more Those who work their way through both Yoga challenging work.This practice is akin to warm- sequences develop an appreciation for subtle aspects of ups in preparation for any type of physical activity, carefully regulated movement and breathing,and as a the purpose of which is to establish a coherent and result show an interest in further developing their integrated psychological,physical,and metabolic practice after the program concludes.We maintain a list preparatory context.In the MBSR program,the of experienced teachers whom we recommend for this sequence begins with positions that are not overly purpose,in much the same way that anyone wishing to challenging,then move on to somewhat more deepen their meditation practice can be referred to demanding poses,none of which however go appropriate teachers.This is especially important in light beyond the level of a typical introductory Yoga of the fact that deepening a Yoga practice typically class.There is a sufficient amount and variety of progresses into increasingly challenging inner landscapes movement to engage most of the major musculos- of physical sensations and cognitive reactions necessitat- keletal units in both sequences. ing great patience and a tolerance for postural novelty to 3.Incorporate counter poses into Yoga sequences: work through.In the MBSR program,participants are Counter poses are described by Desikachar as advised to 'work within their own perceived limits'when helpful for counteracting the effects of certain practicing asanas,a prudent recommendation given the strenuous poses (Desikachar,1999,p.26).The idea lack of individual attention that is possible in this context. of a 'counter pose'is that movement in one plane or Going into,and perhaps even beyond such perceived direction should be counteracted by movements in physical boundaries,is a task better left to practice with a the opposite direction.For example,forward bends skilled and experienced teacher. complement back bends,and vice-versa.Given that The MBSR program provides a safe and effective relatively few asanas in either sequence are highly introduction to Yoga,which if practiced regularly can strenuous,there may not be as great a need for provide a good foundation for further refinement. counter poses,but both Yoga sequences make We have prepared a table of both MBSR Yoga sequences liberal use of forward (upward,if supine)bends, that identifies and describes the individual poses,provides which comprise the most common form of counter their Sanskrit names,and identifies the type of movement poses. involved (forward bend,backward bend.axial extension. 4.Practice dynamic (moving)poses prior to doing twist,lateral bend).Interested readers are invited to static poses:The rationale for this recommendation contact the corresponding author for a copy.Overall, is that static poses are more demanding from both a the sequence of asanas employed in this program physical (strength)and metabolic standpoint.Static incorporate a number of positive features,along with poses entail supporting partial or total body weight areas of possible improvement.To place the MBSR-based without movement,similar (though not identical) Yoga practice into a broader context,we propose a to isometric exercises.Static poses entail reduced framework developed by well-known teacher and writer circulation because of the absence of the pumping T.K.V.Desikachar (1999).His influence on contempor- action of muscles that are necessary for venous ary Yoga practice is substantial,and notable for a down- return,especially from the lower extremities.In to-earth orientation making it accessible to a wide range general,it is recommended that beginners hold of practitioners.His recommendations are helpful in static Yoga poses for only a few seconds,a practice structuring one's Yoga practice,and may be useful as well followed in the MBSR Yoga sequences.In fact,the in terms of providing general guidelines for use in MBSR sequences in general have dynamic qualities: clinical research applications.Both MBSR-based Yoga few poses are held for any length of time,seldom sequences implicitly incorporate these 5 straight-forward more than two or three breaths.The overall pace is recommendations. slow,however,as far as movement in and out of
poses – as alternatives for individuals who find the regular poses unduly challenging. Severely deconditioned individuals often require additional preparation with respect to range of motion, strength, and balance before undertaking this sequence, which can be daunting to someone who has never done Yoga before, despite the overall mild intensity of the poses that comprise the sequence. Perhaps the most important principle with respect to teaching either sequence is taking nothing for granted in terms of the physical capabilities of program participants to perform even very basic asanas. Those who work their way through both Yoga sequences develop an appreciation for subtle aspects of carefully regulated movement and breathing, and as a result show an interest in further developing their practice after the program concludes. We maintain a list of experienced teachers whom we recommend for this purpose, in much the same way that anyone wishing to deepen their meditation practice can be referred to appropriate teachers. This is especially important in light of the fact that deepening a Yoga practice typically progresses into increasingly challenging inner landscapes of physical sensations and cognitive reactions necessitating great patience and a tolerance for postural novelty to work through. In the MBSR program, participants are advised to ‘work within their own perceived limits’ when practicing asanas, a prudent recommendation given the lack of individual attention that is possible in this context. Going into, and perhaps even beyond such perceived physical boundaries, is a task better left to practice with a skilled and experienced teacher. The MBSR program provides a safe and effective introduction to Yoga, which if practiced regularly can provide a good foundation for further refinement. We have prepared a table of both MBSR Yoga sequences that identifies and describes the individual poses, provides their Sanskrit names, and identifies the type of movement involved (forward bend, backward bend, axial extension, twist, lateral bend). Interested readers are invited to contact the corresponding author for a copy. Overall, the sequence of asanas employed in this program incorporate a number of positive features, along with areas of possible improvement. To place the MBSR-based Yoga practice into a broader context, we propose a framework developed by well-known teacher and writer T.K.V. Desikachar (1999). His influence on contemporary Yoga practice is substantial, and notable for a downto-earth orientation making it accessible to a wide range of practitioners. His recommendations are helpful in structuring one’s Yoga practice, and may be useful as well in terms of providing general guidelines for use in clinical research applications. Both MBSR-based Yoga sequences implicitly incorporate these 5 straight-forward recommendations. 1. ‘Start where you are’ (vinyasa krama): Program participants are encouraged to be accepting of their current mind/body state and to work patiently within whatever limitations they experience. Both in-class and home practice sessions are treated as opportunities to qbe where you are,q which further implies the importance of present-moment, focused attention when doing Yoga. 2. Begin by ‘loosening’ the body: Virtually all forms of Yoga practice begin with preparatory, or 'warm up', asanas that prepare body and mind for more challenging work. This practice is akin to warmups in preparation for any type of physical activity, the purpose of which is to establish a coherent and integrated psychological, physical, and metabolic preparatory context. In the MBSR program, the sequence begins with positions that are not overly challenging, then move on to somewhat more demanding poses, none of which however go beyond the level of a typical introductory Yoga class. There is a sufficient amount and variety of movement to engage most of the major musculoskeletal units in both sequences. 3. Incorporate counter poses into Yoga sequences: Counter poses are described by Desikachar as helpful for counteracting the effects of certain strenuous poses (Desikachar, 1999, p. 26). The idea of a 'counter pose' is that movement in one plane or direction should be counteracted by movements in the opposite direction. For example, forward bends complement back bends, and vice-versa. Given that relatively few asanas in either sequence are highly strenuous, there may not be as great a need for counter poses, but both Yoga sequences make liberal use of forward (upward, if supine) bends, which comprise the most common form of counter poses. 4. Practice dynamic (moving) poses prior to doing static poses: The rationale for this recommendation is that static poses are more demanding from both a physical (strength) and metabolic standpoint. Static poses entail supporting partial or total body weight without movement, similar (though not identical) to isometric exercises. Static poses entail reduced circulation because of the absence of the pumping action of muscles that are necessary for venous return, especially from the lower extremities. In general, it is recommended that beginners hold static Yoga poses for only a few seconds, a practice followed in the MBSR Yoga sequences. In fact, the MBSR sequences in general have dynamic qualities: few poses are held for any length of time, seldom more than two or three breaths. The overall pace is slow, however, as far as movement in and out of Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice 67
68 Salmon et al. poses is concerned.Perhaps in recognition of the capabilities and postural boundaries of each individual. fact that most program participants have little Making these sensations the focus of one's undivided experience doing Yoga,the sequence has been attention is the embodiment of mindfulness practice.An developed in such a way that it does not place added benefit of this style of practice is that it can help inordinate demands on postural or circulatory lessen the likelihood of injury or overuse,given that capabilities,while at the same time offering a participants are encouraged to work very deliberately to degree of challenge that can help sustain motiva- stay within boundaries they sense or know to be safe. tion and interest. It is interesting to think in terms of how Yoga and other 5.Balance major poses with simpler counter poses: movement practices could form the foundation of a This recommendation is intended to complement psychological developmental progression leading the effects of doing asanas in any given direction or inwardly toward cognitive refinements that are depen- plane of movement via movement in an opposing dent on earlier stages,analogous to how Piaget's stages of direction.Because of the overall low demand cognitive development begin with overt physical activity. characteristics of the MBSR sequence,this does Movement-based interventions have been implemented not appear to be as much of a potential problem as for victims of torture (Harris,2007),and could potentially might be the case with a more challenging serve as here-and-now 'grounding techniques'(Crosby, sequence.But it is worth pointing out that both Mashour,Grodin,Jiang,Osterman,2007)for PTSD and MBSR Yoga sequences include requisite counter other trauma patients.In the context of the MBSR poses that appear to provide a good balance of program,Yoga may serve as a catalyst or foundation for opposing movement and stretching patterns. subsequent cognitive processes related to meditative awareness.At the very least,Yoga may become the salient F.Yoga and Mindfulness:Clinical Significance focus of attention because of the way that movement is Yoga is an integral element of the MBSR program. intrinsically interesting-many people who find sitting Because the program originated in a medical setting.Yoga meditation too formal,boring or forbidding take quickly was originally incorporated as a gentle means of counter- to movement patterns that are done with care and acting disuse atrophy prevalent in patients and more attention.Movement itself seems to have a stimulating generally in our sedentary culture.As described by Kabat- effect,both in terms of the body's involvement and Zinn (2003a)this characteristic complemented the known perhaps also in terms of certain cognitive processes of ability of meditation to reduce autonomic nervous system awareness that are stimulated -increased alertness. reactivity.These two 'ancient consciousness disciplines'(p. awareness.etc.which has obvious survival value. 86)were united through the common link of mindfulness. Movement has a way of capturing present-moment Kabat-Zinn is careful to emphasize mindfulness in Hatha attention in a manner that static,sitting meditation does Yoga practice,clearly differentiating it from"physical fitness not.When you are sitting still,it is easy to let your mind dressed up in spiritual clothing,"(p.87).He places less wander because of the fact that you do not have to keep emphasis on precise form and technique than on a sincere track of your body's position in space or of the intention to be present and awake to oneself on a moment- environmental context in which behavior is occurring. by-moment basis,regardless of one's physical capabilities. Sitting promotes resting,and perhaps a relaxation of "Mindful Yoga is a specific attitude and attentional stance focused attention,unless one is deliberate about engaging that we bring to our practice,both on the mat and in daily it.On the other hand,movement often sharpens sensory life:namely,a refined,moment-to-moment nonjudgmen- awareness,especially when one is doing things for the first tal,non-striving attending to the entire range of our time,or engaging in behavior patterns that involve skilled experience'”(p.89). activity.Even something'simple'like tying one's shoe can From this perspective,Yoga is clearly well characterized become the center of focused attention.Of course,many as 'mindfulness in motion,'an opportunity for sustained behavior patterns and sequences become automated over attention to body and breath during a progressive time,leaving the mind free to wander,as is the case when sequence of postural configurations.Attention may be one is 'just sitting.'But engaging mind and body is directed as well to thoughts and emotions that accom- relatively easy in the practice of Yoga,which continually pany,and are often stimulated by,movement,an offers new challenges and possibilities in the sense of a important manifestation of the mind/body connection. practically infinite number of asanas and development Yoga practice centers on a tangible,physical base for levels that can be experienced. exploring physical capabilities and limitations.It gener- ates a steady stream of proprioceptive and interoceptive G.Final Issues:Clinical Practice Research cues that collectively contribute to a felt sense of move One of the main reasons that Yoga should be of interest ment in space,demarcated by the particular physical to MBSR-oriented clinicians is that it offers an especially
poses is concerned. Perhaps in recognition of the fact that most program participants have little experience doing Yoga, the sequence has been developed in such a way that it does not place inordinate demands on postural or circulatory capabilities, while at the same time offering a degree of challenge that can help sustain motivation and interest. 5. Balance major poses with simpler counter poses: This recommendation is intended to complement the effects of doing asanas in any given direction or plane of movement via movement in an opposing direction. Because of the overall low demand characteristics of the MBSR sequence, this does not appear to be as much of a potential problem as might be the case with a more challenging sequence. But it is worth pointing out that both MBSR Yoga sequences include requisite counter poses that appear to provide a good balance of opposing movement and stretching patterns. F. Yoga and Mindfulness: Clinical Significance Yoga is an integral element of the MBSR program. Because the program originated in a medical setting, Yoga was originally incorporated as a gentle means of counteracting disuse atrophy prevalent in patients and more generally in our sedentary culture. As described by KabatZinn (2003a) this characteristic complemented the known ability of meditation to reduce autonomic nervous system reactivity. These two ‘ancient consciousness disciplines’ (p. 86) were united through the common link of mindfulness. Kabat-Zinn is careful to emphasize mindfulness in Hatha Yoga practice, clearly differentiating it from “physical fitness dressed up in spiritual clothing,” (p. 87). He places less emphasis on precise form and technique than on a sincere intention to be present and awake to oneself on a momentby-moment basis, regardless of one’s physical capabilities. “Mindful Yoga is a specific attitude and attentional stance that we bring to our practice, both on the mat and in daily life: namely, a refined, moment-to-moment non-judgmental, non-striving attending to the entire range of our experience” (p. 89). From this perspective, Yoga is clearly well characterized as ‘mindfulness in motion,’ an opportunity for sustained attention to body and breath during a progressive sequence of postural configurations. Attention may be directed as well to thoughts and emotions that accompany, and are often stimulated by, movement, an important manifestation of the mind/body connection. Yoga practice centers on a tangible, physical base for exploring physical capabilities and limitations. It generates a steady stream of proprioceptive and interoceptive cues that collectively contribute to a felt sense of movement in space, demarcated by the particular physical capabilities and postural boundaries of each individual. Making these sensations the focus of one’s undivided attention is the embodiment of mindfulness practice. An added benefit of this style of practice is that it can help lessen the likelihood of injury or overuse, given that participants are encouraged to work very deliberately to stay within boundaries they sense or know to be safe. It is interesting to think in terms of how Yoga and other movement practices could form the foundation of a psychological developmental progression leading inwardly toward cognitive refinements that are dependent on earlier stages, analogous to how Piaget's stages of cognitive development begin with overt physical activity. Movement-based interventions have been implemented for victims of torture (Harris, 2007), and could potentially serve as here-and-now ‘grounding techniques’(Crosby, Mashour, Grodin, Jiang, & Osterman, 2007) for PTSD and other trauma patients. In the context of the MBSR program, Yoga may serve as a catalyst or foundation for subsequent cognitive processes related to meditative awareness. At the very least, Yoga may become the salient focus of attention because of the way that movement is intrinsically interesting – many people who find sitting meditation too formal, boring or forbidding take quickly to movement patterns that are done with care and attention. Movement itself seems to have a stimulating effect, both in terms of the body’s involvement and perhaps also in terms of certain cognitive processes of awareness that are stimulated – increased alertness, awareness, etc. which has obvious survival value. Movement has a way of capturing present-moment attention in a manner that static, sitting meditation does not. When you are sitting still, it is easy to let your mind wander because of the fact that you do not have to keep track of your body’s position in space or of the environmental context in which behavior is occurring. Sitting promotes resting, and perhaps a relaxation of focused attention, unless one is deliberate about engaging it. On the other hand, movement often sharpens sensory awareness, especially when one is doing things for the first time, or engaging in behavior patterns that involve skilled activity. Even something ‘simple’ like tying one’s shoe can become the center of focused attention. Of course, many behavior patterns and sequences become automated over time, leaving the mind free to wander, as is the case when one is ‘just sitting.’ But engaging mind and body is relatively easy in the practice of Yoga, which continually offers new challenges and possibilities in the sense of a practically infinite number of asanas and development levels that can be experienced. G. Final Issues: Clinical Practice & Research One of the main reasons that Yoga should be of interest to MBSR-oriented clinicians is that it offers an especially 68 Salmon et al