Winter 2016

a publication of The International Association of Therapists Yo g a T h e r a p y To d a y Volume 12, Issue 1, $5

SYR 2015 P e r s p e c t i v e R e p o r t s Meeting the Needs of the Triple Aim

F e a t u r e Yoga Therapy a r t i c l e s in Practice Yoga Therapy Optimizing Referral Pelvic Floor Health Guidelines Metabolic Syndrome Establishing and Yoga Professional Ethics Yoga for the Re-embodied Self

Mark Your Calendars S Y TAR 2016 June 9–12, 2016 SYR 2016 September 19–21, 2016

YogaTherapyToday Editor’s Note PUBLISHER International Association of any of you know and love our EDITOR IN CHIEF Yoga Therapists cover model for this issue, Kelly Birch, E-RYT-500, PYT-500 MEleanor Criswell, EdD. Many LAYOUT/PRODUCTION COPYEDITORS Ken Wilson of you have seen her at IAYTʼs con- Lokiko Hall and Stephanie Shorter, PhD ferences sitting on the stage with the Yoga Therapy Today other board members, and some of is published in the spring, summer, and winter. you have never met this gracious IAYT BOARD & MANAGEMENT and dedicated teacher and practi- President Dilip Sarkar, MD, FACS,Vice CAP, President tioner who has served in various Carrie E. Demers, MD, Secretary capacities for IAYT over the years. Amy E. Wheeler, PhD, Treasurer John Kepner, executive director of ExecutiveEleanor Criswell, Director EdD, IAYT, writes: Advertising Manager John Kepner, MA, MBA Conference Manager Abby M. Geyer “Eleanor Criswell has been a key pillar of the IAYT board of Accreditation Administrator Debra Krajewski directors since our renewal in 2004, serving in all officer Certification Manager Aggie Stewart, MA, E-RYT-500, CYT Beth Whitney-Teeple PhD, E-RYT 500 capacities and supporting—in her own quiet, insightful, and influential way—all of IAYT's initiatives. In particular, she has MISSION been a champion of our Policy Governance model. She IAYT supports research and education in yoga, and serves as a recognized early on that a sound governance model is a professional organization for yoga teachers and yoga therapists necessary foundation of a successful professional associa- worldwide. Our mission is to establish yoga as a recognized and tion. She has also been an international ambassador for respected therapy. IAYT, representing IAYT three times in India since 2011. MEMBERSHIP In recognition of her extraordinary service, she was honored with the IAYT Presidential Award in 2013. Dr. Criswell IAYT membership is open to yoga practitioners, yoga teachers, yoga therapists, yoga researchers, and healthcare professionals returned to the board in 2015. She serves as board liaison who utilize yoga in their practice. to the Accreditation Committee and, most recently, has been a champion of our new ethics policy.” MEMBER BENEFITS International Journal of Yoga Therapy • Subscription toYoga the Therapy Today Dr. Criswell taught a Psychology of Yoga course for 33 • Subscription to years at Sonoma State University, is founding director of the Access to IAYTʼs research resources and digital library Humanistic Psychology Institute (now Saybrook Graduate • Professional recognition through IAYTʼs online listings School and Research Center), and is currently a Distinguished • Discounted registration at IAYT conferences Consulting Faculty member for Saybrook Graduate School. CONTACT IAYT We at IAYT have been and continue to be tremendously P.O. Box 251563 privileged to have Dr. Criswell as a guiding light in the field of Little Rock, AR 72225 yoga therapy. Phone: 928-541-0004 (M-F, 10AM – 4PM CST) www.iayt.org • [email protected] In this issue, Dr. Criswell, along with board member Dr. Amy HOW TO SUBMIT TO YOGA THERAPY TODAY Wheeler, contributes an important article on IAYTʼs ethics policy, Writers including why we need one, what it consists of, and what it [email protected]. means for IAYT members. Dr. Timothy McCall and colleagues YogaEmail Therapy a query orToday completed article to offer an adapted excerpt of their chapter that will appear in a relies on submissions from the membership. groundbreaking book on yoga practices in healthcare, to be Please submit reports and articles on training, views and insights published early 2016. Also included are two reports on this relating to the field and profession of yoga therapy, as well as on integrative practices and business practices. Review author guide- year's SYR by our own Dr. Stephanie M. Shorter, who brings an lines on the IAYT website/Publications/YTT. Articles are reviewed original, insightful overview of scientific research and whatʼs and accepted on a rolling basis and may be submitted at any time. important for our professional field; a must-read Perspective on Advertisers the Triple Aim and yoga therapy's potential for integration into For advertising rates and specifications, contact Abby Geyer at the changing healthcare paradigm; a trio of excellent Yoga Ther- 702-341-7334 (M–F, 9 AM–3 PM, PST) or [email protected]. apy in Practice articles on pelvic floor health, metabolic syn- Editorial decisions are made independently of advertising drome, and re-embodiment; a lovely article on how devotional arrangements. practice may help our clients; and our final educational offering REPRINT POLICY from Sherry Brourman as our Mentorʼs Corner columnist. International Journal ofIAYT's Yoga reprint Therapy policy appliesYoga Therapy to all articles Today in the As always, I am deeply grateful to all the writers in this issue and . Fee: $1 per copy per for their excellent contributions and continue to feel honored to article. The policy works on the honor system, e.g., if two articles serve in this capacity as editor of our precious membership are copied for 25 students, please send IAYT a check for $50 and YTT note “for reprints” on the check. Questions? Email Debra Krajewski magazine. at [email protected]. In service, ENVIRONMENTAL STATEMENT Kelly This publication is printed using soy-based inks. The paper contains 30% recycled fiber. It is bleached without using chlorine and the wood pulp is harvested from sustainable forests. Cover photo: Eleanor Criswell Photo credit: Gabriel C. Pérez, www.gabrielperez.com

2 YogaTherapyToday | Winter 2016 www.iayt.org TableOfContents Winter 2016 2 Editor’s Note 4 Members News 8 4 On the Global Movementby John to Kepner, Establish MA, MBA, High Executive Standards Director for the IAYT Training of Yoga Therapists, 4 ByComparison Barbara Dancer, of Yoga Chair, Therapist British Council Training of Yoga Requirements Therapy 46 Baxter Bell Elected to the IAYT Board of Directors 46 IAYT New Member Schools in 2015 46 IAYT Donors 6 Conference Corner , by Rachel Krentzman Conference 8 SYR 2015 Diversity in Collaboration and Refining of Measures: 18 ByA Review Stephanie of M. the Shorter, 2015 PhD, Symposium RYT on Yoga Research

12 Science for the Yoga Therapist

ByThe Stephanie Collaborative M. Shorter, Future PhD, of RYT Yoga Research

16 Mentor’s Corner

BySeeing Sherry through Brourman, Shoulders: PT, E-RYT Observations and Interpretations

18 Feature Articles 18 ByYoga Timothy Therapy McCall, Referral MD, Leigh Guidelines Blashki, M.H.Sc, or Healthcare Grad Cert Y.T, Practitioners Cert Ayur, Dip Yoga, Subodh Tiwari, John Kepner, MA, MBA, and Loren Fishman, MD 28

20 ByEstablishing Eleanor Criswell, Professional EdD, and Amy Ethics Wheeler, in the PhD Field of Yoga Therapy

22 Perspective

ByYoga Kristine Therapy: Kaoverii Meeting Weber, MA, the eRYT500, Needs of and The Brett Triple Sculthorp, Aim LCSWA, LCASA, CSAPC

28 Insight by Jennie Lee, E-RYT The Joy of Devotion, 32 Yoga Therapy in Practice 36 32 ByOptimizing Shelly Prosko, Pelvic PT, Floor PYT, CPI Health Through Yoga Therapy

36 ByMetabolic Baxter Bell, Syndrome MD, E-RYT-500 and the Promising Potential of Yoga

40 ByYoga Catherine for the Cook-Cottone, Re-embodied PhD, Self: RYT The Therapeutic Journey Home

44 Review Yoga Therapy for and Anxiety: ByCreate Robert a Butera, Personalized PhD, Erin Holistic Byron, MA, Plan and to Staffan Balance Elgelid, Your PT, Life PhD Reviewed by Matthew J. Taylor, PT, PhD YogaTherapyToday | Winter 2016 3 MembersNews On the Global Movement to Establish High Standards for the Training of Yoga Therapists By John Kepner, IAYT Executive Director Comparison of Yoga Therapist Training Requirements By Barbara Dancer, Chair, British Council of Yoga Therapy

here has been a global movement to Prerequisites British Council for Yoga International Australasian Therapy Association of Yoga Association of Yoga establish high standards for the train- (BCYT) Therapists (IAYT) Therapists (AAYT) Ting of yoga therapists. In 2008, the Australasian Association of Yoga Thera- Teacher training Minimum 200-hour 200-hour teacher train- Minimum 350 hours of pists (AAYT) was the first to publish train- course (180 contact ing, such as a for ing standards. The AAYT has updated hours), for example, the Alliance 200-hour regis- Yoga Australasia Regis- their standards twice since then, most 200-hour tered school program tered teacher training (RYS-200) or equivalent recently to approximately the same level as the IAYT standards. The British Council Teaching experience 120 hours over one year One year, can be con- Minimum of two years for Yoga Therapy (BCYT) was second, current with teacher or 300 hours regular publishing their standards in 2010. We at training yoga teaching, up to IAYT published our standards in 2012. one year or up to 150 hours of which may be concurrent with yoga As of November 1, IAYT has accredit- teacher training ed 24 programs in three countries that meet our standards, with about another Personal practice Minimum three years Minimum of one year, Minimum two years dozen or so under active review. AAYT can be concurrent with teacher training has recognized eight programs, including three in New Zealand. BCYT has recog- Yoga Therapy Training BCYT IAYT AAYT nized or accredited thirteen programs, eight of which are still currently running. Hours/years Minimum 550 hours Minimum 800 hours Minimum 650 hours AAYT has 153 Registered Yoga Thera- Minimum 18 months Minimum two years Minimum two years pists. The BCYT is not an individual-mem- Contact hours Minimum 300 direct con- Minimum 600 contact 70% of the 650 hours bership organization, but estimates that tact hours hours must be contact hours 300–400 individuals have graduated from (455 hours) recognized programs. We plan to open our application process for individuals to Teaching and practicum Of 300 contact hours: Practicum minimum: 500 hours teaching, apply for IAYT certification by June 2016. hours Min. 30% theory 150 hours 150 hours practicum Min. 50% practicum 20% theory/practicum Barbara Dancer, chair of the BCYT, prepared a comparison of the training Other specified hours Minimum 250 noncon- Maximum of 200 dis- n/a standards from the BCYT, IAYT, and tact hours, with a recom- tance-learning hours AAYT, and has kindly given permission for mendation of between six and eight hours of home us to share it. Note, all the standards are study per week fundamentally based upon competencies and/or learning outcomes; hours and Trainer Qualifications CVs submitted with Faculty members have Appropriate qualifica- duration are not sufficient to compare rela- accreditation application. well-established expert- tion for the area in tive quality. Most noteworthy, at least in ise and experience in which they teach. the course(s) they It is recommended my opinion, is how similar they are, and teach, including train- each trainer/mentor how all three organization are working ing, certification, or a has Training and toward continued improvement. The stan- diploma in the field in Assessment dards reflect a long-term goal of mine: a which they teach, along qualification. global convergence of high standards in with a minimum of two the training of yoga therapists that will years practical experi- ence. serve societies well and, I hope, help to transform our conventional model of Mentoring n/a Mentors are appointed Mentors should be healthcare into one more focused on by the program suitably qualified in holistic health and healing. director. either yoga therapy or a * With grateful acknowledgement to Mentors are supervised specific health field at a by the program director level equal to or Barbara Dancer of the BCYT and Leigh or a faculty member. beyond that of the Blashki of the AAYT for current numbers training their mentees on recognized programs and individuals are taking. YTTin the UK and Australasia, respectively. (Members News continued on page 46)

4 YogaTherapyToday | Winter 2016 www.iayt.org

ConferenceCorner Conference Corner features events sponsored by IAYT.

Yoga As Therapy ing T.K.V. Desikachar, B.K.S. Iyengar, and On Saturday, Yifat Durga Hershko, Conference Pattabhi Jois and have spent many who is a physical therapist and yoga Netanya, Israel, Wingate Institute months immersing themselves in the prac- instructor, spoke about the role of yoga in Oct. 16–17, 2015 tice and lifestyle. The thing that most evidence-based medicine and emphasized impressed me about the yoga in this coun- the importance of communication with By Rachel Krentzman try is that there seems to be less emphasis health professionals by sharing a “com- on the physical aspect and more accept- mon language.” I participated in a class ance of the complete eight-fold path, which entitled “Women's Health through Pelvic ince moving to Israel a little over is often lacking in Western culture. Floor Awareness” with Ayelet Harari, and I two years ago, I have been fortu- personally offered a workshop titled Snate to be invited and welcomed Honi Rosen, administrative director of the “Demystifying the Sacroiliac Joint.” In this into both the yoga and yoga therapy com- IYTA since 2000, spoke to me about the workshop, we discussed the difference munity with warmth and openness. This high quality of yoga that many foreign between lower- and sacroiliac year, the Israeli Yoga Teachers' Associa- teachers observe in this country when they joint pain, how to do a quick assessment tion (IYTA), along with a committee of pro- come to conduct workshops. “In Israel, the on students, and how to modify your stu- fessionals led by Sigal Bieber, yoga thera- experience of yoga is an authentic inquiry dents' practice to focus on stability and pist, organized its second annual confer- and hunger for the depth of practice,” she integrity rather than flexibility and mobility. ence titled “Yoga As Therapy” at the states. Wingate Institute in Netanya, Israel. The The conference concluded with a theme of the conference was “Pancha Tsippy Negev, a leader in the field of roundtable discussion consisting of a : The Five Layers of Being,” and yoga therapy in Israel and the current group of participants sitting casually in a consisted of twenty-three workshops and chairwoman at IYTA, opened the confer- circle on the lawn and sharing thoughts lectures over a two-day period to an audi- ence with an engaging story about the dia- about how we can improve our relation- ence of over 150 attendees, most of logue between Varuna and Bhrigu from the ships with clients and create meaningful Taittiriya Upanishad whom were yoga teachers interested in as an initiation to the healing though the exploration of all five learning more about the therapeutic bene- paradigm of the pancha kosha, inviting . We agreed that it is important to fits of yoga for specialty populations. Wide embodiment of these five aspects of our see ourselves as guides in our clients' ranges of topics were discussed, including being. process as opposed to “healers” and that yoga for anxiety, yoga for , yoga for creating an environment of equanimity and trauma, women's health, yoga for hyper- The guest of honor was Mukund V. trust is of paramount importance. As we tension, , research, and yoga Bhole, MD, from Lonavia, India. He spoke held hands and closed the conference as yoga anubhava ethics. of , “experiential yoga,” as a cohesive group of pioneers, I felt hope in a means toward freedom from three caus- my heart and faith knowing that our field of As a recent wave of terror has hit es of pain: physical, biological, and spiritu- yoga therapy is alive and vibrant, deeply every corner of the country, it seemed al. With over thirty-three years experience penetrating Israeli culture at its core. more important than ever to participate in in yoga therapy and research, Bhole this gathering of like-minded individuals brought a vast amount of wisdom to the If there is hope for peace here in the promoting the use of yoga to heal others table about what yoga therapy is and what YTTMiddle East, this was the place to feel it. from pain and suffering. It is an exciting it is not. time in Israel for yoga therapists, because Rachel Krentzman is a physical therapist, the field in this country is relatively new I attended an interesting workshop by yoga therapist, and founder of Embody and rapidly developing in conjunction with Iris Klein about using sound, , & Yoga in San Diego, the progress in the United States and breath, and strength to work with individu- CA. Her first book abroad. als with cerebral palsy and severe physical Yoga for a Happy Back: limitations. Erel Ben-Tzadok, a certified A Teacher's Guide to Spinal Health will be released in Although yoga therapy is a new focus Hakomi practitioner specializing in yoga for through Yoga Therapy May 2016. She now lives in Ra'anana, in Israel, yoga itself is deeply rooted in the trauma recovery, gave an interesting lec- Israel with her two sons. For info: culture. After the mandatory army service, ture covering how trauma is processed in [email protected] many young individuals take time off to the nervous system, adapting yoga class- travel in India. Consequently, many teach- es for individuals suffering from PTSD, and ers in this country have stumbled upon meeting students where they are in their and studied with masters of yoga, includ- stage of recovery.

6 YogaTherapyToday | Winter 2016 www.iayt.org

SYR2015Reports Diversity in Collaboration and Refining of Measures A Review of the 2015 Symposium on Yoga Research

By Stephanie M. Shorter The evening session ended with five benefits of practicing yoga. In fact, confer- investigators being recognized with Swami ence planner Sat Bir Khalsa, PhD, men- he Symposium on Yoga Research Kuvalyananda Scholarship Awards for tioned that the structure of the meeting is (SYR), the premier meeting of yoga their outstanding research abstracts. Rep- designed for interaction among all of the Tresearchers in the West, was held resenting a wide range of research ques- attendees to build community and foster again this year at the for tions, these investigators included (shown new collaborations. Creating the condi- Yoga & Health, September 28–30, 2015, left to right in the photo) P. Shyam Karthnik tions where experts from different subject at the onset of the glorious Berkshire (COPD rehabilitation), Dr. Rochelle Rosen autumn. Just as the leaves turning colors signal that it is time for reflection and transformation, so too the academic dis- cussions inside reflected upon the state of yoga research and how to translate raw data into healthcare policy changes to transform the health of millions of people.

Designed to be equally applicable to new investigators and yoga therapists, the brief “Yoga Research 101” preconference workshop kicked off the meeting with its focus on refining research methods and extrapolating results into evidence-based therapy that can apply the best available evidence in particular settings. In essence, this approach scales up the philosophy of yoga therapy from tailoring the treatment to the individual to tailoring the interven- tion to a specific environmental context. This agenda, however, represents a huge amount of effort because it involves test- Photo credit: All SYR photos by Gabriel C. Pérez, www.gabrielperez.com ing different populations in different set- Five scholars were honored with Swami Kuvalyananda Scholarship Awards. tings at multiple times. The attendees of this meeting are the “who's who” of build- ing the foundation of this body of patient- (outcome expectations and beliefs about areas can become research collaborators 1 centric, setting-specific work. yoga), Elizabeth Whissell (movement is a very fruitful strategy. t is a global 2 kinetics in ), Dr. Katie Schuver trend and is correlated with both higher The opening night events launched ( in women), and Dr. Peter Bay- frequency of publishing and higher proba- 3 the symposium proper with a celebratory ley (pain in veterans). The second annual bility of securing grant support. (See the feel, starting with the traditional blowing of Samuel B. Hanser Visionary Award from “Science for the Yoga Therapist” column the conch shell by IAYT executive director the IEL was granted to Ishan Walpola, a on Page 12 [by this author] for an elabo- John Kepner, followed by a warm greeting McGill University graduate student in rated perspective on the value of cross- from IAYT board president Dilip Sarkar, Translational Neuroimaging, for his fMRI fertilization in scientific collaborations.) MD, FACS, CAP. Kripalu Institute for work on the impact of pranayama and Measuring with Increased Sophisti- Extraordinary Living (IEL) director Edi on brain aging. cation: Muscles to Psyche Pasalis, MBA, MTS, shared an inspired Cross-Fertilized Collaborations and inspiring message about appreciating yoga researchers as a breed of activists Other recurring themes throughout the who are working for social change. In few More than ever, the SYR speaker lineup gathering were about refining research words, she distilled the essence of the represented a diversity of background questions and building more sophisticated entire gathering by describing our collec- expertise, with everyone bringing his or outcome measures. For example, the tive goal of “putting scientific credibility her unique perspective to bear in building integrity of yoga research is a testable under this important practice.” the empirical literature documenting the question itself: how can we best investi-

8 YogaTherapyToday | Winter 2016 www.iayt.org SYR Reports continued gate yoga outcomes and what exactly are we measuring? The next few years will he Patient Reported Outcomes Measurement Information System (PROMIS, bring validation studies of several new www.nihpromis.org) measures are a collection of self-report questionnaires that yoga outcome measures that have been Texemplify how the NIH is focusing on person-centered outcomes and perspectives. rigorously developed and calibrated. For Combinations of these different measures can provide a comprehensive view of an individual's health status as they tap into different aspects of physical, mental, and example, one SYR poster presentation social wellbeing. PROMIS measures are designed to be equally applicable for offered a preliminary report on the first rig- research or clinical purposes (e.g., for chronic diseases), for special populations, or orous rounds of measurement calibration for assessing wellness across the general, nonclinical population at large. The to develop a novel measure to assess out- PROMIS initiative is built from the collaborations of many researchers, statisticians, come expectations for practicing yoga. and healthcare professionals who join their efforts in realizing the NIH mission to Using a sample of 119 adults who were develop better self-report measurement tools for both adult and child use. Results trying to quit smoking, scholarship award- obtained from PROMIS questionnaires may help to design or refine a treatment plan winner Rochelle Rosen and her col- or to support better patient-physician communication in managing chronic disease leagues showed good consistency (relia- states over time. bility—i.e., producing the same numbers PROMIS measures are free to use and are currently available in these general cate- when retested) and accuracy (validity-i.e., gories: confirming that one is measuring what one • Sleep Disturbance intends to measure) for their new scale. • Sleep-Related Impairment Their results also pointed to several pat- • Gastrointestinal Symptoms terns in beliefs and expectations about • Negative Impact of Illness yoga. For instance, demographics that • Positive Impact of Illness were correlated with greater expectations • Applied Cognition: General Concerns of outcomes included being female, being • Applied Cognition: Abilities non-Latino White, and being physically fit. • Self-Efficacy In contrast, age, education, and income • Social Isolation • Quality of Social Support did not correlate with beliefs and expecta- • Ability to Participate tions about the benefits of practicing yoga. • Satisfaction with Social Roles • Satisfaction with Discretionary Activities On a related note, one of the keynote speakers, Alyson Ross, RN, PhD, a nurse Within these general categories are multiple specific measures. For example, researcher from the National Institutes of PROMIS questionnaires can be used for data collection on pain, fatigue, alcohol Health (NIH), presented a primer on the use, sexual function, depression, and the nature of an individual's supportive social use of new NIH-funded outcome meas- interactions. The PROMIS project is a monumental endeavor and measures are typi- ures and how they can be applied within cally getting completed for adult use before the child population; therefore, some the context of studying yoga. These free- measures are not yet finished for child patient use. to-use measures all share the umbrella Researchers will be tracking PROMIS scores in individuals across the lifespan label of “PROMIS” (Patient Reported Out- and will also start looking toward validating the measures for cross-cultural use and comes Measurement Information System) health comparisons. Processes are in place for integrating PROMIS data into and are the result of a multicenter collabo- patients' electronic health records and, to encourage greater engagement in collect- rative group acting on a global NIH initia- ing data from younger children, multimedia and gamification strategies are being tive started more than a decade ago. See implemented where, for example, responding to the questions would complete a the sidebar for more information. puzzle or build an avatar.

The evolution of the PROMIS initiative began in 2004 with six research centers on board to help in measurement development. Over the years, different iterations of the measures have been test- ed (normed) on thousands of individuals and the network has now grown to twelve research centers. According to the NIH website, PROMIS measures have been used in 523 published research studies, and counting. The NIH is building strategic alliances with other organizations to help usher in wider adoption of these PROMIS measures in research, clinical practice, and policymaking.

The PROMIS Health Organization (www.promishealth.com) is a 501(c)(3) nonprofit foundation that has been created by the scien- tists originally funded by the NIH to develop the PROMIS system. This foundation has now grown to a global membership of con- cerned individuals that want to amplify the "patient's voice" in healthcare.

Visit www.nihpromis.org to find out more or to download a free zip Dr. Sat Bir Khalsa chats with P. Shyam Karthnik, a file of available PROMIS instruments. young researcher who had traveled from India. www.iayt.org YogaTherapyToday | Winter 2016 9 SYR Reports continued

Foundations for Moving Forward Reflections on SYR

Looking toward the future of yoga I was encouraged to see the results of research, there is a long way to go before collaborative efforts between individuals being able to scientifically explain the interested in furthering yoga research. Individuals and institutions, some with howcausal mechanisms of action—that is, yoga works. Elevating yoga therapy yoga backgrounds and others without, as an accepted treatment modality within working together to meet a common the mainstream healthcare system is a goal. stepwise process, and we are still in the foundational stage. Like the medical Nydia Tijerina Darby, PT, DPT, MS, adage of “first, do no harm,” these early ERYT-500+ steps involve showing that practicing yoga Yoga Educator, Researcher, does not generally lead to adverse effects, Doctor of Physical Therapy is well tolerated (i.e., feasible, with partici- Director of Nydia's Yoga Therapy Stu- pants in yoga interventions reasonably fol- dio, San Antonio, Texas lowing their practice protocol), and pro- duces positive benefits. Only after these basics are covered can the agenda move There is much further to go. We have more fully into quantifying the benefits Presenter Keishin Kimura yet to reliably identify the mechanisms and explaining the causal mechanisms of action. That is, what about the prac- at work. tice creates these outcomes? Several models have emerged and we are in More than ever, the SYR speaker lineup represented a the process of studying them. To do this, we need to refine our measures to diversity of background expertise, with everyone better detect these mechanisms and bringing his or her unique perspective to bear in bring specificity to our outcomes. building the empirical literature documenting the Catherine Cook-Cottone, PhD, RYT benefits of practicing yoga. Licensed Psychologist Associate Professor, Department of References Counseling, School, and Educational Realizing these goals is a long-term 1. Adams, J. (2012). Collaborations: The rise of research net- Psychology, SUNY Buffalo, New York initiative, and IAYT, through the design of works. Nature, 490, 335–336. SYR as a very interactive conference as 2. Gazni, A., Sugimoto, C. R., & Didegah, F. (2012), Mapping well as other forms of support for the field, world scientific collaboration: Authors, institutions, and coun- I'm excited about the beginning of a col- is facilitating tomorrow's realization of the tries. Journal of the American Society for Information Science laboration to generate reporting stan- and Technology, 63(2), 323–335. explanatory promise of yoga research. dards for yoga research, which will When the practices are fully understood at 3. Hall, K.L.. et al. (2012). Assessing the value of team sci- serve as guidelines for thorough and ence: A study comparing center- and investigator-initiated the cause-and-effect level, the therapeutic grants. American Journal of Preventive Medicine, 42(2), consistent reporting. If we don't know benefits of yoga will have changed count- 157–163. the details of what happened in a less thousands of lives in studios and YTT study's intervention, how can it inform healthcare settings around the world. our work with students and clients?

Steffany Moonaz, PhD, RYT-500 Associate Academic Director of Integra- tive Health Sciences Maryland University of Integrative Health, Laurel, Maryland

The Kripalu Institute for Extraordinary Living welcomes applications for the 2016 Samuel B. Hanser Visionary Award. Find out more at kripalu.org/hanser- award. Applications are due by February 12, 2016.

SYR attendees listening to a keynote presentation in Kripalu’s Main Hall

10 YogaTherapyToday | Winter 2016 www.iayt.org

SciencefortheYogaTherapist SYR 2015 The Collaborative Future of Yoga Research

By Stephanie M. Shorter Attendee demographics are another need to build the knowledge base around major factor that makes SYR a power- yoga therapy, communicate it to others, nlike my typical approach to writing house of a conference and a reflection of and get it translated into practice and poli- this column, I'm going to offer more yoga therapy culture. Not only are there cy feels very real. Perhaps it is the yoga Uof a perspective this time, with no researchers who are committed to meas- practice itself that makes yoga new yoga-related data—a sort of philo- uring the benefits of practicing yoga, there researchers and therapists more openly sophical companion piece to the SYR are many yoga therapists in attendance— collaborative in nature. Or perhaps yoga review on Page 8 in this issue. I'm inter- often with no formal training in research as a scholarly topic necessarily has to ested in finding the value in how what's methods—that show remarkable dedica- touch upon many topics, from anatomy to outside of our field can fertilize more so- tion to learning the language and methods psychology to relationship dynamics, phisticated approaches to yoga therapy of scien-tific research while also designing which gives many entry points to many dif- research through collaboration and cross- and leading many interventions for stud- ferent types of expertise. Or perhaps we discipline thinking. Furthermore, I propose ies. The intersection of these two areas of are seeing a zeitgeist change, a shift in that what is collectively developing within yogic expertise is pushing the yoga the way of being, in science more general- the yoga therapy research community is a research literature faster than it would oth- ly that is starting to rally different minds to mindset that welcomes cross-fertilization erwise have developed. bear in problem-solving—a trend that from different areas of expertise and, in doing so, a culture is developing that may well speed up the dissemination and translation of yoga into healthcare policy and practice. Collaborative Opportunities

By design, SYR is a conference that is built to support and catalyze new collabo- rations.* Creating this collegial space is why much time is structured into the schedule for participant discussion, includ- ing extended poster presentation ses- sions, and why it is a single-track meeting, which means not having to choose between three things happening at once that all capture your interest. These IAYT conference-design decisions reflect the kind of collaborative culture that we are creating together. Coming from the per- spective of many other research confer- ences that I've attended over the years, Photo credit: All SYR photos by Gabriel C. Pérez, www.gabrielperez.com often where morning posters come down SYR participants in Kripalu’s Main Hall. at lunchtime and the rush starts again to take in all of the afternoon posters of in- terest, there is a welcome break in the pace: a valuable opportunity to discuss, When it comes to the question of how applies to yoga research but is equally digest, integrate, and come back later with to get yoga therapy accepted into the applicable in many other areas of science. questions, and an invitation for attendees mainstream healthcare paradigm, seeking Whatever the reason, or perhaps a combi- to find the points of overlap in their work. answers feels quite urgent when status nation of all of these factors, based on my *SYR is designed as a Gordon Conference, quo means that so many people suffer observations it seems that yoga as was described in a previous edition of daily with chronic diseases and when researchers tend to be more collaborative : “In the Gordon model, yoga therapy, especially when offered as a with other scientists and more reciprocal aYoga small, Therapy select Today group of peers is given unique opportunities for discussion, collabo- lifestyle intervention, can often bring with yoga therapists who inform yoga ration, building informal networks; time for immediate relief with few or no long-term interventions and apply the results in their reflection and contemplation; and a quiet negative side effects. Is it the opportunity daily professional practice. tranquil environment in peaceful nurturing of alleviating suffering that has yoga surroundings in the hopes that the outcome will be a lifetime of collaboration and scien- researchers more amenable to cross-disci- After completing every study, yoga tific achievement.” Reference: Deife, J. pline collaboration than is typical for most researchers need to reach out equally to (2010). 'SYR' Sat Bir. scientists? After all, yoga researchers and scientists, funders, policy-makers, and (3), 21-22. Yoga Therapy Today, therapists know what is at stake. The (continued on page 14) 6

12 YogaTherapyToday | Winter 2016 www.iayt.org IAYT Accredited Member Schools with Yoga Therapy Training Programs (as of 12/1/15): • Ajna Yoga Centre (CA) • American Viniyoga Institute (US) IAYT • Ananda School of Yoga and Meditation (US) congratulates its Member Schools whose • AUM hOMe Shala (US) yoga therapy training programs have been • Essential Yoga Therapy (US) • Functional Synergy Yoga Therapy (CA) awarded IAYT accreditation! • Guru Ram Das Center for Medicine and Humanology (US) To date, 24 Member Schools have programs that have • Wellness/Yoga Qigong Academy (CA) earned this distinction by demonstrating • Inner Peace Yoga Therapy (US) compliance with the rigorous IAYT Educational Stan- • Integrative Yoga Therapy (BR & US) dards for the Training of Yoga Therapists. • Kula Kamala Yoga (US) • Maryland University of Integrated Health (US) • Niroga Institute (US) More accreditationIAYT.org decisions are in process! • Phoenix Rising Yoga Therapy (US) Check for up-to-date information. • Yoga School of Yoga and Holistic Health (US) • Soul of Yoga Institute (US) IAYT honors all our Member Schools who are • Spanda Yoga Movement Therapy (US) • Stress Management Center of Marin (US) submitting their yoga therapy training programs • Wellpark College of Natural Therapies (NZ) to this rigorous process. • YATNA (Yoga as Therapy North America) (US) • YogaLife Institute (US) Together, we are paving the way for making yoga • Yoga North International Soma Yoga Institute (US) a recognized and respected therapy worldwide! • Yoga Therapy International (CA) IAYT.ORG • Yoga Therapy RX LMU (US)

www.iayt.org YogaTherapyToday | Winter 2016 13 Science for the Yoga Therapist continued

clinicians. One of the themes touched upon multiple times during SYR was com- municating one's research findings as widely as possible for maximum impact. Publication itself is not the end goal; another important part of collaboration is reaching a new audience. For instance, in the “Yoga Research 101” SYR preconfer- ence, Arlene Schmid, PhD, OTR, gave strategic advice on publishing outside of research journals focused on yoga. For instance, if one is studying the benefits of yoga for cancer patients, she advises seeking the audience of an oncology jour- nal to spread the influence of the data and gather new supporters for yoga therapy. Practically Out of the Box

Disciplinary boundaries are not discrete and fixed—sometimes we seem to forget that—and crossing them through collabo- rating with eclectic scientists and publish- ing in venues other than yoga-related or complementary and journals can lead to exciting new vistas that showcase our research topic from a whole new perspective. Similarly, it is a false divide to think of yoga researchers and yoga therapists as separate. The cul- ture is already in place, with more co-min- gling happening between the two profes- sional groups; indeed, many individuals identify equally strongly as both yoga researchers and the yoga therapists who apply the knowledge. Across many areas of research, it typically takes more than a decade for results to be applied in the real world. Are A SYR tradition is that a moderator honors the presented with a gold IAYT scarf we seeing something unusual happening here in yoga research? Something that is Stephanie M. Shorter, more of a continuous cycle of data-theory- PhD, RYT, is a behav- application? The give-and-take between ior designer and an scholars and clinicians—yoga researchers expert on mind-body and yoga therapists—can perhaps allow research methods. for more rapid implementation of the scien- Trained as a behav- tific results into the thinking and practices ioral neuroscience and of yoga therapists. IAYT's two sister con- cortical electrophysiology researcher, she ferences, SYR and SYTAR, are at the core published studies in visual perception, of defining the culture of attention, and movement control before scholarship. That is, a culture of empirical shifting her focus to yoga research. Pas- quantification and standardization (SYR) sionate about how yoga and other con- meeting clinical intuition and individualiza- templative modalities can move the practi- tion (SYTAR). The blend of all of it is truly tioner from individual transformation to bigger than the sum of its parts. We are collective transformation, she is also the moving beyond isolated fields of science editor of a publication about social change with application of results woefully lagging called that is affiliated years behind. This is living science now, with theKosmos United Journal Nations. You can reach which is—according to my definition, at her at [email protected]. John Kepner and Sat Bir Khalsa lighting electric least—whatYTT yoga is all about in its candles as part of the opening night ceremony essence.

14 YogaTherapyToday | Winter 2016 www.iayt.org 2016SYTAR June 9–12 • Reston, Sponsors VA SYR Sept. 19–21 • Stockbridge, MA Diamond Sponsor (SYR Co-Presenter)

Gold Sponsors

Silver Sponsors

Exhibitors

Piel Canela Peru Fair Trade Organization Living School

Media Sponsors

Association & Affiliate Sponsors Academic Sponsors

For 2016 Sponsorship Opportunities, Please Contact Debra Krajewski at [email protected] M e n t o r ’ s C o r n e r Seeing through Shoulders O b s e rvations and Interpre t a t i o n s

By Sherry Brourman exhibit joint shapes and movement arcs To assess the shapes and patterns that reveal movement habits such as deeper into the body we must first under- hole-body movement, breathing shoulder internal or external rotation that stand the influence of the spinal curves on patterns, and psychosocial often include psychosocial ramifications. the shoulders and thoracic cage because Wdynamics are often reflected in connective tissues continually adapt to our shoulders. Communication between Let's look at some shapes and conse- long-term, habitual postures. In kyphosis, the cervical spine, which houses the quential body landscape. An excessively the anterior shoulder musculature will tend brainstem, and the thoracic spine, which lordotic cervical spine (see Fig. 1) is often to adaptively shorten while the posterior musculature will adaptively lengthen. Once houses the heart and lungs, uses the accompanied by some amount of thoracic the proximal shoulder joint musculature shoulders as transmitters of structural and kyphosis (round mid-back) as well as has shifted in this way, the transmission of physiological data. For example, a forward excess lumbar lordosis.3 Because it is not joint-shape influence continues, not only always visible, the thorax (rib cage) may head weighing heavily on the cervical distally into the elbows and hands so that not appear rounded, and the restricted spine creates the need for internal shoul- pronated forearms and flexed elbows der rotation, scapular abduction, and a thoracic extension that comes with kypho- deliver hands to the front of thighs kyphotic thoracic spine—all by way of a sis can remain hidden until an attempt to (instead of the sides) but also inferiorly gravitational compensation for the forward do even a small , for example into rib musculature, where the lower front head.1 Over time, this posture causes (see Fig. 2). On closer observation or ribs might descend and compress while changes in bodily functions, often even palpation, you would see or feel a the upper back ribs elevate and broaden depressing respiration and cardiovascular thoracic flatness that is at least temporarily by way of their accommodating intercostal efficiency. These shifts may first appear as unable to extend. Whether round or flat, muscles. These shapes then begin to a downshift in energy/mood-state or as thoracic kyphosis usually causes shoulder affect deeper bodily systems. The rib/tho- shoulder pain, reflecting a difficulty in sus- internal rotation. rax shapes contribute to lung shape and taining yogic homeostasis (a state of bal- ance and wellbeing).2

As yoga therapists, we incorporate all bodily systems in working to create com- prehensive programs that reach the entire bio-psycho-social-spiritual spectrum. We are able to take cues from the shapes and movement patterns of the shoulders to infer structural and physiological ramifi- cations, as well as emotional climate, only when we understand how the shapes have developed and currently respond to each other.

Seeing Shapes

Our movement habits begin in early devel- opment and are influenced by factors such as genetic inheritance, parental and cultural models, our physical history— habits, , injuries—and our emo- tional climate, both past and present. The way that we use or do not use muscles determines our movement patterns. Mus- cle usage is influenced by the complex interplay of the koshas (body, energy flow, thoughts and beliefs, and state of wellbe- ing). Even tall, lean ectomorphic body types whose muscles remain lean no mat- ter how much they exercise (as opposed to stockier mesomorphic bodies whose muscles grow in diameter quite easily) Figure 1 Figure 2

1 6 Yo g a T h e r a p y Today | Winter 2016 w w w. i a y t . o r g Mentor’s Corner continued breathing capacities because of the lung capacities and spinal stability, fluid · Are there visual cues that imply melt- strong membranous connections between movement can be perfectly healthy. ing/releasing/opening? Or do they imply lungs and the inner surfaces of the thorax. Breath Assessment tensing/holding/closing? When you are observing the shape of the thorax, you are also observing the shape If you read my last column about the 4 of the lungs. Now let's move on to more specific breath importance of studying the feet in an initial assessments to discuss how to validate or assessment, you may be wondering, If you imitate excess thoracic kypho- invalidate what we have seen so far in “Well, which is it? Should yoga therapy sis in your own body and attempt a deep shoulder shapes. evaluations begin by reading from the feet breath, you can feel how the front lower or by reading from the shoulders and lobes of the lungs are compressed and Because we know that soft tissues adap- breath assessments?” To answer, I'll say lose some capacity. Depressed lung vol- tively shorten or lengthen with long-term that I have found that the overall engineer- ume means less oxygenated blood being skeletal positioning, the current postural ing system of each body is a simple transported to the heart, less cardiac effi- state is usually determined by movement Legoland-like puzzle in which every ciency, and potential implications on over- habits designed long ago to manage grav- weight-bearing joint (which is really all of all energy levels. Less energy is often ity and breathing in that body. Even lung them at some point in a yoga practice) perceived as or creates negative mood. capacity for inhalations and exhalations is both complements and is affected by Imitate again and breathe with this lower determined by available muscle patterns every other weight-bearing joint. This lung restriction for a whole minute and that reflect old movement habits through- means that we can peer in from almost notice if you experience any emotional out the body. These habits create the cur- any vantage point: feet, knees, hips, shifts. Even as a brief exercise, this pos- rent functional (or dysfunctional) muscular spine, shoulders, or breath, depending on ture can feel disconcerting and demoraliz- length; muscles are habitually used in the the priorities most needed for your client's ing, so that over time, posture can affect same manner because the same muscles first assessment. Regardless of the entry mood and long-term difficult moods can work in their same teams for any and all point chosen, you will essentially arrive at also affect posture negatively. Conversely, bodily activity. the same conclusions to begin an effec- using yoga therapeutically can affect pos- tive multi-kosha yoga therapy program. 5 YTT ture and mood positively. As mentioned above, constantly rounded Validation and Invalidation of Our shoulders, forward head, restricted breath- Observations ing patterns, and cardiovascular inefficien- References cy can lessen body economy and the 7 1. Kanlayanaphotporn, R. (2014). Changes in sitting posture sense of bodily freedom. From these affect shoulder range of motion. Journal of Bodywork and It is important to note here that not all physical movement habits, we can begin Movement Therapies, 18(2), 239-243. early assessments get validated with fur- to think about potential psychoso-cial ele- 2. Nair, S., Sagar, M., Sollers, III, J., Consedine, N., & Broad- bent, E. (2015). Do slumped and up-right postures affect ther exploration; in fact, invalidation of our ments. stress responses? A randomized trial. Health Psychology, assessment is as informative as valida- From Structure to Psychosocial 34(6), 632-641. tion! We make assessments to under- 3. Knott, P. T., Mardjetko, S. M., & Techy, F. (2010). The use stand bodies so that we can articulate for of the T1 sagittal angle in predicting overall sagittal balance of the spine. Spine Journal, 10(11) 994-998. our clients how and why we are choosing To get an initial systematic take on the 4. Calais-Germain, B. (2005). The anatomy of breathing (pp. the programs and sequencing designed to emotional and perhaps spiritual reflections 51, 63, 127-129). Seattle, WA: East-land Press. help them heal themselves. Body shapes in a breathing pattern, ask yourself the fol- 5. Mullur, L. M., Khodnapur, J. P., Bagall, S., Aithala, M., & and movement patterns make wonderful lowing questions while observing your Dhanakshirur, G. B. (2014). Role of yoga in modifying anxiety potential signposts. client: level in women. Indian Journal of Physiology and Pharma- cology, 58(1), 92-95. 6. Levangie, P. K., & Norkin, C. C. (2001). Joint structure and Considering the validation/invalidation · Where is the inhalation initiated? Ideally, function: A comprehensive analysis. Philadelphia, PA: F.A. investigation, a client with thoracic kypho- this would be from the center of the Davis Company. sis, including what appears in mountain body so that the entire diameter of the 7. Todd, M. E. (1937). The thinking body: A study of the bal- pose as excess shoulder internal rotation, diaphragm increases, which capitalizes ancing forces of dynamic man. New York, NY: Paul B. Hoe- ber, Inc. may have plenty of strong shoulder exter- on central power. nal rotation hidden to the eye due to bony · Are inhalations and exhalations initiated compression. Even though we can't see gradually or are they sudden? the external rotation, it may be functioning · Do the clavicles rise up and overacti- Sherry Brourman, PT, perfectly well. This client may even have vate the neck flexor musculature and E-RYT, a physical ther- developed normal lung volume by using the sympathetic nervous system? Do apist since 1973, is gravity well—pressing onto the ground to the upper trapezius muscles rise up? director of Tensegrity lift and stretch into his or her full height; · Do the exhalations go to completion Center for Yoga Thera- the pressing down becomes an anchor for comfortably and consistently? py. Sherry uses a pan- the ultimate width of the wide-opening · Are breaths placed comfortably 6 camaya model in con- thorax. Explore whether you can slouch between words as your client speaks? ducting workshops and seminars interna- and breathe comfortably. Now press · Is the breath pattern interrupted or tionally and internship programs for yoga strongly into the ground, lift up inside, stopped during posture transitions or and gait therapy. She is the author of breathe deeply, and note the difference in moments of asana difficulty ? and the upcoming book Walk your potential lung and rib expansion lat- · Does the breath pattern seem to calm Yourself Well (Handspring, erally as well as vertically. Despite spinal the client, thus engaging the parasym- UK).Using www.sherrybrourman.com. Yoga Therapeutically curve deviations and/or joint asymmetries, pathetic nervous system? www.iayt.org YogaTherapyToday | Winter 2016 17 FeatureArticle Yoga Therapy Referral Guidelines for Healthcare Practitioners

By Timothy McCall, Leigh Blashki, Subodh Tiwari, John Kepner, and Loren Fishman that they be conscious and willing to take have, the number of sessions per week, part. Otherwise, patients with virtually any and length of time before revisiting the medical condition, whether bedridden or referring physician. If the referring physi- ambulatory, can do suitably adapted yoga. cian is knowledgeable about yoga therapy, he number of people practicing yoga the prescription may specify desirable continues to grow rapidly. Yoga ther- and/or contraindicated practices. apy is also becoming more popular both in healthcare and community set- Therapeutic yoga appears to be Ttings, increasing numbers of yoga thera- pists are being trained, and the research extremely safe. The strenuousness base in support of yoga therapy continues of the practice is titrated to each to grow stronger. Many healthcare providers are aware of the benefits yoga student. Beyond medical conditions, can bring patients, yet some remain unsure of how to include yoga in the treat- the yoga therapist factors in the ment plan, the nature of a yoga therapy consultation—or even how to refer a client's overall level of fitness, patient to a yoga therapist—and what to stamina, frailty, and specific needs expect from yoga therapy. Yoga thera- pists, in turn, may be unsure how to inter- and desires for therapeutic act with the medical profession. This arti- cle is intended to advise both interested outcomes. clinicians and the yoga therapists they interact with. What is Yoga Therapy?

Yoga therapy is the use of various yoga practices—such as poses, relaxation tech- niques, breathing , and medita- tion—to help people with a wide variety of Photo Credit: Maria Moreira, courtesyYoga of Therapy The and Simply Holistic Yoga Health Institute for health conditions, both physical and psy- chological. It can be a useful adjunct to medical care or, in some cases, can be Typically, private yoga therapy consulta- When advising patients, it is important used in place of conventional approaches tions include the following: to differentiate between a general yoga like drug therapy or surgery. class conducted by a yoga teacher and 1. Conducting an intake interview and/or yoga therapy, whether individual or in a Yoga therapy is often done through reviewing an intake form along with group. In developing a referral network, individual consultations. In this way, it is reports from healthcare practitioners that healthcare practitioners are encouraged to similar to other healthcare modalities. include current treatment, including speak with those in their locality promoting However, yoga therapy can also be pro- medications themselves as yoga therapists, evaluating vided in group settings in which partici- 2. Assessing the current health condition their training, competence, experience, pants have a similar condition and/or seek based on yoga therapy principles willingness and ability to communicate, similar therapeutic outcomes. In one-on- 3. Identifying underlying causes of the pre- and trustworthiness. one settings, the level of assessment can senting condition from the yoga therapy be detailed, allowing for a tailored treat- perspective Although yoga therapists are not ment plan to suit the client. In group yoga 4. Setting priorities and treatment strategy licensed and the term “yoga therapist” is therapy sessions, however, the level of in consultation with client not protected, reputable third-party cre- assessment is generally limited and the 5. Developing and implementing the yoga dentials are starting to emerge. Currently, treatment plan less individual. In either therapy program, which may include healthcare practitioners may search the case, the yoga practices may be modified dietary and lifestyle advice websites of the Australian Association of to make them safer or more accessible to Yoga Therapy Referrals Yoga Therapists (in Australia and New clients who may be frail or for whom Zealand), the Complementary and Natural standard yoga practices may be Healthcare Registry (in the United King- contraindicated. A yoga therapy prescription by a physician dom), and the Council on Yoga Accredita- (or other healthcare professional) looks tion (International) for yoga therapists Since the patients themselves must do the much like a physical or occupational thera- qualified by these organizations. By the practices to gain any benefits, all that is py referral. It should include diagnosis, latter part of 2016, a listing of yoga thera- required for successful yoga therapy is goals of therapy, cautions about special pists certified by the International Associa- conditions that the patient has or might

18 YogaTherapyToday | Winter 2016 www.iayt.org Feature Article continued tion of Yoga Therapists (IAYT) should be need to be aware of the potential interac- Healthcare providers do not need to available on the IAYT website. tions of yoga practice and drug therapy. have an in-depth understanding of yoga to For example, diuretics as well as many make skillful referrals to yoga therapists. Although yoga therapists do receive drugs with anticholinergic properties Since many practices that might seem to some education in basic biomedical termi- increase the risk of orthostatic hypoten- be contraindicated can be safely adapted nology and pathophysiology and may fur- sion, which could present a problem to to meet the needs of individual students, ther educate themselves to communicate students quickly rising from the floor or and since different yoga approaches vary better with healthcare providers, simplicity coming out of or . enormously, it is generally not incumbent on the part of the healthcare provider Anticoagulants increase the risk of hemor- on the referring clinician to specify which when making referrals is highly desirable. rhage in the event of a fall, which would yoga tools to avoid. Rather, if the referring Complex reports should be summarized in alter what a therapist would recommend. clinician provides general guidelines about basic language. Patients may be more his or her concerns, the yoga therapist likely to make an appointment with a yoga It is not uncommon that when people can figure out which practices should be therapist and commit to the advice given if begin to practice yoga regularly their need omitted or modified. For example, in a their healthcare practitioner provides a for medication decreases. The change patient with diabetic retinopathy, the yoga specific referral, rather than simply generally happens gradually over weeks therapist could be advised to avoid any advising the patient to seek out a yoga to months but could occur sooner if the practices that increase intraocular therapist. students ramp up their practices quickly. pressure. The greatest risk in this regard are drugs Final Thoughts Yoga therapy usually involves a num- that lower blood pressure or serum glu- ber of consultations with the yoga thera- cose levels, risking syncope and hypo- pist. Follow-up sessions allow the thera- glycemia, respectively. Therapists must A common challenge in yoga therapy is pist to refine the plan, make sure what the focus their serial patient evaluations on patient compliance. A few words from the student has been practicing is being done these possibilities and send their clients referring clinician may help motivate in an appropriate way, and to address any back to the referring physician, or at the patients to continue their yoga program. It new concerns that may have arisen in the very least, call the physician if changes is also important that patients be reminded interim. In the process of teaching the rou- are detected or strongly suspected. that yoga therapy is usually an adjunctive tine to the client, the therapist will some- therapy and that they should continue with times determine that the regimen as If the patient takes analgesics, anti- their other treatments under the care of planned is not quite right and will make inflammatory drugs, or similar medications their healthcare practitioners. It is the modifications. Whenever possible, details for or another painful condition, responsibility of both the yoga therapist of the yoga evaluation and plan should be adjustments might be advisable in either and the referringYTT clinician to reinforce this shared with the referring clinician. the drug schedule or time the patient prac- message. tices to allow therapeutic blood levels to The Principles and Practice Yoga therapy consultations are typi- be optimal during yoga. Any exercise, ofAdapted Yoga in from Health Care cally several days to a few weeks apart including yoga, can bring on asthma , edited by and the client is provided with a program attacks in susceptible individuals. If Sat Bir Khalsa, Lorenzo Cohen, Timothy of yoga therapy recommendations to prac- patients use an inhaled bronchodilator, McCall, and Shirley Telles (Handspring tice (at home, work, or elsewhere). The advise them to use it approximately 15 Publishing, January 2016). program may be written, photographed, or minutes before starting their practice. provided as audio or video recordings to Contraindications and Cautions in Timothy McCall, MD, support the patient. Many clients have Yoga Therapy is an internist, yoga three or four consultations over a number therapist, author, of weeks. In some instances, a healthcare and director of practitioner and yoga therapist may As with any healthcare intervention, a cli- Yoga As Medicine believe that a patient is best served by nician should weigh the risks versus the Seminars and regular therapeutic sessions, possibly benefits of yoga therapy. Therapeutic Teacher Trainings at meeting once a week over a number of yoga, as opposed to general yoga class- the Simply Yoga months. es, particularly vigorous ones, appears to Institute for Yoga be extremely safe. In contrast to most Therapy and Holistic When yoga therapy is being contem- classes, in yoga therapy the strenuous- Health. Leigh Blashki plated, it is important to consider what ness of the practice is titrated to each stu- is a yoga therapist other treatments may already be part of dent. Beyond medical conditions, the yoga and the founder of the Australian Institute the treatment plan. For example, a patient therapist factors in the client's overall level of Yoga Therapy, the president of Yoga may be receiving physical therapy for a of fitness, stamina, frailty, and specific Australia, and a member of the IAYT musculoskeletal injury, part of which needs and desires for therapeutic out- Certification Committee. Subodh Tiwari is includes prescribed stretching. The yoga comes. the Joint Director-Administration of the therapy component of the treatment plan Kaivalyadhama Yoga Institute in Lonavla, needs to factor in these stretches to be Given the nature of yoga therapy as a Pune, India. John Kepner, MA, MBA, is a sure the programs don't counter each holistic mind-body practice, there are no yoga teacher and therapist and the execu- other or lead to overwork of a body part. overall contraindications to yoga therapy tive director of the International Associa- Therefore, in yoga therapy referrals, be per se. Not all yoga therapy involves phys- tion of Yoga Therapists. Loren Fishman, sure to mention what else is being done. ical postures (asana) or breath work MD, is the medical director of Manhattan Interactions of Medication and (pranayama), although these practices are Physical Medicine and Rehabilitation, an Yoga Therapy Practice commonly a part of treatment strategies. It author, yoga teacher, and an assistant involves providing only what the client clinical professor at the Columbia College needs and is capable of practicing. of Physicians and Surgeons. Referring clinicians and yoga therapists www.iayt.org YogaTherapyToday | Winter 2016 19 FeatureArticle Establishing Professional Ethics in the Field of Yoga Therapy By Eleanor Criswell and Amy Wheeler field, specific categories of behavior and pists their trust. An ethical code is perhaps Educational Standards for the expectations of practitioners within the more important for yoga therapists than Trainingn its of Yoga Therapists,* field must be spelled out. We might liken it psychotherapists because yoga therapy IAYT to the medical professional, which oper- involves a psychophysiological working Istates that “Yoga therapy is the process ates under the general edict of “First, do relationship where ego boundaries may of empowering individuals to progress no harm,” and yet has a detailed and spe- blur; for example, there is sometimes a toward improved health and wellbeing cific code of ethics. perceived state of union between therapist through the application of the teachings and practices of yoga.” Yoga therapy is conducted by a yoga therapist; the yoga therapist applies the teachings of yoga “in a therapeutic context in order to support a consistent yoga practice that will increase self-awareness and engage the client/student's energy in the direction of desired goals,” the goals being those of the client/student and of yoga therapy. The yoga therapist has "specialized train- ing and skill development to support the relationship between the client/student and therapist and effect positive change for the individual.” Further, IAYT has as its mission to “establish yoga as a recog- nized and respected therapy.” Research has shown that the relationship between the therapist and the client/student is the key to successful therapy. As a profession aiming to provide a bridge between yoga therapy and healthcare, this means that yoga therapists need to operate ethically and consistently with the ethical principles from other healthcare professions as well as its own. The purpose of this article is to explore the foundation for a code of ethics in the field of yoga therapy, what IAYT has done so far to develop an ethical code, and expectations for certified yoga thera- There are many ethical dilemmas that and client/student or a strong identifica- pists regarding codes of conduct. come up in any healing practice, including tion with the therapist by the client. Both Purpose of a Code of Ethics yoga therapy. For example, operating ethi- therapists and clients need to safeguard cally ensures clients' confidentiality, safety, the welfare of the client/student. In addi- freedom from sexual exploitation, and the tion, the yoga therapist should not harm A code of ethics is developed by a group negative aspects of dual relationships clients with inappropriate yoga practices. of people within a professional community (relationships with the client in other con- Transference and to guide the professional behavior of its texts); ethical behavior also protects the Countertransference members. The code is intended to protect integrity of the field. These are the ground clients as well as the individual practition- rules for what clients can expect yoga er and the professional field as a whole. therapists to follow. It is important to remember that transfer- The purpose of an ethical code in the field Protecting the Field of Yoga ence and countertransference may be of yoga therapy is to educate everyone— Therapy and Clients/Students more likely to occur in yoga therapy than clients, therapists, and allied profession- in some other healthcare practices als—about what the client/student has a because of the close therapeutic relation- right to expect in regard to ethical behav- Yoga therapy is in the process of develop- ship that develops. Transference refers to ior within the context of therapeutic yoga. ing as a professional field. It needs to be a transfer of client's feelings (whether con- protected from misuses that may tarnish it sciously or not) from past experiences to You might be asking, doesn't yoga in the eyes of potential clients, employers, the therapist; countertransference refers therapyyamas inherently have an ethical code— healthcare institutions, and so on. An ethi- to the therapist's feelings from past experi- the ? Isn'tahimsa yoga therapy based on cal code for yoga therapy includes ences being transferred to the client. the concept of ? And you would be detailed guidelines for the practice of yoga These feelings are inherent to the thera- correct. However, as in any professional therapy in such a way that will not exploit peutic relationship and if not recognized *http://www.iayt.org/?page=AccredStds or harm the people who give yoga thera- by the yoga therapist for what they are,

20 YogaTherapyToday | Winter 2016 www.iayt.org Feature Article continued they can lead to inappropriate behaviors. process requires that each school apply- expected of him or her professionally. The Transference and countertransference ing for program accreditation have an offi- IAYT member base includes yoga thera- were first noted in the psychotherapy rela- cial code of ethics/professional conduct for pists, yoga therapy trainers, yoga therapy tionship. (For more explanation, see the their particular yoga therapy program. The students, and yoga therapy clients. All American Psychological Association's ethi- IAYT Accreditation Committee reviews members of our community will benefit cal principles and codes for behavior, each school's code of professional ethics. from expanded training in the area of ethics and professionalism. www.apa.org/ethics/code/.) Certification and Ethics Trust and Safety Ethics Regulation within IAYT The accreditation of schools does not Last, the IAYT at an organizational level The power differential between therapist address the ethics of individuals in prac- needs to be prepared to regulate col- and client is of note here, especially when tice. Hence, everyone who applies for IAYT leagues who are members of the organiza- we consider that empowerment may be certification (starting in 2016) will be asked tion. (IAYT cannot regulate yoga therapists projected on the therapist by the to read and give confirmation that they who are not part of our organization client/student. The yoga therapist may agree to the IAYT code of ethics before because we have no control over yoga have considerable experience and per- they can receive their personal credential. therapists practicing in the field who are not haps a degree of self-realization, and so a They will be required to sign the code of members.) IAYT has several ways in which perceived power differential can lead the ethics at each certification renewal. it can encourage members to comply with client to follow whatever the therapist sug- Interim Code of Ethics the ethics process, including refusal to gests without self-reflection and autonomy. grant membership, revocation of member- The therapist must recognize the power ship, suspension of membership, written imbalance and not exploit the client in any It follows that there was a need for the reprimand, censorship, and many other domain. Because clients/students fre- IAYT to form an interim code of ethics and activities listed in the Procedures for Disci- quently go into a deeply relaxed state in supporting documents in order to get plinary Actions document. The IAYT can the presence of the yoga therapist, it is ready for the grandparenting process. On also suggest that each complainant file the August 1, 2015, the IAYT announced and appropriate charges with a law enforce- important that they are safe duringfeel safe. times of vulnerability and that they published its interim code of ethics, the ment agency if the law has been broken. grounds for professional discipline, the Conclusion

It is an understatement to say that the cre- It is important to remember that transference ation of ethical standards is new territory and countertransference may be more likely to for a small nonprofit such as IAYT and that it will require significant resources. occur in yoga therapy than in some other The IAYT wants to make sure that cre- ation of the ethical standards and the healthcare practices because of the close inevitable consequences are handled with great care, compassion, professionalism, therapeutic relationship that develops. and clarity. Thank you for your support, and we look forward to finalizing the code of ethics and supporting documents so Trust and safety are very important in procedures for professional discipline, and that our community, clients, and practition- the yoga therapeutic environment. Yoga the complaint form. All four documents ers can feel safe and secure in knowing therapists must continue their yoga devel- have been received well by our communi- that we have an excellent codeYTT to rely on opment and have a healthy personal life. ty. IAYT has received positive feedback as in the field of yoga therapy. This helps to ensure that the yoga thera- well as suggestions for refinement. This pist does not attempt to meet her/his per- process will continue in the upcoming months. Eleanor Criswell, EdD, sonal needs in the therapeutic relation- is emeritus professor ship. The yoga therapist must be extreme- Disciplinary Review Panel of psychology, Sono- ly careful not to compromise the integrity ma State University; director of the Novato of the therapeutic relationship or to violate An Ethics and Disciplinary Review Panel Institute for Somatic the personal boundaries of the has been formed to deal with complaints client/student in any way. Research and Train- in a professional and timely manner. This ing; and past president Accreditation and Ethics panel is made of three to five respected of the IAYT. and long-term members of our community, all of whom have served the field of yoga The IAYT has already made excellent for decades. They have experience with Amy Wheeler, PhD, progress with respect to creating ethical ethics in the fields of psychology, medi- has been a professor standards for the yoga therapists within its cine, and ayurveda. The names of the of kinesiology at Cali- purview. First, the IAYT finalized compe- individuals on the panel are listed on the fornia State University tency-based training standards for the IAYT website. for 18 years. Amy's training of yoga therapists in 2012. Com- Ethics Education degrees include a BA petency-based standards are important and an MA in health because they ensure that each person promotion and a PhD in education and psychology. She is on who graduates from an IAYT-accredited The formation of ethics in the field of yoga therapy is also an opportunity to further the board of directors for the IAYT. Amy is program is able to demonstrate their pro- the director of the upcoming Yoga Thera- fessional competence as a yoga therapist. educate yoga therapists. The IAYT will be developing courses for members to take py Certificate Program at California State The first accredited programs were online so that each member feels confi- University, San Bernardino. announced in 2014. The accreditation dent in the understanding of what is www.iayt.org YogaTherapyToday | Winter 2016 21 Perspective Yoga Therapy: Meeting the Needs of The Triple Aim

By Kristine Kaoverii Weber and Brett Sculthorp

Biopsychosocialspiritual Model he MGH Benson-Henry Institute arise from grounded conceptual models. 1 3 recently released a cohort study The Triple Aim may be just that model. It Tshowing that relaxation practices like is a framework that can help us think yoga postures, breathing practices, and about why and how yoga should be inte- meditation can reduce the need for med- grated into the healthcare system. ical care by 43%. A February 2015 report Launched in 2007 by the Institute for from the Centers for Disease Control and Healthcare Improvement (IHI), a nonprofit 2 Prevention (CDC) cited yoga as one of focused on testing new models of care, the most commonly utilized complementa- best practices, and effective innovations, ry and integrative medicines in America. The Triple Aim intends to optimize health While a growing number of researchers system performance by serving three and federal agencies like the CDC and the goals: improving the health of populations, National Institutes of Health (NIH) reducing costs, and improving patient acknowledge the medical benefits of these experience of care. practices, the question of how to integrate yoga into the healthcare system remains “Value” in healthcare is a buzzword, largely unaddressed by these agencies. and it's not only about saving money. Patients deserve to have safe, appropri- 4 The healthcare system is complex, and For those immersed in the yoga ate, and effective care at affordable costs. health outcomes, even more so. Health world, it can feel like we live in an alter- The Triple Aim is now widely looked to as outcomes are determined by many differ- nate universe when it comes to health- a framework for creating better healthcare, ent factors including the social determi- care. Some yoga professionals don't want partly because it was adopted into the nants of health, new kinds of epidemics, anything to do with the system—citing Affordable Care Act in 2010. Let's explore and increased rates of chronic disease. insurance headaches, corruption, and how The Triple Aim could be utilized as a The biopsychosocialspiritual model is con- obsolete conceptual models—while others reference for mainstreaming yoga therapy sidered the gold standard for understand- find it difficult to get the medical communi- into healthcare by looking at each of its ing and treating manyUpanishadic diseases. kosha It might ty to take the therapeutic benefits of yoga three goals through the lens of yoga. remind you of the seriously. The reality is that until yoga 1. Yoga Therapy for Improving the model and, indeed, it is a Western onto- therapy is integrated into the healthcare Health of Populations logical model that shares some of the system, individuals and populations will same characteristics. continue to be excluded from its potential to significantly improve their health. Focusing on population health is essential When human beings are perceived as The Triple Aim to realizing The Triple Aim. Yoga therapy multilayered and intrinsic to their environ- can be adapted to a range of populations. ments, the viewpoint of the causes of dis- From children to seniors, from the chroni- ease begins to shift, as do the approaches cally ill to at-risk youth, from hospitals to to disease treatment and prevention. community health centers, yoga therapy Health is seen not as a purely biological or can address a range of needs in any pop- personal phenomenon; it is the result of an ulation or organization and facilitate the 5 intricate web of interrelated factors, behav- development of a “culture of health” in a iors, patterns, and interactions. For yoga community. Unlike massage, chiropractic, therapists, it may seem obvious that the or other complementary and integrative benefits of yoga permeate all layers of this medicine (CIM) modalities that require model, and research has demonstrated one-on-one intervention, yoga therapy can that yoga has numerous structural, physio- be provided in group settings and prac- logical, mental health, and social benefits. ticed at home. It is accessible, adaptable, What may be less obvious to yoga thera- low risk, low cost, and has a broad and pists, however, is that these benefits can growing research base. It has the potential be scaled to population health through, for to be integrated into any number of servic- example, integrated care strategies that Professionals all over the country are es—for example, a mental health outpa- merge mental health and primary care offering yoga therapy in healthcare set- tient program at a community mental services. If the well-known benefits of tings, which means there is a precedent health center, a weight loss program in a yoga—such as improved parasympathetic for integrating yoga. However, what is health department, and an employee well- nervous system function and psychoemo- lacking is a planned, coordinated effort ness program at a hospital. tional benefits—are scaled to the commu- between yoga therapists and healthcare nity level, we will start to see shifts in pop- organizations. Coordinated efforts typically ulation health outcomes. Tremendous

22 YogaTherapyToday | Winter 2016 www.iayt.org Perspective continued

2. Yoga Therapy Can Reduce Costs potential benefits to society could be real- apy is provided in groups, direct costs ized by approaching yoga therapy through (therapist's fee, equipment, overhead, etc.) a population health lens. The United States will spend about are low. From a lifestyle medicine or pre- $10,000 per person on healthcare in 2015 vention perspective, these costs become Health Professional Education 7 ($3.2 trillion in total), yet our outcomes almost negligible.

Understanding health through the biopsy- The Triple Aim intends to optimize health chosocialspiritual model opens the possi- bility of a broader agenda for health pro- system performance by serving three goals: fessional education. How do healthcare improving the health of populations, reduc- professionals need to be educated in order to better understand and address ing costs, and improving patient experience the complex web of health-related factors? How can CIM providers build bridges in of care. thinking and collaboration across what has become a landscape of highly specialized and disciplinary areas of healthcare? look more like those of a developing coun- Yoga-based lifestyle change can The National Center for Interprofes- try. Much of the expense can be attributed reverse heart disease and positively 8 sional Practice and Education has a role to (1) high administrative costs (one quar- impact other chronic illnesses. Many of in coordinating and documenting new edu- ter of all costs); (2) high costs of medica- these illnesses (as well as chronic pain cation models, practice competencies, tions, durable medical equipment, and and addiction challenges) respond well to and initiatives across the United States. It salaries; and (3) the relatively higher rate lifestyle therapy, which is starting to be has adopted an interdisciplinary mindset of interventions compared to other industri- considered best practice in some areas of 9 and is open to new ideas and new areas alized countries. medicine. While yoga professionals need of professional engagement. This center Yoga therapy services, however, can to be careful not to oversell yoga's bene- and similar organizations can be nodes for be delivered in ways that are not top heavy fits, yoga therapy may enhance care, CIM integration, where yoga therapy train- in staff or administration, that do not make other interventions work better, and 10 ers can become a part of implementing require any expensive equipment, and with may shorten recovery times. The authors whole health pedagogies. minimal interventions that involve props to of the recent MGH Benson-Henry Institute help with asana practice. When yoga ther- study wrote: (continued on page 26)

www.iayt.org YogaTherapyToday | Winter 2016 23 24 YogaTherapyToday | Winter 2016 www.iayt.org www.iayt.org YogaTherapyToday | Winter 2016 25 Perspective continued

“The data suggests that the intervention Researchers at the University of health, and look to maximize profit and should be applied to all at-risk popula- Eastern Michigan analyzed why some volume, healthcare has a long way to go tions, since the intervention has minimal states have higher costs than others and before realizing the goals of The Triple risk, minimal cost, and yields substantial drew this conclusion: Aim. A newer development in the health- benefits for patients with a wide variety care world is value-oriented Accountable Care Organizations (ACOs) and medical 14 The United States will spend about homes. These organizations are likely to $10,000 per person on healthcare in 2015 be the frontrunners of the Triple Aim and potentially an excellent vehicle for the ($3.2 trillion in total), yet our outcomes integration of yoga therapy. look more like those of a developing ACOs are groups of providers and suppliers such as hospitals, rehab facili- country. ties, and various specialist service providers that seek to coordinate popula- tion health and reduce costs across geo- of illnesses. The long-term effect of “The most effective cost containment graphic regions. They also include med- these interventions on healthy popula- measures may be those that increase ical homes—typically patient-centered (or tions is unclear, but the data suggests education and promote healthy primary care) medical homes (PCMHs). that mind–body interventions should lifestyles. Not only do these actions ACOs meet individual needs by acting as perhaps be institutedsimilaras to vaccinations a form of pre- or lead to reductions in health care spend- a coordinating point for care. All of the ventative care ing, they also improve the health status organizations in the ACO are rewarded by driver education 1 .” (emphasis mine) of the population, and may help to Medicare/Medicaid or insurance compa- achieve other important social policy nies for lowering costs, increasing per- Low-Cost Locations 12 goals.” formance, and improving health out- comes, and they are all penalized if they 3. Yoga Therapy Improves Patient don't. An example of value-based care, More people utilize mental health services Experience of Care when those services are co-located with ACOs receive incentives for working 11 primary care providers. This is called together to collectively find the most effi- “integrated care” and it's a growing trend Healthcare institutions realize that the cient and effective evidence-based strate- gies. If yoga professionals understand and in the healthcare world. We live in a fast- financial bottom line improves when promote yoga therapy as a powerful strat- paced society; it's difficult to find the time patients have a better experience of care. egy for meeting the goals of the Triple to address all aspects of healthcare, but When the whole person (as opposed to Aim, they can potentially carve strong better healthcare can readily be provided the disease only) is treated, the experi- inroads into ACOs and PCMHs and help when people can access different modali- ence of care improves. Healthcare is tran- these organizations to meet their goals of ties under one roof. We can translate this sitioning from volume to value. CIM is an providing value-based care. idea from mental healthcare to CIMs like obvious next step in providing high-quality, First Steps yoga therapy. Yoga therapy will be better cost effective, whole-person value in accessed when it is provided at health- healthcare. Yoga therapy could be a sim- care settings under the endorsement and ple and effective way for healthcare insti- A comprehensive, top-down, strategic supervision of licensed providers. Not only tutions to offer better value-based care. decision to integrate yoga therapy into will this integrate the service into existing healthcare would be the strongest indica- systems, it will also give yoga therapy the Yoga is person-centered rather than tor of a paradigm shift, away from the cri- professional stamp of approval to improve disease-centered. It is empowering and sis-management silo of service delivery participant buy-in. helps patients take an active role in their and toward the ideals of what wellness- based healthcare can truly provide—heal- Prevention own healthcare rather than being passive recipients of treatment. Much of the task ing, reclaiming, thriving, and sustainability. of managing chronic diseases is in the Grassroots efforts to integrate yoga in The Affordable Care Act's emphasis on hands of patients themselves. Healthcare communities will be the small steps that prevention is another opportunity for professionals are exploring new ways to support this shift. 13 reducing costs through yoga therapy. Cur- improve patient self-management. One Research supporting the effective- rently, yoga therapy research tends to of the guidelines for improving patient ness of yoga continues to grow, but more focus on yoga for conditions and dis- self-management is to offer support in eases, but little attention is given to pre- research is needed on cost-effectiveness groups. Yoga therapy is easily adaptable and how yoga can be integrated in com- vention and its public health application, to support groups, can improve the effec- including the integration of health litera- munities. Yoga is unique in providing inter- tiveness of those groups, and can provide ventions across the four domains of public cy—the capacity to know and make good a forum to help people learn valuable decisions about health. Prevention is the health—treatment, recovery, prevention, tools to manage and improve chronic con- mother lode of cost saving, but because and health promotion. The time for yoga ditions. it's neither sensational nor crisis-oriented, to become a part of the healthcare system it receives far less attention and support Other Trends is here. The yoga therapy community than other areas of healthcare. Yoga ther- should partner with healthcare leaders to apy (and safe, well-taught yoga in gener- initiate both top-down policy-level advoca- al) has tremendous potential as a Because health systems currently tend to cy and initiatives and bottom-up local-level widespread prevention strategy. be uncoordinated, focused on individual integrative models. Yoga professionals (continued on page 46)

26 YogaTherapyToday | Winter 2016 www.iayt.org www.iayt.org YogaTherapyToday | Winter 2016 27 Insight The Joy of Devotion

By Jennie Lee The questions I focused on with each which teaches devotion as part of yoga in kriya individual were “How do we practice devo- action ( yoga), I could see that just hakti feeling is the practice of selfless tion?” and “What does devotion require devoted was not enough. It also B devotional worship directed to one from us?” Prior to this exploration, I had requires right effort ( ). This makes supreme divinity. If God is not in thought of devotion as more of a feeling sense in terms of any relationship; love your belief system, then perhaps consider state that expressed itself naturally has to be backed up with intentional bhakti as devotion to the energy of univer- through the love that I held for a person or action. If we want to have a deep and ful- sal love. a passion. But in studying Sutra 2.1, filling connection to someone, it is not

Emphasizing an all-surrendering love as the means for communion with the divine, bhakti is one aspect of yoga prac- tice that can facilitate the state of unity consciousness, or , according to the . The literal meaning of bhakti, according to Monier- 2 Williams' Dictionary, is "attach- ment, participation, devotion to, fondness for, homage, faith, or love, worship, piety to (as a religious principle or means of salvation).” Some outer forms of bhakti kirtan yoga that are popular today include (call and response) chanting, mantra repe- tition, and ceremonial dedications to one's preferred concept of the divine. These human rituals, like any religious rites, when infused with loving attention bring us closer to union, but if performed mechani- cally become void of meaning. Meditation too can be a ritual undertaken with deep devotion or it can be a perfunctory discipline.

Recently, several of my yoga therapy clients were struggling with their medita- tion practice. They are all committed prac- titioners, but each felt stagnant and want- ed more than just a half hour of focused sitting. One of the clients had no formal religious belief system; one had a Catholic background but was not currently attend- ing church; and one expressed that she experienced a limited sense of the divine through nature. All of them wanted to gain a greater personal sense of what the divine is, how they were connected to it, and how a deeper understanding might help them find greater peace and purpose in their meditation practice and in their lives. So, I decided to explore with them the practice of devotion, or , as a way to enrich their experience.

28 YogaTherapyToday | Winter 2016 www.iayt.org Insight continued

enough to simply love them from afar—a movement. We discipline ourselves to full comprehension in exchange for a frustrating energetic divide remains if take time and energy away from the nor- seemingly intangible experience. there is no communication or activity mal outward focus that commands the between us. For a satisfying relationship, majority of our daily attention. We surren- The client who perceived the divine we must spend time with them, listen to der our constant need for stimulation and through nature had the greatest result. I them, and take action to love them in pleasure by withdrawing the senses from asked her to remember a moment when ways that are meaningful to them. Our the outside world ( ) and we turn she felt suffused with joy in nature. She inner devotional focus fuels the outer ourselves inward to experience personal described a certain cast of light she had dharana expression of our love in personal and communion with the divine ( ). This seen at sunrise one morning. Then I unique ways. inner focus is an essential companion to asked her to use this image as her point The Yoga Sutra on Ishvara outer yoga practices. And it is a step in the of focus in meditation for two weeks. She Pranidhana direction of liberation from all suffering and practiced concentrating wholeheartedly on the expansion of our individual conscious- a brilliant light within. By doing so, she samadhi ness that is . began to connect to the same feeling of To help my clients learn how to build this awe she felt in nature during her time of personal connection through the active The second aspect of surrender is in meditation. Following from this, she began yoga of devotion, we began discussing a the realm of thought. Once physically still to experience more open-heartedness and few translations of Yoga Sutra 2.45. in meditation, we discipline the mind to get a general feeling of greater love. quiet through meditative techniques such “Through wholehearted dedication (Isvara as breath awareness or control, mantra The client with no religious back- Pranidhana) we become intoxicated with repetition, and visualization. Another way ground had previously practiced a mindful- the Divine.” to shift out of thinking and into heart-cen- ness-based form of meditation that includ- “By total surrender to God, Samadhi is tered awareness is to focus on a spiritual ed a cognitive aspect. I asked her to try attained.”1 quality such as compassion or a represen- approaching her practice with the intention tation of the divine in order to inspire love. of opening the channel of divine connec- “Absolute surrender and devotion to the This is tricky because, although it is easy tion. She worked on her inner willingness Divine enables soul freedom.” to think about the things or people we to receive and to be content with the mys- love, many yoga students don't have any tery of what lies beyond known experi- ence, without the need to understand it all Following the , we practice being from a cognitive perspective. She reported having moments of deeper peace during even-minded in both joy and suffering, tranquil meditation and some strong intuitive mes- before friend and foe, equanimous with both sages that helped with career and rela- praise and insult, pure in heart, and willing to see tionship challenges. God at work in every moment of our lives. Finally, the client with a Catholic upbringing noticed ways in which she fears approaching the divine. She has Overall, this sutra indicates that the personal sense of the divine and therefore tried to incorporate the aspects of her reli- intended devotional focus is the divine don't feel love for It. So the question aris- gious background that feel true and loving essence, or God, and that bliss, expan- es, “How do we practice devotion to some- as a bridge over to a bhakti meditation sion, and omniscience are the rewards of thing that we don't even know? And this practice. I have encouraged her to focus that devotion. Some secular translations leads to the next aspect of surrender— on love in whatever way she experiences express that pure awareness leads us to surrendering the need to know. it and to hold that energy as her focus in full integration. It is clear from the various meditation. She finds this practice enables translations that a big part of devotional From the standpoint of the limited her to be more open and receptive during practice has to do with surrender. But what human mind, it is impossible to know the meditation. surrender does mean here? And what infinitude of the divine. Yet we can have a exactly are we being asked to surrender? personal experience of it if we surrender As all three of my clients are finding, thought and the need to intellectually the greatest devotional offering of all is the Aspects of Surrender know into devotion. This is where all three surrender of the personal self. We offer of my clients had the most difficulty. It is our desires, fears, attachments, percep- First, when we come to seated meditation human nature to want to comprehend our tions, thoughts, feelings, sense of being practice, we surrender our bodily actions experience, yet in this case they were separate, and our need to know on the in the world; we give up our habitual being asked to give up the possibility of altar of meditative devotion to the higher Self. www.iayt.org YogaTherapyToday | Winter 2016 29 Insight continued

The Path of Devotion 3. Determine your style of bhakti practice. ence of God in all beings and in all circum- stances. Following the Bhagavad Gita, we Fortunately, since by definition the divine practice being even-minded in both joy Experiment with different bhakti practices. essence is understood to be within all, and suffering, tranquil before friend and When you find one that resonates in your seen or unseen, there are innumerable foe, equanimous with both praise and in- heart and inspires joy and love, stick with ways to walk the path of devotion. Any sult, pure in heart, and willing to see God it for an extended period of time to allow way that we choose to keep our minds at work in every moment of our lives. In for full saturation. the quiet moments of meditation, we can and our eyes fixed on and perceiving God 4. Use every moment as an opportunity. is just fine, just so long as it brings us to more effortlessly slip into inner communion inner peace and love, along with loving with the divine beloved and enjoy the bliss 5 action. The Bhagavad Gita explains that it of bhakti. A fulfilling relationship of recipro- If we keep devotional love in our hearts as is easier to comprehend and become cal love is formed and meditation becomes we engage in daily life, it changes the fla- devoted to God in manifested forms, to rich with ever-expanding joy and peace. vor of all our interactions. Whether feeling connect personally to the infinite through This has been my experience of medita- joyful or challenged, we can ask our- its expression as mother, father, friend, or tion since I began focusing deeply on the selves, “How is this person or situation an guru. However, it is entirely possible to devotional aspect of practice. My clients opportunity to practice wholehearted adore God in formlessness as well have found that it was easier to remain devotion to the divine?” committed to daily practice with this focus. through the qualities of love, peace, com- 5. Enjoy the sweetness of surrender. passion, or joy. They have also experienced

The greatest devotional offering of all is the Within the practice of devotion is deep rest. We find that we can relax as we sur- surrender of the personal self. render the ultimate control over life and trust the flow of our unfolding to universal love. By letting go of the ego's constant To create a living, working relationship less pressure to achieve anything and demands, desires, and stories, we enjoy with the divine that is meaningful to us, we more ability to receive through meditation more of the blessings that bhakti yoga might need to strip away old concepts of instead. As a result of practicing the sur- brings. Meditation becomes less of a dis- God that were passed to us from others. If render of self as a devotional offering, we cipline and more of a celebratory joy. As your perception of God feels limiting in all felt greater joy and freedom from emo- we offer our devotion to the divine source any way, it may be time to surrender that tional attachments. of all life,YTT we are filled in return with boun- thought and open to the possibility of a tiful love. new experience of the divine in your medi- To summarize the process of establishing References tation practice. The release of limiting a meaningful, heart-centered bhakti prac- 1. Satchidananda, S. (2012). The Yoga Sutras of Patanjali (p. 140). Buckingham, VA: Publications. beliefs or dogmas with the intention of tice or to help a client open to the bountiful 2. Monier-Williams, M. (1899). A Sanskrit-English diction- expanding awareness through devotion is blessings of devotion, consider these five ary: Etymologically and philologically arranged with special powerful surrender practice. elements: reference to cognate Indo-European languages. Oxford, UK: Clarendon Press. Inner Renunciation 1. Be clear about what you are devoted to. 3. Joy Devi, N. (2007). The secret power of yoga (p. 220). New York, NY: Three Rivers Press. 4. Lee, J. (2016). True yoga: Practicing with the Yoga Sutras for happiness and spiritual fulfillment (p. 139). Woodbury, Another way of practicing bhakti yoga is Ask yourself this question: “What am I MN: Llewellyn Worldwide. by inwardly dedicating all action to God. most dedicated to?” For some, the answer 5. Yogananda, P. (2008). The yoga of the Bhagavad Gita (p. This inner renunciation can be performed may be a child or spouse, a creative pas- 126). Los Angeles, CA: Self Realiza-tion Fellowship. by householder as well as by renun- sion or career. For others, it may be per- sonal growth or spiritual evolution. Or it ciants or monastics. When we acknowl- Jennie Lee is the edge God as the only doer of all actions, may be the divine in whatever form or faith author of then we recognize that the divine is the they hold dear. True Yoga: Practicing with the only rightful recipient of all results of those 2. Set your priorities. actions and through this understanding we Yoga Sutras for Happi- ness and Spiritual Ful- keep devotion in heart and mind through- (Llewellyn fillment out the day. In this way, we become mas- Rank your answers to the question above Worldwide, January terful at nonattachment and contentment in terms of how much time and energy you 2016). Specializing in Yoga Therapy for ( ). give to each. Is this a good balance? 17 years, Jennie's writings are featured in , and more.Huffington She Post,counsels Mind by Body Skype Green inter- As we release personal attachments and nationally. www.jennieleeyogatherapy.com expectations, we begin to see the pres-

30 YogaTherapyToday | Winter 2016 www.iayt.org www.iayt.org YogaTherapyToday | Winter 2016 31 YogaTherapyinPractice Optimizing Pelvic Floor Health Through Yoga Therapy By Shelly Prosko

elvic health is the best possible functioning and management of “Pthe bladder, bowel, and repro- ductive organs. It is not merely the absence of disease or weakness in these organs. Pelvic health plays an important role in complete physical, mental, social, 1 and sexual well-being."

Each of us has a pelvic floor. Howev- er, we do not typically pay much attention to it unless we are experiencing a problem in the area that interferes with our daily lives. Symptoms of pelvic floor dysfunc- tions can be categorized as bladder and bowel issues, pelvic organ prolapse, sexu- 2 al dysfunctions, or pelvic pain disorders. Frequent bathroom visits; feeling a sud- den urgency to void; chronic constipation; pain with intercourse, urination, or bowel movements; severe pain or cramping with menstruation in women; or even slight uri- nary leakage with coughing, sneezing, or

laughing are just a few examples of pelvic Photo Credit: Yoga Figure 1 health issues that are common for both men and women and can potentially lead to further complications or imbalances. The first step for any practitioner health and function. Many of the PFMs Many people do not seek help, perhaps working in the area of pelvic health is to interdigitate with one another, with because they think some of these are nor- acquire basic knowledge about the pelvic attachments to other muscles, mem- mal changes that happen with aging or floor (PF) and the factors that influence branes, or fascia. These extensive and after childbirth, or that the problems can- pelvic floor muscle (PFM) performance. complex anatomical connections are not be helped or managed, but there is Increasing our understanding improves our testimony to the many roles that the PF help. Healthcare professionals such as ability to discern which yoga methods to plays. pelvic health physical therapists are part use to help our clients optimize their PFM of a medical team that assesses and Roles of the Pelvic Floor function and overall pelvic health. treats pelvic health issues. Yoga therapists can also be successfully integrated into What is the Pelvic Floor? The PF supports the pelvic organs and this medical team to provide a safe, effec- plays an essential role in bowel, bladder, tive, and powerful complementary thera- The PF consists of several layers that reproduction, and sexual function. The peutic practice. Examples of this success- include membranes, fascia, sphincters, additional roles the PF plays in breath- ful integration can be found in a variety of and muscles. The more superficial layers ing, core timing, posture, hip function, medical settings such as pain clinics, include the anal and urethral sphincters. and standing balance ability are often physical therapy clinics, and women's The deepest layer of the PF includes mus- not mentioned, but they are equally health centers. As yoga therapists, we cle groups levator ani and ischiococcygeus important for yoga therapists to provide an invaluable contribution to the 4-7 (as illustrated in Figs. 1 and 2) and is com- address. In order for the PFMs to fulfill management of pelvic health dysfunctions monly referred to as the pelvic diaphragm these roles in a healthy way, they need by using our unique skills guided by yoga (PD). The pelvic diaphragm is a group of to be extensible (flexible) and capable of philosophy and by using approaches such 3 pancha maya kosha dome-shaped muscles that have connec- being released, relaxed, engaged, and as the model of koshas tions from the ventral aspects of the coc- controlled in a functional and coordinated health that addresses all five or 4-7 cyx and sacrum to the dorsal aspect of the manner with other muscle groups. layers (physical, mental, emotional, ener- pubic bone and medial aspects of the Many factors can influence PFM per- getic, and spiritual) of the human organ- sides of the pelvis. Some of the muscles formance, such as the extent of damage ism that is involved in any dysfunction and also loop around the urethra, vagina (in to the muscles due to childbirth, surgery, healing journey. This article will favor the 8-10 annamayakosha women), and rectum. Piriformis and obtu- or other trauma; postural alignment11; physical layer, , although 4, 6 rator internus (also illustrated) are two hip breathing patterns; the timing of PFM we should keep in mind that we cannot muscles that line the inner walls of the PF recruitment along with its synergistic address one kosha without influencing the 5-7 and attach to the femur bone, resulting in muscle groups; and hormonal imbal- others. 12 a noteworthy connection of the PF to hip ances during .

32 YogaTherapyToday | Winter 2016 www.iayt.org Yoga Therapy in Practice continued

We also know that a correlation exists ness and feeling of connection is absent (garland pose) can facilitate awareness of between pelvic health issues and mental or lacking, it will be challenging to relax, the PD and its proper excursion during and emotional health. Unmanaged stress engage, or control the PFMs or manage breathing. can increase the sympathetic nervous persistent pain in the area. Part of an ini- system response, contributing to greater tial PFM-awareness practice can include a Tactile feedback at the perineum can sensitivity of certain nerve cells that can basic and brief educational session about also help heighten awareness. Placing an influence the experience of pelvic pain. PF anatomy as described above. The accordion-folded yoga blanket vertically Stress can also negatively influence blad- client can palpate his or her own ischial under the body and loopingmakarasana it back along der function. The brain, nervous systems, tuberosities, coccyx, and pubic bone to get the PF while lying in (croco- PFMs, and bladder muscles all work a sense of the bony landmarks where the dile pose) can provide effective feedback. together in a sophisticated manner to PFMs connect. You can include a visuali- As the individual breathes, he or she can achieve bladder control. Anxiety, depres- zation or mental imagery of the PF in a sense the pelvic diaphragmatic rhythm as sion, and posttraumatic stress disorder guided body scan awareness meditation the sensation and pressure changes are are shown to be associated with urinary with your client. Breath awareness prac- felt at the perineum from the contact with 13, 14 incontinence. Also, sexual dysfunctions tices with mindful observation of the natu- the blanket. Be mindful that this kind of in the United States have been shown to ral PD rhythm during a quiet and relaxed exercise may not be appropriate for every- be correlated with emotional issues such abdominal diaphragmatic breath pattern one, particularly those who have experi- 15 as depression and anxiety. can be extremely helpful in refining a enced trauma related to the pelvic area or client's awareness. First, simply allow your those suffering from a pelvic pain disorder With just a glance at the above infor- client to explore his or her experience with that results in hypersensitivity to the mation, one can begin to appreciate the what is happening to the PD during a perineum. variety of valuable tools and effective relaxed and natural breath cycle without approaches that yoga therapists have in trying to change anything. It is common for Explore cueing your client to focus our toolbox to help guide individuals suf- people to describe the direction of move- awareness on different parts of the PF fering from pelvic health issues to ment of the PD during a breath cycle (front, back, right, and left sides) while progress toward improved overall pelvic opposite to what the normal healthy direc- performing a variety of poses, movements, health. tion of movement should be. If this is the and breath practices. How Yoga Therapy Can Help: The case, then it is important to provide educa- Role of the Yoga Therapist tion about the natural direction of the PD Pelvic floor awareness can be taught excursion throughout the breath cycle. The and practiced in numerous ways. It is (1) Awareness PD moves in the same direction as the essential for you as the yoga therapist to respiratory diaphragm. On the inhalation, practice these techniques on yourself so the PD descends and expands, as if that you can discover your most effective The first step to optimizing PFM function “receiving” the pelvic organs. On the exha- cueing that will help optimize PD aware- is to address the client's awareness of lation, the PD ascends as it recoils back ness for your clients. and connection to the PF. People who suf- up into its restingsupta dome-shaped position. (2) Release and Relax the PFMs fer from PF dysfunctions, particularly for a Poses such as bal- prolonged period of time, appear to lack asana(reclined cobbler's pose), modified awareness of their PF and often times (extended child's poseananda with knees bal- Even if an individual's pelvic health issue report feeling a sense of disconnect from asanaapart and big toes together), is due to weak or poorly activated PFMs, it it, as if it is not part of them. If this aware- (happy baby pose), and is still possible for the PFMs to hold an unfavorable amount of tension. If a muscle is tense, it does not mean that it is neces- sarily strong. It can be simultaneously weak and tense. For proper functioning, the PFMs need to be extensible, similar to other muscles in our body. If the PFMs are repeatedly engaged or consistently being held unnecessarily (either voluntarily or involuntarily), they can become hyper- responsive or overactive, and problems can potentially arise such as pelvic pain, incontinence, constipation, hip or groin pain, low-back pain, or sacroiliac pain. Research shows that pelvic floor muscle contraction exercises (Kegels) can exacer- bate some conditions such as overactive bladder, urge incontinence, and pelvic pain dysfunctions and therefore are not 6,16 recommended as an intervention. The key message here is that relaxing and releasing PFMs is often times an over- looked but important intervention for many pelvic health issues.

Poses that can help stretch and Figure 2 potentially release PFM tension include www.iayt.org YogaTherapyToday | Winter 2016 33 Yoga Therapy in Practice continued

gomukhasanathe ones mentioned above and also pelvic health physical therapist and the feeling of vulnerability or threat for the (cow-face pose), modified together you can work as a team to opti- client. Placing yourself to the side of your (pigeonbaddha pose mize your client's ability to relax, engage, client and where they can see you is gen- konasanapreparation, bending forward),sucirand- and control his or her PFMs. There are erally an appropriate place. However, each hrasana (cobbler's pose), ways that yoga therapists can help individ- person and situation is different. Watching (eye of the needle pose: lying on uals improve the efficacy of PFM engage- and listening for any signs of physical, back or seated with back to wall: cross ment. I recommend starting with the edu- mental, or emotional discomfort is always ankle over opposite thigh;ananda bring thigh to cation, awareness, and PD breathing important in any session and referring chest), and modified practices as above for several sessions, your client to a mental health specialist as (half happy baby pose: one leg straight, then later integrate a transversus abdo- indicated. other one bent). Notice the involvement of minis-assisted thoraco-diaphragmatic 18 (4) and Koshas the hip musculature in these poses due to (TATD) breath pattern. The TATD breath the connection to the PF as previously includes a slight engagement of the trans- mentioned. I highly recommend cueing the versus abdominis (TA) that provides a As yoga therapists, we may also take into individual to allow the PF to release and graded resistance to the respiratory consideration what we have learned from complete its full excursion during the diaphragm as it descends on the inhala- traditional yogic wisdom about the ener- breath cycle while performing these tion, resulting in maximal diaphragmatic getic connection ofMuladhara the pelvic area to the poses, along with visualization and aware- excursion and increased expansion of the first two chakras. (root ), ness methods, to optimize PFM relax- rib cage. Since we know that the respira- located near the base of the spine in the ation. tory diaphragm, TA, and PFMs all engage area of the perineum, is often associated in sophisticated, automatic, and coordinat- with qualities of foundational support, The extent of PFM relaxation ed ways, focusing on breathing methods Svadhishthanasense of belonging, safety, and security. depends on more than the physical pose that enhance the respiratory diaphragm (sacral chakra), located chosen. It may also depend on the state and TA activation can potentially facilitate near the coccyx in an area between the 5,6,19 of the nervous systems; what the individ- PFM engagement. Research also sug- navel and pubic bone, is often associated ual believes about the pose and tech- gests that activation of certain hip muscu- with our creativity, emotions, joy, and sex- nique; how the individual is physically, lature plays a role in functional integration uality. It is not uncommon to see these 20 mentally, and emotionally responding; the of PFM engagement. particular qualities negatively affected in nature of the therapeutic alliance; and the people suffering from pelvic health dys- breath pattern. Yoga therapists have The yoga therapist can use this infor- functions. We can use our knowledge and knowledge about numerous yoga meth- mation to facilitate PFM engagement by various techniques we have learned in ods, philosophy, and concepts that can choosing poses and movements that are yoga therapy related to addressing these influence these factors positively, so these associated with engaging hip muscles two chakras to further complement the can also be incorporated into the individ- such as adductors, gluteus maximus, and plan of care. ual's yoga therapy plan to help release the deep hip rotators while at the same PFM tension, as appropriate. time implementingUjjayi the TATD breath pat- I feel it is essential to emphasize the (3) Engaging PFMs tern. (victorious) breathing can also importance of addressing all layers of the accompany the TATD breath during these pancha maya kosha model of health, poses: which bears a striking resemblance to our Isolated strengthening of PFMs outside modern day biopsychosocial (BPS) model the context of breathing and function may • (mountain) with block of health. I find that, unfortunately, the not necessarily transfer to improved ability utkatasanabetween inner thighs BPS model tends to neglect the spiritual of the PFMs to function the way you need • (chair or fierce pose) with aspect of healing. When we create a them to when you need them to. Some- setublock banda between inner thighs space for our clients that promotes self- times when the PF dysfunction appears to • (bridge pose) reflection and self-inquiry, allows them to be related to PFM weakness, it turns out it one-leggedwith block between bridge pose inner thighs explore their stories, and helps them is actually the result of a timing issue • (lift one leg off reconnect to purpose, they may experi- where the PFMs are not coordinating with mat while keeping pelvis level and neu- ence a deeper sense of connection with other muscles of the system that they are ardhatral) chandrasana themselves, others, and nature, which can supposed to be working with, such as the • vriksanana (half moon pose) be profoundly healing and empowering. respiratory diaphragm, transversus abdo- • (tree pose) Yoga therapists are in a strategic position minis, and lumbar multifidus (to name a • I-III (warrior I-III poses) to integrate this spiritual component into 4-6, 17 few). The key message here is that • utkata konasana(triangle pose) the BPS model in a way that is unique and addressing pelvic floor health is not • (goddess or fiery angle relevant to each individual, perhaps trans- always simply about performing an isolat- pose) forming the BPS approach into a “biopsy- mula bandha. marjaryasana/bitilasana 21 ed Kegel or engaging • alanasana (cat/cow pose) chosocialspiritual” approach that more • (high or crescent closely parallels the pancha maya kosha Learning how to engage the PFMs pose) model. Bridging this gap between yoga with proper synergistic timing with other therapy and our current healthcare para- muscle groups with awareness, mindful Keep in mind that individuals suffering digm can truly result in what we promote movement, and breathing can be a daunt- from PF dysfunctions may have a history as a more holistic approach to addressing ing task. Furthermore, it is not within a of trauma associated with the PF such as pelvic health and wellness. yoga therapist's scope of practice to eval- sexual abuse. Poses where the PF is in a What is the Research Saying? uate PFMs. This evaluation requires position that may result in the individual skilled manual palpation or use of electro- feeling vulnerable (e.g., happy baby, diagnostic measuring devices by a reclined cobbler's) may not be initially Outcome research in the area of yoga licensed health practitioner. Therefore, it is appropriate. Be mindful of where you as therapy for pelvic health is scarce and wise to refer your client to a licensed the therapist position yourself. Position much more will be required before signifi- yourself in such a way that would reduce (continued on page 48)

34 YogaTherapyToday | Winter 2016 www.iayt.org www.iayt.org YogaTherapyToday | Winter 2016 35 YogaTherapyinPractice Metabolic Syndrome and the Promising Potential of Yoga

By Baxter Bell better understand-ing of what is going on Diabetes: Type 1 versus type 2 here. Let's start with prediabetes. hen I was a full-time family doctor Prediabetes Metabolic syndrome refers to type 2 dia- and just thinking about teaching betes (T2D) as opposed to the autoim- Wyoga, metabolic syndrome had mune-caused type 1 diabetes (T1D) in not yet been medically defined. In fact, it In prediabetes, a person is in an interme- which the pancreas no longer makes was not until about 13 years ago that the diate stage between normal endocrine insulin. Those with T1D need to take components that make up this syndrome system function and dysfunction. The synthetic insulin to remain alive and well; began being clearly articulated as prob- recognition of this intermediate stage is a lifestyle modifications alone would lead lems by the medical establishment in the relatively new concept, recognized only in to a quick death for this much more United States—components such as “pre- the last 10 to 15 years. The Centers for acutely serious condition. T2D, on the diabetes” and “prehypertension.” This arti- Disease Control and Prevention (CDC) other had, which usually arises from cle is intended to provide a basic overview puts it this way: decreased physical activity, gradual of metabolic syndrome and the use of weight gain, and dietary and other fac- yoga therapy for metabolic syndrome for “A person with pre-diabetes has a blood tors, is potentially addressed with the education of yoga therapists—not as a sugar level higher than normal, but not lifestyle treatments like yoga, exercise, tool for diagnosis, which is only to be high enough for a diagnosis of diabetes. and weight loss. Thus, yoga therapy done by a qualified healthcare provider. He or she is at higher risk for develop- treatments for metabolic syndrome ing type 2 diabetes and other serious or T2D will be different to those Metabolic syndrome is diagnosed health problems, including heart dis- addressing T1D. when a person has at least three of the ease, stroke, cancer, and . following four health conditions present: Without lifestyle changes to improve (1) prediabetes, (2) prehypertension, (3) their health, 15% to 30% of people with insulin function as the linchpin of the other abnormal cholesterol values, and (4) obe- pre-diabetes will develop type 2 dia- factors that make up metabolic syndrome, 1 sity of a specific type. An individual may betes within five years.” especially high blood pressure, choles- have metabolic syndrome and feel rela- tively fine and healthy. The main benefit of identifying metabolic syndrome lies in its predictive benefit for future health: those with metabolic syndrome are at greatly increased risk of developing full-blown type 2 diabetes mellitus (T2D), cardiovas- cular diseases, some , and dementia. Uncovering metabolic syn- drome should be a call to action because all of the conditions listed above are reversible if caught early enough. Once reversed, the risk of developing these serious health conditions drops back to normal and you are more likely to live a longer, healthier life. Yoga has a role to play in this, and we will get to that shortly.

“But wait,” you might be thinking, “If this is a 'syndrome,' maybe it doesn't affect very many people and is quite rare, and I and my yoga therapy clients don't In prediabetes, individuals develop terol abnormalities, and systemic inflam- really need to worry about this… right? insulin resistance, meaning that their cells mation. Western lifestyle interventions and Sadly, the answer is no. It is not uncom- do not respond normally to insulin, a hor- early yoga studies both show promise in mon; it is estimated that about one-third of mone made by the pancreas. Insulin helps turning this around. Americans have metabolic syndrome. And to transfer sugar molecules (glucose) from Obesity in all likelihood, it is still being underdiag- carbohydrates in the food that you eat nosed at this time. from your blood stream into the cells, which need it daily to function. Some This second contributing factor in metabol- Let's take a moment to look at each health professionals, such as Mark ic syndromecentral refers obesity to a specific kind of aspect of metabolic syndrome to get a Hyman, MD, a functional medicine doctor, obesity— —where adipose see this particular shift away from normal fat is concentrated in the belly area to give

36 YogaTherapyToday | Winter 2016 www.iayt.org Yoga Therapy in Practice continued

rise to abdominal weight gain, leading to levels of LDL cholesterol, elevated levels of looked at yoga therapy and insulin resis- an “apple-shaped” torso and abdomen. triglycerides, or low levels of HDL choles- tance (several studies), yoga therapy and This pattern is in contrast to weight gain in terol. Considered in isolation, these abnor- hypertension (many studies), yoga thera- the hips and buttocks. It is not only the malities alone would not necessarily trigger py and obesity (multiple studies, even location of the weight gain, but also the treatment with cholesterol-lowering meds, ones that found effec- amount that adds this risk factor. especially if the person has no other risk tive), and yoga therapy and cholesterol factors for heart disease.* A first-line abnormalities. In each case, yoga therapy The thresholds for being classified as approach is often to recommend dietary was found to be beneficial, although as overweight are a body mass index (BMI) changes, stress management, and with almost all yoga research, the size of of 25 to 30 and as obese with a BMI over increased physical activity. the studies was small, the use of control 30. The CDC offers a free BMI calculator groups inconsistent, and larger studies at www.cdc.gov/healthyweight/assessing/ If we now circle back around to how were recommended to confirm and bmi/index.html. It is important to note that Western medicine addresses metabolic strengthen these early findings. BMI thresholds are different for different syndrome, we find that Western medicine ethnic groups, so that some people with a talks a decent game when it comes to These authors also looked at the BMI of 26, such as South Asians, Chi- treatment. Western medicine recommends connection between stress and metabolic nese, and Black Americans, are consid- increased physical exercise, diet modifica- syndrome. Chronic stress and depres- ered obese. This distinction is obviously tion, weight loss, and stress reduction. But sion exacerbate several markers of important if you work with these groups of the effectiveness of these interventions in metabolic syndrome; they are also people. Diet, physical activity, stress, and stalling this syndrome or better yet revers- increasingly recognized as risk factors for environmental exposures all play a role in ing it has been tepid at best. If the doctor heart disease. The studies included in the evolution of obesity. Again, both West- sees no progress and suggests pharma- the review indicated that yoga helped ern lifestyle interventions and early yoga ceutical solutions, these are not without reduce chronic stress. Other reviewed studies both show promise in turning this their own problems, some of which can studies showed that yoga reduces symp- around. indirectly worsen the factors of metabolic toms of depression and anxiety, and decreases anger and tension, all of It is estimated that about a one third of Americans which could improve stress management and so may indirectly improve metabolic have metabolic syndrome. And in all likelihood, it is syndrome. still being underdiagnosed at this time. The risk of developing T2D can be decreased with rigorous lifestyle inter- ventions involving weight loss and Prehypertension: increased physical activity. However, the As with prediabetes, syndrome. For example, some BP medi- paradox is that people who are over- prehypertension is an intermediate stage cines can actually worsen insulin resist- weight and sedentary are at highest risk between normal blood pressure (BP) and ance. Some would argue that the failure of for metabolic syndrome, but their ability commonly accepted levels of elevation of preventive approaches is because the to participate in and adhere to a vigorous BP that give you the diagnosis of hyper- healthcare system pays doctors to treat exercise regimen may be limited. A back tension. Also like prediabetes, the medical with medications and does not fund the door possibility takes advantage of the establishment only recently formally rec- kinds of preventative programs that would fact that stress may play a role in the ognized this as a condition (2003). BP is actually address the underlying issues of development of metabolic syndrome. considered normal if it's below 120/80 mm metabolic syndrome. I leave examining that Therefore, relaxation techniques such as Hg. proposition for another time and instead certain kinds of yoga could serve as ask this question: Can yoga tools be equal effective adjuncts to other lifestyle modifi- The prevalence of prehypertension is to or even surpass present lifestyle efforts cations. an estimated one-third ofalmost American always adults. to turn around metabolic syndrome? Summary and Conclusion Having pre-hypertension leads to full-blown hypertension or high To begin to answer that question, let's HP if it is not actively addressed. The bot- look at some of the findings of a review Metabolic syndrome is a condition with tom line is that both prehypertension and study from 2004 that reviewed the yoga increased risk for the development of sig- 2 high BP increase your risk of heart attack, research literature from 1970–2004. The lit- nificant disease, disability, and death stroke, and heart failure, even if you don't erature review suggested that yoga as ther- down the road. Initial yoga studies, have metabolic syndrome. Treatment rec- apy can positively affect both cardiovascular although not conclusive, show promise in ommendations by your doctor are often disease and metabolic syndrome. The addressing individual components of the varied, but lifestyle interventions definitely authors identified studies that individually syndrome as well as the syndrome itself. can positively impact this variable, and From my perspective, I consider yoga yoga fits in nicely here as well. therapy to have the following applica- * “cholesterol” as a broader term no longer has tions: Cholesterol Abnormalities the same impact on heart disease prediction, and we may find that systemic inflammation is • Yoga practices, both restorative and the underlying factor in the development of active, could be used as a preventative Abnormal levels of cholesterol that qualify plaque in this condition, but for now, specific strategy for presently healthy individu- for consideration in metabolic syndrome kinds of cholesterol molecules are still being als without any or only one or two con- are one or more of the following: elevated used to make clinical treatment decisions all ditions that make up the syndrome. the time. www.iayt.org YogaTherapyToday | Winter 2016 37 Yoga Therapy in Practice continued

• Yoga practices could be used as tarting in 2008, a series of three studies jointly looked directly at yoga therapy adjuncts or helpful additions to treat 3-5 Sfor treating metabolic syndrome. The first study by Cohen and colleagues metabolic syndrome once it is present was a feasibility study that attempted to determine if a protocol of restorative and to potentially “cure,” treat, or yoga would be achievable by overweight or obese individuals with metabolic syn- reverse the syndrome. drome—in other words, would they take their yoga medicine? The researchers found that 92% of those enrolled were able to complete the 10-week study—an In all likelihood, yoga would not act as encouraging compliance percentage. Whether restorative yoga can improve a stand-alone treatment, but would be metabolic syndrome still has yet to be answered empirically. added to a well-rounded treatment plan that might also include dietary changes The protocol of this study was designed by Judith Lasater, a well-known and and addressing hormonal and digestive highly respected restorative yoga teacher. Each group yoga class consisted of a imbalances, to name a few. brief series of warm-up stretches and breathing exercises followed by 10 poses Acknowledgements that were held for 5–10 minutes each. Study participants attended fifteen 90- minute yoga classes over 10 weeks. Special thanks to Rachel Lanzerotti, MSW, eRYT500, Certified Yoga Therapist, for her Poses included: assistance in sharing her experience as • Half-dog at the wall one of the yoga teachers for the Kanaya • Wall-hang standing forward bend et al. and Coreya et al. studies, and also • Seated bound-angle pose to Suza Francina, who was involved in the • Reclining twist initial study and whoYTT helped to clarify the • Supported bridge initial protocol used. • Supported legs up the wall References • Child's pose 1. www.cdc.gov/diabetes/basics/prediabetes.html • Supported lying-down bound-angle (queen's pose) 2. Innes, K. E., Bourguignon, C., & Taylor, A. G. (2005). Risk • Deep relaxation pose indices associated with the insulin resistance syndrome, car- diovascular disease, and possible protection with yoga: a sys- 4 The two follow-up studies by Kanaya and colleagues and Coreya and col- tematic review. Journal of the American Board of Family 5 leagues were really two arms of the same study looking at a much larger group Practice, 18(6),491-519. of participants for a longer period of time. The protocols for these studies were 3. Cohen, B. E., Chang, A. A., Grady, D., & Kanaya, A. M. designed by Roger Cole, PhD, a well-respected teacher of . (2008). Restorative yoga in adults with metabolic syndrome: A randomized, controlled pilot trial. Metabolic Syndrome and 4 Related Disorders, 6(3), 223-229. Kanaya and colleagues compared restorative yoga (experimental group) to 4. Kanaya, A. M., Araneta, M. R., Pawlowsky, S. B., Barrett- active stretching (control group) to see whether metabolic parameters were signif- Connor, E., Grady, D.,Vittinghoff, E., Schembri, M., Chang, A., icantly changed through restorative yoga. Results showed that restorative yoga Carrion-Petersen, M. L., Coggins, T., Tanori, D., Armas, J. M., had an advantage over simple stretching in regards to glucose levels, & Cole, R. J. (2014). Restorative yoga and metabolic risk fac- although both experimental participants and controls showed improvement in tors: The Practicing Restorative Yoga vs. Stretching for the many areas. The take-home message was that both restorative yoga practices Metabolic Syndrome (PRYSMS) randomized trial. Journal of and yoga-like active stretching may be better than usual recommendations for Diabetes and its Complications, 28(3), 406-412. individuals with metabolic syndrome. There is no obvious downside to adding 5. Coreya, S. M., Epela, E., Schembria, M., Pawlowskyb, S. yoga into the mix of options for addressing this condition and there are many pos- B., Cole, R. J., Aranetad, M. R., Barrett-Connord, E., & Kanayaa, A. M. (2014). Effect of restorative yoga vs. stretch- sible upsides. ing on diurnal dynamics and psychosocial outcomes

5 in individuals with the metabolic syndrome: The PRYSMS Coreya and colleagues examined if restorative yoga versus active stretching randomized controlled trial. Psychoneuroendocrinology, 49, was more effective in changing cortisol levels, which are theorized to be an 260-271. underlying cause of metabolic syndrome. Unexpectedly, active stretch was shown to have an advantage in this regard, doing better on both cortisol levels and stress assessments. Baxter Bell, MD, ERYT-500, brings his It is important to note that in both arms of these follow-up studies, interest- unique skills as a ingly, the authors choose a control intervention carefully constructed to retain cer- physician, medical tain key aspects of yoga—active stretching, range of motion, and healthy body acupuncturist, and alignment, without strong exertion or relaxation, but without the focus on breath yoga educator. He is and yogic concepts that were included in the yoga group. Shy of those last two on the faculty of at least four yoga thera- components, the control group sounds a lot like a typical class. py training programs in the United States and Canada and is a primary faculty pre- One of the possible factors that may have given the control group an advan- senter at the Niroga Institute in Berkeley, tage in these studies was the more social aspect of the stretching classes versus California. Bell writes weekly on therapeu- the more introspective way the yoga sessions were done. Again, this is potential tic yoga topics on his blog good news when we consider that most modern group yoga classes are also Yoga for quite social. More studies will need to be done to parse out the specific effects of Healthy Aging: Information, AdviceTo and learn yoga practices versus non-yoga practices. more,Companionship visit www.baxterbell.com. on the Journey.

38 YogaTherapyToday | Winter 2016 www.iayt.org www.iayt.org YogaTherapyToday | Winter 2016 39 YogaTherapyinPractice Yoga for the Re-embodied Self The Therapeutic Journey Home

By Catherine Cook-Cottone once heard self-harm described like this, professionals and that you should be “Sure, cutting is hell, but it's a hell I con- coordinating your care with theirs. Specifi- s yoga therapists, perhaps the most trol. It's a better hell.” You see, for those cally, the clients' therapists and/or med- unique feature of our work is the who don't feel safe, competent, or at icals doctors should clear them for yoga Afacilitation of embodiment. Embodi- home in their own bodies, there is a drive therapy. Further, the yoga therapist should ment is the natural state of being, a place to do anything to make sure they never monitor clients' progress and update the from which the development of an inte- really go there. As a researcher, psycholo- treatment team regularly. Within this con- grated self begins. It is a felt sense of gist, and yoga teacher, I know that these text, yoga can offer repeated integrating being present in the physical body; of solutions are red herrings, distracting us experiences that facilitate clients' safe being able to process and utilize emotions from the essential issues like a strong- return to their bodies. Through their expe- in decision making; and of effectively act- smelling fish used to divert the hounds riences in yoga sessions, clients can cre- 9,10,11,12 ing as an integrated whole, both from the true scent when hunting. Peace ate new embodied ways of being. autonomously and within the context of of mind, contentment, and self-regulation (See Table 1 on page 42.) 1,2 relationships. More specifically, embod- ied self-regulation is the ability to experi- ence thoughts, feelings, and physical sen- A critical aspect of the processes of healing, sations with a sense of competence and effectiveness in the service of emotion, growth, and re-embodiment is the practice of 1 cognitive, and behavior regulation. In this getting comfortable with the uncomfortable. way, we can meet external challenges with a sense of self-agency, intention, and voice while standing firmly grounded, steady in both heartbeat and breath.

For some, though, the body does not always feel like a safe place to be. At best, it is uncomfortable there. This can be especially true for those with trauma and dissociation, anxiety disorders, dys- regulated emotions, addiction, and eating disorders. Either consciously or uncon- sciously, those who are struggling in these ways may adopt the notion that the body is not a good or safe place to be. Some go into their heads—their thinking selves—intellectualizing, over-analyzing, ruminating, and engaging in the never- ending pursuit of gaining more information or "thinking things through" in hopes of resolving their struggles. Some use alco- hol, drugs, food, sex: whatever it takes to cannot be found in addiction, dissociation, not be fully here. Others engage in self- self-harm, or eating disorders. Yet, that is Embodiment is facilitated in several perpetuating cycles of addiction and disor- where these higher states of mind are ways. First, the yoga therapist presents der, gambling, bingeing and purging, often sought. bare awareness of—and attention to—a 1,13 starving, using, cutting, shopping, or rag- Yoga to Embody client's yoga practice. The client's pres- ing. This way they can stay at a surface ent-moment experience is central to the behavioral level and stay distracted by the yoga therapist's focus. Within this context, cycle of compulsive self-destruction fol- As an adjunct therapy for self-regulatory the yoga therapist can demonstrate 1,3,4 5 lowed by hiding, fixing, and/or (usually disorders, yoga can help. There are awareness and attention through mindful only temporarily) sobering up. Some go beautiful examples of re-embodiment listening, seeing, and reflecting upon the even further and dissociate, in a sense through yoga practice, such as Matthew client's verbal expressions, efforts, and 6 leaving their bodies and becoming so dis- Sanford's journey through physical and challenges. For example, a client strug- connected that they feel and think almost emotional trauma, as well as stories of gling to stay present in tree pose might nothing. recovery from disordered eating as illus- say, “I don't know if I can do this. I never 7 trated by Chelsea Roff and Christina seem to be able to balance. I am afraid I 8 These disembodied solutions may Sell. It is important to note that with clini- will fall.” Seeing the client's effort and lis- even appear to “work.” When disembod- cal-level disorder (e.g., addiction, eating tening to her words, the yoga therapist ied, it can feel as if you are safe from any disorder, trauma, self-harm, and mood dis- could empathically and supportively threat that being truly present in your own order), your clients should be engaged in respond, “Tree pose can be challenging. body might yield. As a human, I get it. I therapy with mental health and/or medical You are afraid you will fall. What if we start

40 YogaTherapyToday | Winter 2016 www.iayt.org Yoga Therapy in Practice continued

with breath and centering, and then you the down-regulation, or calming, of the zone is a space in which, yes, they might can try placing the ball of your foot on the nervous system. It is theorized that feel uncomfortable, but they are, in fact, floor as an anchor and work from there?” through attunement and resonance, the emotionally and physically safe. Moreover, through physical actions the client gradually internalizes the self-regu- 12,17 yoga therapist can use breath and move- lated state of the therapist. I am reminded of a conceptualization ment synchrony as well as physical mirror- by Viktor Frankl, a professor of neurology 14,15,16 ing. In these ways, the client has the Third, a critical aspect of the process- and psychiatry at the University of Vienna experience of being seen (i.e., validated), es of healing, growth, and re-embodiment Medical School. During World War II, he invited to try, given choice, supported, and is the practice of getting comfortable with spent years in concentration camps, encouraged. the uncomfortable. This is a journey of including Auschwitz and Dachau. Despite awareness and discernment and involves the great loss and tragedy that he experi- Second, it is important that the yoga moving into what can be referred to as the enced during that time, his body of work therapist's own embodiment is demon- “growth zone.” This zone is a space in emphasized meaning and personal strated through actions and words inten- which clients can heal and practice more empowerment. HeMan's makes Search an important for Mean- tionally promoting integration and embodi- effective ways of being. The growth zone point in his book ing20 ment within the client. That is, the thera- is often outside of an individual's comfort that can be summarized like this: pist's way of being in his or her body is a zone, and this is true for most people. Between stimulus and response, there is a positive example of how the client is work- However, it is important to remember that space. In this space lies your power to ing to be in his or her body. To illustrate, for some clients, the moment they feel choose your response. In your response embodiment of unconditional positive unsafeuncomfortable they are sure they are lies your growth and freedom. In his work, regard, openness, and acceptance is . It is an important distinction to Frankl goes on to describe what resides in modeled through actions. The yoga thera- make. When an individual feels uncomfort- the space between stimulus and pist's breath is steady, body engaged in able and unsafe, disengagement, dis- response: not the anguish that so many open and accepting postures, the spine is embodiment, and dis-integration can actively avoid through disembodied behav- 18,19 aligned, and feet are grounded. The yoga occur. As a yoga therapist, you can iors, but rather the space where growth therapist's voice is steady and kind. His or explain and explore the space of the and freedom can be found. her words encourage presence and growth zone, and you can invite the client 18 embodiment during physical effort, support to try presence and breath. With practice, Practice in embodied presence has breath and body attunement, and prompt clients can come to realize that the growth great implications for tolerating craving,

www.iayt.org YogaTherapyToday | Winter 2016 41 Yoga Therapy in Practice continued

23 Integration Therapeutic Yoga Therapist Yoga Therapy Client nidra. Further, there are some tech- Feature (eventually internalized by niques that may be contraindicated with the client) this population, such as beginning medita- tion instruction using an open focus (e.g., choiceless awareness, just sitting) rather Awareness and Focus on the student's physi- Externally experiences than a closed focus of awareness (mind- Attention cality, breath, and emotional unconditional positive fulness of breathing, mantra) or guided presence regard in efforts. focus and physical assists without familiar- ity and/or permission from the client. See 13 Awareness, openness, accept- Internally brings focus to Emerson and colleagues for a set of ance, and loving-kindness physical body, breath, and trauma-sensitive yoga principles. cognitive and emotional experiences. In summary, the quest for the embodi- ment of the disembodied can present Intention Encouragement of presence, Presence, embodiment, much like the self-perpetuating journey of embodiment, and growth and growth the hungry ghost (a metaphor from Bud- dhist teachings of a ghost with a huge Communication Contingent verbal and nonver- Listening and watching for belly and tiny mouth): eternally fruitless; bal communication specific to verbal and nonverbal guid- the seeker never finding what is truly the student's physical, emo- ance for physical, emo- sought—satisfaction of the craving for ful- tional, and attention state tional, and attention states fillment and peace. Conversely, an embodied experience of the self is the starting point for healthy self-regulation, Physicality and Chal- Centered, integrated, and sta- Embodied, intentional 1 lenge ble breath and physical physical movement and effectiveness, and contentment. The skills embodiment breath and presence of the yoga therapist are key mechanisms of change in this Positive encouragement and Positive efforts toward process. Through effective yoga therapy, verbal tracking of progress progress including the the body can be re-experienced as a safe including the ability to exert ability to exert effort (e.g., place for our clients' awareness and pres- effort (e.g., increase flexibility increase flexibility and ence to reside. With practice, the self- and strength) with ease and to strength) with ease and to destructive and dysfunctional tools for down-regulate the nervous down-regulate the nervous coping become unnecessary. Ultimately, system system the body is re-experienced and re-embod- ied as aYTT safe, empowered, and grounded home. Table 1: Therapeutic Features of Yoga in the Promotion of Integration and Embodiment

References self-regulation in anger, and control of sion, the yoga therapist functions as a 1, 21 1. Cook-Cottone, C. P. (2015). and yoga for compulsive acts. The goal is growth positive, compassionate coach. The yoga embodied self-regulation: A primer for mental health profes- and to learn how to get comfortable in the therapist is attentive to the state of the sionals. New York, NY: Springer Publishing. uncomfortable. As B. K. S. Iyengar is often client, noticing breath, heart rate, and 2. Piran, N., & Teall, T. (2012). The developmental theory of embodiment. In H.B. Ferguson, M. P. Levine, M. G. McVey, & cited as saying, “The pose begins when effort. Following periods of work in the N. Piran (Eds). Preventing eating-related and weight-related you want to leave it.” With a calm, effec- growth zone, the therapist guides the disorders: Collaborative research, advocacy, and policy tive, and powerful presence, the yoga client to periods of recovery through change (pp. 169-198). Waterloo, Ontario: Wilfred Laurier therapist helps clients reduce the neuro- restorative poses. For example, active University Press. logical tendency to automatically react to and balancing poses (e.g., warrior poses, 3. Klein, J., & Cook-Cottone, C. P. (2013). The Effects of triggers in a defensive nervous system crow pose, and tree) can be countered Yoga on Eating Disorder Symptoms and Correlates: A Review, International Journal of Yoga Therapy, 23(2), 41-50. flight-fight-or-freeze response while they with grounding poses (e.g., forward fold 4. Wittenauer, J., Ascher, M., Briggie, A., Kreiter, A., & increase their future ability to be in active and child's pose). Growth and embodi- Chavez, J. (2015). The Role of Complementary and Alterna- intentional presence when challenged. ment is achieved through periods of tive Medicine in Adolescent Substance Use Disorders. Ado- Clients become rewired for successful growth and rest at a pace that feels toler- lescent Psychiatry, 5(2), 96-104. negotiation of their triggers by practicing able to the client. 5. van der Kolk, B. A., Stone, L., West, J., Rhodes, A., Emer- presence and breath, digging into the son, D., Suvak, M., & Spinazzola, J. (2014). Yoga as an adjunctive treatment for posttraumatic stress disorder: A ran- physical experience, and feeling all that is The body of research on yoga and 12 domized controlled trial. Journal of Clinical Psychiatry, 75(6), happening within their bodies. Siegel and yoga therapy with those who have emo- e559-e565. 18 Emerson and Hopper call this process tion regulation difficulties and trauma his- 1,18 6. Sanford, M. (2008). Waking: A memoir of trauma and “widening the window of tolerance,” and tory is growing. Accordingly, yoga thera- transcendence. Emmaus, PA: Rodale Books 22 Linehan calls it “distress tolerance.” pists should stay current on findings 7. Roff, C. Eat, breathe, thrive. [Website] Retrieved Novem- through continuing education and review- ber, 2015, from http://www.eatbreathethrive.org/chelsea- Fourth, the yoga therapist ensures ing the research. Notably, asana practice roff.html 8. Sell, C. 2003. Yoga from the inside out: Making peace with that the process feels safe and manage- is only one of the many tools yoga thera- your body through yoga. Prescott, AZ: Hohm Press. able by pairing effort with rest and restora- pists have to offer. For example, there is tion directly contingent upon the present promise in practices using guided body- (continued on page 48) needs of the client. Throughout the ses- based techniques, such as iRest yoga

42 YogaTherapyToday | Winter 2016 www.iayt.org www.iayt.org YogaTherapyToday | Winter 2016 43 Review cultural competence will give yoga thera- What are the book's limitations? If pists additional language for better inter- you are looking for a detailed asana/ facing with their clients and their local pranayama practice descriptions, this isn't referral networks, especially conventional the right book. The authors overcome this healthcare practitioners. The book is publisher's word limit by regularly repeat- intentionally Sanskrit-lite, but does regu- ing the importance of having a local larly reference origins and how they fit in teacher to further instruct and provide our modern society. feedback. If the reader wants an exhaus- tive referencing and explication of the A major strength of this book is how classical writings of yoga and how they user-friendly it is. The use of lists of the inform anxiety and stress, that too is not in exercises, , and Sanskrit glossary the book, for the same reasons. The other makes for a versatile tool for the reader. limitation is the publisher's antiquated invi- Each chapter has a succinct list of the tation to the reader to communicate with summary points of the chapter, and within the authors via a postal address to the the chapter are very clear instructionskoshas for publisher. The authors are all very respon- Yoga Therapy for Stress the exercises that bring the to life. sive to inquiries, but to have to write a let- There are chapters that illuminate and ter and post it via the snail-mail system? and Anxiety: Create a invite inquiry into how yoga therapy can Fortunately, all three are IAYT members, Personalized Holistic Plan support care for anxiety and stress so you can find their contact information in through the intellect, emotions, occupa- the member section of the IAYT website. to Balance Your Life tion, and overall health. This “off the mat” By Robert Butera, PhD, Erin Byron, portion of the book is often given just a My recommendation is that you ease MA, and Staffan Elgelid, PT, PhD short plug in many other books. Not so your own stress and anxiety over how to here, as each topic has its own chapter better serve your students who struggle Woodbury: Llewellyn Publications full of explanations, exercises of explo- with stress and anxiety by putting this Review by Matthew J. Taylor ration, and yoga practices. This process book on your reading stack or recom- will get your students to more easily mended list for students. The authors hose of us in yoga therapy have a appreciate yoga as lifestyle, rather than have set a new bar for bringing yoga into Tunique challenge. Our mission to make being just one more workout they don't our society as a recognizable and respect- yoga a respected and recognized therapy have time to get to and which therefore ed therapy. Phew!—oneYTT less thing to requires that in our communication to the adds more stress and anxiety! worry about! consumer audience we must develop beyond offering classical esoteric descrip- The practical utility that the book tions of the therapeutic benefits of yoga. offers is its greatest strength. There is no This means communication should be cul- formulaic “do this to get that” turally competent (in language and context in this book. Unlike so many matching the audience), rooted in the larg- yoga therapy books that er body of knowledge of conventional direct a reader to do this to therapeutics, and have practical utility in relieve that symptom (the the real-worldYoga livesTherapy of everyday for Stress con- and medical model), the authors Anxiety:sumers. Create a Personalized Holistic have set the book up to per- Plan to Balance Your Life mit readers to build and dis- delivers on all cover their own practices for three of those criteria. remembering their innate wholeness. This design ful- The authors, through their unique fills IAYT's“Yoga definition therapy of yoga is blend of yoga training (Butera), convention- thetherapy, process of empowering al mental health skills (Byron), and rehabili- individuals to progress tation and movement sciences (Elgelid) toward improved health and have created a guide to first understanding well being through the appli- what stress and anxiety is for individuals in cation of the philosophy and modern society. They then introduce yoga practice of Yoga.” therapy and merge these concepts into Empow- modern mind-body medicine for the reader. erment of the practitioner is From there, they set up a number of chap- a great goal in general, but ters guiding the reader to discover their with anxiety and stress dis- own insights after which they invite the orders, it is even more criti- reader's unique personal response to the cal that the student develop various new perspectives and practice a sense of efficacy and con- technologies of yoga. fidence in life. The healing process of inquiry laid out in Does this mean the book is only for the book will cultivate that those new to yoga? Hardly. At a minimum, enacted and embodied the book is a masterful template for mak- experience for those readers ing yoga therapy accessible to a broader who have been tossed market that can be used by anyone plan- about through various prac- ning to write a book or to write better web- tices and remedies in their site content. The organization of the book quest to resolve their anxiety is that good. The authorspancha have also maya very from outside themselves koshacomfortably brought the rather than from within. model into our modern lexicon. This

44 YogaTherapyToday | Winter 2016 www.iayt.org www.iayt.org YogaTherapyToday | Winter 2016 45 Members News IAYT New Member Perspective continued from page 4 Schools in 2015 continued from page 26 Baxter Bell Elected can facilitate this shift by becoming more Abbysan Yoga (Thailand) engaged in a broader range of health to the IAYT Board of Alchemy Yoga Therapy Training (US) and research institutions and by conduct- Allow Yoga (US) ing their own small-scale research, as Directors Ayurvedic Institute (US) well as by training the healthcare work- Breathing Deeply Yoga Therapy (US) force in the value of including yoga thera- Meru Institute (US) YTTpy in an integrated healthcare system. Soulspace Yoga and Wellness (US) Baxter Bell, MD, Heat to Heal (US) References ERYT-500, brings his InBody Academy (US) 1. Stahl, J., et al. (2015). Relaxation response and resilien- unique skills as a Somatic Yoga Therapy (US) cy training and its effect on healthcare resource utilization. PLoS ONE. DOI: 10.1371/journal.pone.0140212 physician, medical Kind Yoga (US) 2. Clarke, T., Black, L., & Stussman, B. (2015). Trends in acupuncturist, and Living Yoga Therapy (Australia) the use of complementary health approaches among adults: yoga educator into Luna Works Yoga Therapy (Japan) United States, 2002-2012. National Health Statistics play in all the classes Medical Rehabilitiation Yoga Therapy (US) Reports. 3. The IHI Triple Aim. (n.d.). Retrieved August 13, 2015, and workshops he offers. He is on the fac- Ohn Shantih Yoga (Singapore) from ulty of at least four yoga therapy training Ottawa Yoga Therapy (Canada ) http://www.ihi.org/engage/initiatives/tripleaim/pages/default. programs in the United States and Cana- Sarasvati Worldwide Ltd aspx (UK and Hungary) 4. Porter, M. (2010). What is value in health care? New da and is a primary faculty presenter at Southern California University of Health England Journal of Medicine, 2477-2481. the Niroga Institute in Berkeley, California. Sciences (US) 5. What is a culture of health? (n.d.). Retrieved August 13, Bell writes weekly on therapeutic yoga 2015, from http://www.evidenceforaction.org/what-culture- Yoga for Healthy Aging: Spanda Yoga Movement Therapy (US) health Information,topics on his Advice blog and Companionship Svaroopa Vidya Ashram (US) 6. Engel, G. (1977). The need for a new medical model: A on the Journey. Warm Water Yoga Therapy (US) challenge for biomedicine. Science, 129-136. He also works with yoga Urban OM School of Yoga (US) 7. Munro, D. (2015). U.S. healthcare spending on track to hit $10,000 per person this year. Retrieved July 13, 2015, therapy clients in group and individual Yoga As Medicine Seminars & Teacher from http://www.forbes.com/sites/danmunro/2015/01/04/u- sessions weekly in his hometown of Oak- Trainings (US) s-healthcare-spending-on-track-to-hit-10000-per-person- land, California. To learn more, visit his Yoga Light School (US) this-year 8. Ornish Lifestyle Medicine | Undo It. (n.d.). Retrieved website at www.baxterbell.com. Bell will Yoga Medicine (US) Yoga Therapy Center and Shiva Shaki November 13, 2015, from http://ornishspectrum.com/ formally join the board at the annual meet- undo-it YTT Loka (US) ing in February 2016. 9. Buse, J., et al. (2006). Primary prevention of cardiovas- Yogatma Integrated Health Institute cular diseases in people with diabetes mellitus: A scientific (China) statement from the American Heart Association and the American Diabetes Association. Diabetes Care, 30(1), 162- Zen Yoga Studio (US) 172. 10. Schmid A., et al. (2012). Poststroke balance improves with yoga. Stroke. 43, 2402-2407. doi: 10.1161/STROKEA- IAYT Donors HA.112.658211 7/1/15–11/30/15 Thank You! 11. Butler M. (2008). Integration of mental Advertise health/substance abuse and primary care no. 173. (Pre- pared by the Minnesota Evidence-Based Practice Center Donors Donors under Contract No. 290-02-0009.) AHRQ Publication No. in the Publications of the 09- E003. Rockville, MD. Agency for Healthcare Research $5,000 to $9,000 $1 to $99 and Quality. International Association 12. Thornton, J., & Rice, J. (2008). Determinants of health- care spending: A state-level analysis. Laura Bonkosky Applied Economics, of Yoga Therapists Alan Kaye 40(22), 2873-2889. Alison F Brown 13. Self-Management Support for People with Chronic Con- ditions. (n.d.). Retrieved November 13, 2015, from Donors Helena Butler http://www.ihi.org/resources/Pages/Changes/SelfManageme Cathy Campbell nt.aspx $100 to $999 14. Finding Accountable Care | CAPP. (n.d.). Retrieved IJYT November 13, 2015, from Chiaki Ishimura-Smillie International Journal of http://accountablecaredoctors.org/what-is-accountable-care Yoga Therapy Anonymous Samantha Kinkaid Sarah Ann Birger Hansa Knox Johnson Lisa Todd Graddy Elena Rose Kress Kristine Kaoverii John Kepner Yvette Ladd Weber, MA, Joseph LePage Savitha Nanjangud eRYT500, is the founder of Subtle Mira & Shyam Nagrani Denyse Peterson Yoga and the director Yoga Therapy Today Ellen O'Brian Jessie Rhines of the Subtle Yoga Kandice O'Malley Luz Shanti Training Program for Behavioral Health May Devi Uwate Pierre-Richard Theard For a Media Kit and Professionals at the Mountain Area Beth Whitney-Teeple Richard Trzcinski Health Education Center. Brett Sculthorp, Advertising Opportunities LCSWA, LCASA, CSAPC, is a therapist Contact Abby Geyer at Family Preservation Services and the IAYT Advertising Manager co-director of Subtle Health, LLC. They live in Asheville, North Carolina, with [email protected] their son. www.subtleyoga.com

46 YogaTherapyToday | Winter 2016 www.iayt.org www.iayt.org YogaTherapyToday | Winter 2016 47 Yoga Therapy in Yoga Therapy in Practice continued from page 34 Practice continued from page 42 11. Capson, A. C., Nashed, J., & Mclean, L. (2011). The role 9. Kuhl, J., Quirin, M., & Koole, S. L. (2015). Being someone: cant changes in healthcare protocols and of lumbopelvic posture in pelvic floor muscle activation in The integrated self as a neuropsychological system. Social continent women. Journal of Electromyography and Kinesiol- and Personality Psychology Compass, 9(3), 115-132. practices will be made that include yoga ogy, 21(1), 166-177. 10. Menezes, C. B., Dalpiaz, N. R., Kiesow, Gustavo, L., L. G., therapy as a valid and reliable interven- 12. Rahn, D. D., Ward, R. M., Sanses, T. V., et al. (2014). Sperb, W., Hertzberg, J., & Oliveira, A. A. (2015). Yoga and tion. However, recent studies on mindful- Vaginal estrogen use in postmenopausal women with pelvic floor disorders: and practice guidelines. emotion regulation: A review of primary psychological out- ness-based stress reduction and group- International Urogynecology Journal, 26(1), 3-13. comes and their physiological correlates. Psychology & Neu- based yoga therapy for urinary inconti- roscience, 8(1), 82-101. 22 13. Bradley, C. S., Nygaard, I. E., Mengeling, M. A., et al. nence, asanas and for men- (2012). Urinary incontinence, depression and posttraumatic 11. Vago, D. R., & Silbersweig, D. A. (2012). Self-awareness, 23 stress disorder in women veterans. American Journal of strual abnormalities, yoga and irritable self-regulation, and self-transcendence (S-ART): a framework 24 Obstetrics and Gynecology, 206(6), 502e1-8. for understanding the neurobiological mechanisms of mind- bowel syndrome, yoga and premature 25 14. Felde, G., Bjelland, I., & Hunskaar, S. (2012). Anxiety and fulness. Frontiers in Human Neuroscience, 25(6), 296. doi: ejaculation, yoga for menopausal symp- depression associated with incontinence in middle-aged 10.3389/fnhum.2012.00296. 26 women: A large Norwegian cross-sectional study. Interna- toms, and yoga for -related 27 tional Urogynecology Journal, 23(3), 299-306. 12. Siegel, D. J. (2007). The mindful brain: Reflection and lumbar and pelvic girdle pain show posi- 15. Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual attunement in the cultivation of well-being (Norton series on tive effects and a promising future for dysfunction in the United States: Prevalence and predictors. interpersonal neurobiology). New York, NY: WW Norton & Company. pelvic health yoga therapy. Journal of the American Medical Association, 281(6), 537- 544. 13. Emerson, D., Sharma, R., Chaudhry, S., & Turner, J. 16. Smith, M.D., Coppieters, M.W., & Hodges, P.W. (2007). (2009). Yoga therapy in Practice: Trauma-sensitive yoga: I recommend that yoga therapists Postural response of the pelvic floor and abdominal muscles Principles, practice, and research. International Journal of in women with and without incontinence. Neurourology and work closely with the medical team to find Urodynamics, 26(3), 377-385. Yoga Therapy, 19, 123-128. out if there are specific precautions or 17. Wiebe, J. (2015). Female athlete: Ready for impact? 14. Berrol, C. F. (2006). Neuroscience meets contraindications you need to adhere to Retrieved from http://www.juliewiebept.com/product/female- dance/movement therapy: Mirror neurons, the therapeutic and whether or not your client requires athlete-ready-for-impact process and empathy. The Arts in Psychotherapy, 33(4), 302- 18. Garner, G. (2013). Better breathing for a safer spine: The 315. help with PFM relaxation, engagement, or yogic TATD breath. Retrieved from 15. Ramseyer, F., & Tschacher, W. (2006). Synchrony: A core a combination of both. It is important to http://www.gingergarner.com/?s=TATD+breath concept for a constructivist approach to psychotherapy. Con- understand that addressing the health of 19. Neumann, P., & Gill, V. (2002). Pelvic floor and abdomi- structivism in the Human Sciences, 11(1), 150-171. nal muscle interaction: EMG activity and intra-abdominal the pelvic floor is just one part of overall pressure. International Urogynecology Journal and Pelvic 16. Shapiro, L. (2013). Yoga based body psychotherapy: A pelvic health. There are many other body Floor Dysfunction, 13(2), 125-132. yoga based and body centered approach to counseling. parts and systems that are included in 20. Soljanik, I., Janssen, U., Lienemann, A., et al. (2007). The International Body Psychotherapy Journal, 12(1), 42-55. pelvic health and other factors to consider LFG-complex (levator ani muscle-fossa ischioanalis-gluteus 17. Siegel, D. J. (2012). The developing mind: How relation- maximus muscle) and its role for the functional integration of ships and the brain interact to shape who we are. New York, such as nutrition and hormones; state of the pelvic floor. European Urology Supplements, 6(2), NY: Guilford Publications. the nervous and immune systems; and 104-104. 21. Taylor, M. J. (2015). Fostering creativity in rehab. 18. Emerson, D., & Hopper, E. (2011). Overcoming trauma mental, emotional, and spiritual health. Retrieved from http://podcast.healthywealthysmart.com/ through yoga: Reclaiming your body. Berkeley, CA: North Address all koshas to the best of your 2015/09/171-fostering-creativity-in-rehab-w-dr-matthew- Atlantic Books. ability and skill level. An open dialogue taylor 19. Porges, S. W. (2011). The Polyvagal theory: Neurophysi- among all practitioners on the team is 22. Huang, A. J., Jenny, H. E., Chesney, M. A., et al. (2014). ological foundations of emotions, attachment, communica- A group-based yoga therapy intervention for urinary inconti- tion, and self-regulation (Norton series on interpersonal neu- essential to maximize the holistic nence in women: A pilot randomized trial. Female Pelvic robiology). New York, NY: WW Norton & Company. Medicine and Reconstructive Surgery, 20(3), 147-154. approach safely and effectivelyYTT and to 23. Nag, U., & Kodali, M. (2013). Effect of yoga on primary 20. Frankl, V. E. (1984). Man's search for meaning: An intro- optimize the client's healing. dysmenorrhea and stress in medical students. Journal of duction to logotherapy (3rd English ed.). New York, NY: Dental and Medical Sciences, 4(1), 69-73. Simon & Schuster. References 24. Kuttner, L., Chambers, C. T., Hardial, J., et al. (2006). A 21. Marlatt, G. A., Bowen, S., Lustyk, M. K. B. (2012). Sub- 1. Center for Research on Women with Disabilities. (2015). randomized trial of yoga for adolescents with irritable bowel stance abuse and relapse prevention. In Eds. C. Germer & R. Conceptual model for the pelvic health initiative. Retrieved syndrome. Pain Research and Management, 11(4), 217-223. from https://www.bcm.edu/research/centers/research-on- D. Siegel (pp. 221-233). Wisdom and compassion on psy- women-with-disabilities/topics/sexuality-and-reproductive- 25. Dhikav, V., Karmarkar, G., Gupta, M., et al. (2007). Origi- chotherapy: Deepening mindfulness in clinical practice. New health/pelvic-health nal research-ejaculatory disorders: Yoga in premature ejacu- York, NY: The Guildford Press. lation: A comparative trial with fluoxetine. Journal of Sexual 2. Messelink, B., Benson, T., Berghmans, B., et al. (2005). Medicine, 4, 1726-1732. 22. Linehan, M. M. (1993). Cognitive-behavioral treatment of Standardization of terminology of pelvic floor muscle function 26. Cramer, H., Lauche, R., Langhorst, J., et al. (2012). Effec- borderline personality disorder. New York, NY: Guilford and dysfunction: Report from the pelvic floor clinical assess- Press. ment group of the International Continence Society. tiveness of yoga for menopausal symptoms: A systematic Neurourology. Urodynamics, 24, 374-380. review and meta-analysis of randomized controlled trials. 23. Stankovic, L. (2011). Transforming trauma: A qualitative Evidence-Based Complementary and Alternative Medicine. feasibility study of integrative restoration (iRest) yoga nidra 3. Hjartardottir, S., Nilsson, J., Petersen, C., et al. (1997). The doi: 10.1155/2012/863905 female pelvic floor: A dome-not a basin. Acta Obstetricia et on combat-related post-traumatic stress disorder. Interna- Gynecologia Scandinavica, 76(6), 567-571. 27. Martins, R. F., & Pinto e Silva, J. L. (2014). Treatment of tional journal of Yoga Therapy, 21(1), 23-37. pregnancy-related lumbar and pelvic girdle pain by the yoga 4. Hodges, P. W., Sapsford, R., & Pengel, L. H. M. (2007). method: A randomized controlled study. Journal of Alterna- Postural and respiratory functions of the pelvic floor muscles. tive and Complementary Medicine, 20(1), 24-31. Neurourology and Urodynamics, 26(3), 362-371. 5. Talasz, H., Kremser, C., & Kofler, M., et al. (2011). Phase- locked parallel movement of diaphragm and pelvic floor dur- ing breathing and coughing: A dynamic MRI investigation in Shelly Prosko, PT, Catherine Cook-Cottone, healthy females. International Urogynecology Journal, 22(1), PYT, CPI, physical PhD, RYT-500, is asso- 61-68. 6. Key, J. (2013). 'The core:' Understanding it, and retraining therapist and yoga ciate professor at SUNY, its dysfunction. Journal of Bodywork and Movement Thera- therapist, is dedicated Buffalo. She has a pies, 17, 541-559. to promoting the inte- private practice treating 7. Smith, M. D., Coppieters, M. W., & Hodges, P. W. (2008). Is balance different in women with and without stress urinary gration of yoga thera- patients with anxiety, incontinence? Neurourology and Neurodynamics, 27, 71-78. py into our current eating, and mood disor- 8. Moalli, P. A., Jones, I. S., Meyn, L. A., et al. (2003). Risk factors associated with pelvic floor disorders in women healthcare system. She is a graduate of ders and difficulties with self-regulation. undergoing surgical repair. Obstetrics Gynecology, 101, 869- University of Saskatchewan, Professional She founded Yogis in Service, a nonprofit 874. Yoga Therapy Institute, and Life is Now organization. Her recent book is titled, 9. Herbert, J. (2009). Pregnancy and childbirth: The effects on pelvic floor muscles. Nursing Times, 105(7), 38-41. Pain Care. She teaches at medical col- 10. Hilde, G., Staer-Jensen, J., Siafarikas, F., et al. (2013). leges, yoga therapy trainings, and confer- Mindfulness and yoga for self-regulation: Impact of childbirth and mode of delivery on vaginal resting A primer for mental health professionals. pressure and on pelvic floor muscle strength and endurance. ences, and she offers workshops globally. She is associate editor of American Journal of Obstetrics and Gynecology, 208(1), www.physioyoga.ca Eating disorders: 50e1-7. Journal of prevention and intervention.

48 YogaTherapyToday | Winter 2016 www.iayt.org

INTERNATIONAL ASSOCIATION NONPROFIT ORG. OF YOGA THERAPISTS U.S. POSTAGE PAID P.O. Box 251563 MANSFIELD, OH Little Rock, AR 72225 PERMIT #158

CHANGE SERVICE REQUESTED MOVING? www.iayt.org Update [email protected] address online at or email NOT GETTING EMAIL FROM US? [email protected] Please add to your address list or safe senders list.