Complementary Therapies in Clinical Practice 37 (2019) 122–132

Contents lists available at ScienceDirect

Complementary Therapies in Clinical Practice

journal homepage: http://www.elsevier.com/locate/ctcp

Yoga and mental health: A synthesis of qualitative findings

Hannah Capon a,*, Melissa O’Shea a, Shane McIver b a School of Psychology, Deakin University, 1 Gheringhap St, Geelong, VIC, 3220, Australia b School of Health and Social Development, Deakin University, 221 Burwood Hwy, Burwood, VIC, 3125, Australia

1. Introduction positive experience [12,13]. It is also estimated that more than half of those experiencing mental health challenges do not seek treatment to Yoga originated in India over two thousand years ago as a multi- begin with [14]. modal discipline which sought to alleviate suffering and transcend Following these trends, there has been an emphasis on examining the consciousness [1,2]. There is a wide variety of yoga approaches role yoga might have addressing the increasing prevalence of common throughout the world, although Hatha yoga represents the most mental health conditions [15]. Evidence suggests yoga practice can commonly practiced in the western world. With a focus on the reduce symptoms of anxiety, depression and PTSD through a range of mind-body connection, Hatha yoga has an emphasis on physical pos­ biological and psychological mechanisms [16–18]. Nevertheless, some tures, along with the more traditional practices of meditation and uncertainty about the effectiveness of yoga for mental health conditions breathing techniques [2]. Several models of yoga fall under the Hatha remains [19], and health care professionals report feeling ambivalent to classification, varying in the spiritual foundations, focus and approach prescribe or discuss it as an adjunct treatment with their patients [20]. of the practice, including Iyengar, Vinyasa, Kundalini, and more It is typically argued the ‘gold-standard’ for establishing evidence- recently, Trauma Sensitive Yoga. based practice (EBP) is the randomized controlled trial (RCT), sup­ In contemporary times, yoga is being adopted as a “system of heal­ ported by such explications as systematic reviews and meta-analyses ing” to promote physical and mental health in the modern world [3] [10]. As such, evidence for yoga established in RCTs, systematic re­ with participation rates continuing to grow in western countries [4,5]. views and meta-analyses are prioritized and valued over methodologies In Australia, for example, data indicates yoga participation has doubled used in this field [15]. However, studies which seek to meet these in the past ten years, with one in ten people reporting a regular yoga standards are often criticized for being ‘low level’ and limited by practice [6]. When asked about their motivations for practice, many methodological drawbacks, including inconsistencies in the type and report it helps manage physical and mental health conditions, including dose of yoga examined, small sample sizes and the varying outcome anxiety and depression [4]. measures used [19,21,22]. Indeed, rates of poor mental health have been rising, with anxiety However, it can be countered that over-reliance on quantitative and depression estimated to affect one in four adults in a lifetime [7,8]. methods for evaluation has meant the yoga practitioner’s views and Post-traumatic stress disorder (PTSD) is also represented in these sta­ values, integral to the individualised nature of yoga and often captured tistics, although clinically it is separate in the current classification through qualitative methods, tend to be overlooked [23,24]. The alter­ system [9]. People affected by these disorders commonly experience native yet complementary approach of ‘practice-based evidence’ (PBE) symptoms of negative affect in the form of low or anxious mood, diffi­ may be a more appropriate framework for yoga research and yield culty controlling thoughts and social withdrawal [9]. important data to progressing an understanding of the potential benefits Current first line treatments typically include pharmaceuticals and of yoga in the treatment of common mental health conditions, over and psychotherapy, such as cognitive behaviour therapy (CBT) which targets above the mere reduction of symptomology, as well as how yoga might affective symptoms, cognitive distortions and behaviours deemed un­ be integrated safely and feasibly into treatment protocols for adults helpful [10]. Although these treatments have demonstrated moderate to affected by these conditions. high efficacy there remains a significant minority of people, ranging PBE aims to incorporate information drawn from real-world practice from one fifth to one half of adults, who find it difficultto engage with and experience in lieu of or in addition to evidence from quantitative standard psychological treatments [11]. The experiences of the efficacy research studies [25]. Advocates of PBE emphasise the benefits of of antidepressants vary and only half of those prescribed report a considering client and practitioner perspectives through qualitative

* Corresponding author. School of Psychology, Deakin University, 1 Gheringhap St, Geelong, VIC, 3220, Australia. E-mail address: [email protected] (H. Capon). https://doi.org/10.1016/j.ctcp.2019.101063 Received 30 July 2019; Received in revised form 27 September 2019; Accepted 27 September 2019 Available online 27 September 2019 1744-3881/© 2019 Elsevier Ltd. All rights reserved. H. Capon et al. Complementary Therapies in Clinical Practice 37 (2019) 122–132 methods, since these often account for why a particular practice or 2.1. Search intervention had the observed effects [26]. Qualitative methods of in­ quiry that explore the lived experience enable identification of what is A comprehensive search was conducted on 21st February 2019 using significantfor these stakeholders, not just the researcher. This approach the following databases: Embase via EMBASE, Medline COMPLETE via can also explore what factors motivate or inhibit people from engaging EBSCO, PsycInfo via EBSCO, AMED via EBSCO and CINAHL via EBSCO. in the practice, as means of exploring whether the treatment is feasible The search sought to identify all available qualitative studies investi­ or acceptable [24]. Given yoga’s individual, experiential and holistic gating the experiences of individuals who practiced Hatha yoga as a nature [3], if the practitioner’s experience is not considered, there might treatment for the most common mental health conditions, identified in be an incomplete perspective of the acceptability and suitability of yoga the literature as anxiety, depression and PTSD [15,16]. The focus was on for people with mental health conditions and how it could feasibly be Hatha yoga as it represents the most commonly practiced yoga approach utilised as either a primary or an adjunct treatment. in the western world [2]. Several studies have been conducted which explore yoga through a The following search strategy was used: Yoga [Title] AND (“Mental qualitative lens. Most recently and predominantly, research is emerging health” OR “mental illness” OR depressi* OR anxiety OR “posttraumatic regarding the experience of TSY for people across a range of de­ stress”)[Title/Abstract] AND (“Lived experience*” OR “Personal expe­ mographics and presentations, including youth with a diagnosis of rience*” OR qualitative OR “Mixed method*” OR phenomenolog*) anxiety, depression or PTSD [27], women who have experienced inter­ [Title/Abstract], Excluding: Dissertations. The search strategy was personal violence [28], and women with a diagnosis of PTSD based on adapted for each database as necessary. experiencing childhood trauma [29]. TSY is a type of Hatha yoga which Studies were excluded if they: 1) did not include clinical samples is specifically designed to meet the needs of people who have experi­ with anxiety, depression or PTSD; 2) did not assess Hatha yoga; 3) enced trauma [30]. Findings from these qualitative inquiries shine a included quantitative measures only; 4) included participants aged light on the role of yoga in the broader context of participants’ mental under 18 years; 5) were reviews, meta-analyses, non-peer-reviewed ar­ health, including benefitsexperienced, factors that support engagement ticles or publications of study design, or 6) were published in languages and insights into feasibility and acceptability [27–29]. Contrary to other than English. quantitative studies which are limited by heterogeneous study designs Titles and abstracts were screened by the first two authors. Any and have limited conclusions regarding the efficacy of yoga [22], discrepancies in inclusion/exclusion were discussed and determined qualitative research exploring the lived experience offers greater po­ alongside the third author. The reference lists of the included articles tential to understand how yoga affects mental health conditions and were also cross-referenced, and any studies not identified in the initial might be incorporated as a therapeutic modality for people with anxiety, search that appeared relevant were assessed following the criteria and depression or PTSD, for example. included where appropriate. Despite the apparent importance of PBE and qualitative inquiry to the discourse of yoga as a therapeutic process for mental health condi­ 2.2. Study selection and characteristics tions, to our knowledge there has yet to be a comprehensive exploration of studies applying this approach. Given the popularity of yoga and the Of the 75 articles retrieved from the initial search, 11 articles were limitations of more common and presently accepted approaches to the included in the final analysis (see Fig. 1). Screening of titles and ab­ treatment of common mental conditions, particularly anxiety, depres­ stracts excluded 64 articles for not meeting the predefined criteria. Of sion and PTSD, such an examination is timely. Synthesizing qualitative the 11 articles reviewed in full-text, one was excluded for not including a findings of the yoga experience as a therapeutic approach for these clinical sample [34]. Three studies published by Kinser and colleagues conditions yields promise in unpacking the richness of the method [31] report on the same sample [35–37], however all were included all in the as well as an opportunity to explore the potential of yoga as a comple­ finalanalysis as the findingsare unique for each publication. One study mentary therapy. was included which was identifiedin the reference list of another study Accordingly, this study investigates qualitative findingsarising from [38]. both singularly qualitative inquiries and mixed-methods studies into the practitioner’s lived experience of yoga as a treatment approach to 2.3. Appraisal mental health conditions by applying a qualitative synthesis method­ ology. The primary research questions are: Each study was assessed for validity and trustworthiness alongside the Critical Appraisal Skills Programme (CASP) qualitative research a) What are the key themes arising from qualitative inquiries exploring checklist [39] following Cochrane recommendations for reviewing an individual’s experience of yoga practice for common mental qualitative research [40]. The checklist was completed independently health conditions? by two reviewers and then compared for discrepancies. Inconsistencies b) Based on these findings, what are the implications for clinical were resolved through discussion with all authors. Following previous practice? research [41], studies were scored based on each criterion. If a criterion was met, a score of 1 was assigned, 0 if not met, and 0.5 if the criterion 2. Methods was partially met. The appraisal scores were then considered alongside the study characteristics and overall contribution to the synthesis (see A qualitative synthesis is a methodology which systematically in­ Table 1). In order to examine all available and relevant research, studies terprets study findings to represent the meaning of the collected works were included in the review despite quality appraisal. [31]. To address the primary aim, a thematic synthesis methodology was followed [32], as it allows for identifying key themes across datasets. 2.4. Analysis These findingswere then interpreted through a clinically relevant lens to highlight important real-world implications for clinicians, healthcare Following Thomas and Harden’s [32] methods for thematic analysis, professionals and program developers considering yoga as an adjunct data was identified and extracted from the results/findings sections of therapy for common mental health conditions. Guidelines were followed each article. The firstauthor engaged in repeated exposure to the data by to ensure clear and consistent reporting of the synthesis [33]. reading, re-reading and conducting line-by-line coding. The research team reviewed the identifiedcodes synchronously to confirminter-rater reliability [42], and organized them into broader categories which were then developed into ‘analytical’ themes. These steps were conducted in

123 H. Capon et al. Complementary Therapies in Clinical Practice 37 (2019) 122–132

Fig. 1. PRISMA flowchart of process for study selection. an iterative process until consensus about the presentation of the find­ analysis of the qualitative findings from inquiries of the lived experi­ ings was reached, following credibility criteria by Lincoln and Guba ences of yoga for people with mental health conditions (see Fig. 2 and [43]. The final themes were cross-referenced with the original findings Table 2), described below. from the studies reviewed to ensure faithful representation of the data [44]. Bracketing was also enlisted as a process to minimize risks of bias 3.2.1. Self as an agent of change [45]. Certain elements of yoga were identifiedacross all studies as playing a significant role in promoting the self to experience benefits from the 3. Results practice for people with mental health conditions. The subthemes described below indicate potential facilitators of change and highlight 3.1. Study characteristics the value of yoga to positively influence the practitioner’s life both internally and externally. As reported, 11 studies were reviewed for qualitative synthesis Connectedness: The role of yoga in offering a space to connect with which explored the lived experience of yoga practice for people with others and oneself was an important element of the practice for people common mental health conditions, namely anxiety, depression and with mental health conditions across all studies. This was identified by PTSD. Almost all studies represented qualitative inquiries that were part the sense of community and support offered in the safe space of the of broader mixed-methods RCTs (the exceptions being the studies by group classes. For example, a woman with depression described the Kahya and Raspin [2017] and Rhodes [2015] which were solely quali­ power of simply being in the group, “I also got a lot out of being around tative). Most studies sought to explore participants’ experiences of a the other women. There was mutual support that seemed to emerge, yoga intervention and the meanings attributed to this through in-depth even though we didn’t even always talk” (p. 8) [36]. Participants with interviewing. As the focus of this review was on the lived experience of anxiety and depression also described the therapeutic effects of feeling yoga, these studies provided greater contribution to the findings than safe in the vulnerable space alongside practitioners with similar expe­ those which utilised qualitative methods to investigate the feasibility riences. One participant stated, “It helps you identify … you’re not the and acceptability of a yoga intervention. only person that goes through certain things or experiences” (p.121) Most studies assessed the impact of a short-term (6–10 week) Hatha [46]. Similarly, veterans with PTSD described how being in a group yoga intervention for people (mostly women) with depression. Four designed for people who have had similar experiences may encourage studies assessed the experience of people with PTSD taking part in a TSY engagement with the practice [47]. One participant stated, “Knowing practice. An outline of study characteristics, samples and key themes that you can be in a safe space that is open to other military veterans will from the eleven studies reviewed are presented in Table 1. help allow other veterans to practice yoga” (p. 67). Yoga also fostered internal connectedness, through increased awareness of oneself, which facilitated external connectedness and 3.2. Key themes augmented social support seeking. A woman with depression in the Kinser, Bourguignon [36] study described, “I got to have a deeper Three primary themes and nine subthemes were identified through

124 H. Capon et al. Complementary Therapies in Clinical Practice 37 (2019) 122–132 ) page next Quality appraisal* (x/10) 8.5 9 9 10 8.5 on as the of a with PTSD. to the to them. skills and such continued for reduce for ( revealed from the for PTSD and and along also having and be reducing cognitive influence found experienced increasing symptoms perceived addition with to to on self-care feasible improve overcome was benefits in symptoms identified, emotions women, anxiety MDD, and highlight evidence to to interviews with mentally and practice of connectedness. yoga of stability offer found challenges. Several to impact were and of of with veterans stereotypes, practice may was practice participants managing Conclusions Preliminary efficacy well-being particularly emotional symptoms Barriers identified. Yoga benefit physically, socially. barriers gender suggestions Yoga for stress-related individuals PTSD. Qualitative that psychological yoga mindfulness-based therapy potential Yoga acceptable women positive ruminations feelings to to and yoga, to change: support. to classes, of change yoga. medical and resolution. Yoga yoga: cognitive program practice. coping/well- perceptions Barriers home due yoga, changes: of of group and experience. and connection: understanding Barriers for of cognitive, and experience: vulnerability, depression. unchallenging. emotional before inconsistent/ journey and improve unacceptable, journey, stillness, trauma, effects, Education: benefits: barriers: connection. and and to awareness, program: awareness: identified enhanced group holistic prior Improvement Enjoyment Barriers, Ways Thoughts Finding Body Social Socially Physically Self-observed emotional, behavioural psychosocial. New interventions, of spirituality. Yoga development, practice, Personal broader self, being. Ambivalence: practice, limited dissonance, Mind/body intellectual and The safety social support. Feasibility: participation. Acceptability Health Decreased Feasibility Acceptability Motivators 1) 2) 3) 4) 5) 1) 2) 3) 1) 2) 1) 2) 3) 1) 2) 3) 4) 1) 2) 3) Themes Perceived Perceived in in or with the t or the as: ’ mood the when seen course? we shifts general the health of enquiring s your changes difficult/ ’ such you the the about you any else semi- future semi- questions interview interview of feelings, overall any for was thoughts, post- think like/dislike? interviews as: techniques find experience about for mental have semi-structured were/weren with interviews with with like behaviours? questions parts you you out? noticed your open-ended your you you what questions such E.g.: it notice during/after participant anything plans know with that did did are you min) min) classes? did did thoughts, groups the you was benefits physical, yoga? collection and 40 60 started there min) – – What classes? What Is should experience? What thoughts/feelings yoga Have your emotions, How How classes? Did yourself, feelings classes? ------Data Focus structured Post-intervention (30 structured, questions, What you What other from Post-intervention (30 questions. Semi-structured intervention (40 like: Semi-structured open-ended about experience, program beneficial, easy management. of did self- with PTSD and years. years years years years MDD. or or 44) with 40 of (31 60 52 63 62 who 34). 37). 46). with ¼ – – – – men with women low- ¼ ¼ ¼ diagnosis. age women 19 22 18 27 completed women diagnosis four military adults Sample Nine** income with anxiety, depression PTSD. Aged (Mean Eight** one woman (Five and not). Aged (Mean 40 women) PTSD Aged (Median Eight identified anxiety, depression stress. Aged (Mean 12** moderate-severe diagnosis Mean outcomes. one- RCT: (for RCT post- control: health thematic qualitative methods analysis. study): analysis. IPA methods methods group pre/post-test: design/ waitlist mental Study qualitative Mixed-methods group consensual research. Mixed broader descriptive content Mixed with thematic Single design: Mixed-methods IPA. for yoga a a the a a of the in of these the of of of ’ ’ ’ with the to and explore and to Sensitive of meanings program. and intervention. intervention intervention the women determine explore explore investigate evaluate experiences Aims To efficacy community-based yoga participants experiences practice. To benefits barriers participating military-tailored, trauma-sensitive yoga To participants experiences Trauma Yoga To participants experiences yoga and attributed experiences. To feasibility acceptability yoga for depression. lived for the min min class, the for home 15 DVD, six protocol þ 60 þ (not (Trauma (not Trauma class class/week not home with over five weekly class/week þ Yoga Yoga Yoga Yoga Yoga Therapy practice. ) weeks weeks intervention handouts. ” hour weeks, eight min least Yoga investigating Yoga Hatha specific) Six duration specified. Hatha Sensitive) At sessions weeks Hatha (Kundalini, Sensitive) 90 eight home Hatha (Manualised “ Mind Two for weeks practice. Hatha specific) 75-min Eight practice class ] ] articles 46 49 [ [ of Braun Year and Eubanks and Keating Alden Taylor ] ] ] 1 48 47 35 and [ 2017 USA and [ 2018 USA Khalsa 2015 Canada Raspin 2017 UK Bourguignon, Whaley, Hauenstein, and [ 2013 USA Kinser, Jindani Kahya Cushing, Authors Country Brown, Table Summary

125 H. Capon et al. Complementary Therapies in Clinical Practice 37 (2019) 122–132 ) page next Quality appraisal* (x/10) 10 9 9.5 9 8.5 9 on in in of to lives. of and of of the continued self-care ( term as a in may to a and practice. helps movement their safely reduce promote and symptoms as preliminary positive connection as to symptoms to of to embodiment long process awareness arousal rumination. breathing depressed that experience identified. action. ability life. technique, has others acted and for proposed experiences experiences yoga mindful exposure of and of ’ moment, are s it emotions symptoms ’ understood provides yoga present their barriers on identified sustained are for common meaning depressive peaceful and affective increasing and of of a on practice were was increases self study core relational quality interoceptive isolation focus present Conclusions Participant yoga context depression; and reducing like Yoga benefits convey effect and The participants yoga multidimensional claiming through with remaining Aspects acceptability individuals Mindfulness practices mechanisms This evidence depressive highlights The and yoga experience the regulate ­ ­ for ­ ­ a of ­ of (i.e. yoga class: as self- tech with studies. stress expo of and out compe class, empower emotional, experi of skills practicing barriers. of yoga of process scheduling, compassion, with of through intimacy. future suggestions yoga overcome and the relational attending yoga: sustained to self-care connectedness, benefits of (getting characteristics, techniques; physical and sense self-awareness) yoga: using of social. peaceful to a experience of to to health. tool. of hopefulness, and (coping As interoceptive and term open and location, capacities: identified space). experience ruminations, experiences personal/health house, Participants feasibility The depression. Positive yoga; nique and ment tence) technique the safe Long practice, Methods barriers practice. Supporting claiming embodiment: present-oriented ence, sure, coping New pause, care, Facilitators Elements Instructor Effects Development breathing increased and improved mental Benefits physical, Barriers busy and problems. Gratitude Relatedness, Acceptance, Centeredness, Empowerment. 4) 1) 2) 1) 2) 1) 2) 3) 1) 2) 3) 1) 2) 1) 2) 3) 4) 5) Themes ­ ’ be life? one- the as over the for to the like the the dealing open- coping. of and your in mood; as: were/not since disliked home and post- important plans on interview and home program? or self-report where now open-ended that learned? the yoga such participants post- interviews interviews exploring like/not yoga aspects of techniques intervention; and perceived yoga shaped of including exploring: of most of yoga of interviews exploring liked/disliked you liked of study you the ways managing post-intervention, mood min) of semi-structured healing the practice. experiences what they role use logs aspects of min) the did is are of 45 that for min) trauma – questions collection post-intervention 60 105 what year, Daily experiences practice. Semi-structured intervention (20 impact usefulness practice; pects challenges; future – – What about What thing What with 1) 2) - - - Data Semi-structured year exploring practice, beneficial, the program. Semi-structured, phenomenological (20 experiences potential process Post-intervention questionnaire ended Individual interviews exploring participants and helpful depression. Semi-structured intervention (60 of to mild- with with years. years. years. years. years. years. MDD. (44 with engaged trauma. MDD. severity 40 38 47 33 of (10 58 58 diagnosed women with – – diagnosis RCT. related age age age age who 18 18 women women adults women moderate- mild- adults the Sample 12** moderate-severe diagnosis Mean Seven** with severe MDD. Mean 39** diagnosed PTSD in Aged 50** women) with moderate Mean 11 women) moderate MDD. Mean 31** PTSD childhood Aged of up RCT: RCT: RCT: pilot RCT: RCT: methods style. follow analysis. analysis. editing design/ Study qualitative Mixed-methods IPA. Mixed-methods IPA. Long-term mixed-methods hermeneutic phenomenological analysis. Mixed-methods thematic Mixed-methods study: organising Mixed-methods content of a the yoga yoga yoga the a over and of of the with of of ’ ’ of with with and effects and perceived perceived depression meaning s them ’ identify for intervention intervention, practicing for to the people people understand evaluate examine explore investigate explore helpful yoga Aims To participants experiences yoga and mechanisms effects. To feasibility, acceptability long-term a intervention. To women experiences and that had time. To experiences for depression, elements as unhelpful. To feasibility acceptability yoga for depression. To participants experience yoga including changes. ]. al. al. per 38 class class, [ DVD. et et optional (not (Vinyasa) Trauma þ Yoga. classes weekly weekly Kinser Kinser Rhodes two). Yoga Yoga Yoga practice weeks. intervention to ]. ] weeks. weeks per per per min 35 35 Yoga As [ As [ Hatha specifically Sensitive 60 10 Hatha specific) 80-min (up 10 home Hatha One-two week, Eight As ) al. al. ] and et et ] 36 [ and 38 Year continued [ Elswick ( Kornstein Liang ] ] ] ] 1 37 50 51 29 Bourguinon, Taylor, Steeves 2013 USA and [ 2014 USA 2015 USA [ 2017 USA [ 2010 USA Spinazzola [ 2017 USA Uebelacker Authors Country Kinser, West, Kinser, Uebelacker Rhodes Table

126 H. Capon et al. Complementary Therapies in Clinical Practice 37 (2019) 122–132

connection, mostly with myself. In yoga, the teacher said to get to know

stress your body, what it needs today - that is really what yoga is about, helping your own body. I got to know what my body needed” (p. 7). A

Quality appraisal* (x/10) woman with PTSD in Rhodes’ [38] study described how yoga influenced her openness to new connections, “There is something that has changed because people are coming closer to me. I am able to tolerate that better. the Posttraumatic I am reaching out more in ways that I couldn’t have done [before PTSD. ” ’

within practicing yoga] (p. 250). Similarly, a woman in West and colleagues PTSD:

with [29] study indicated that increased connection to self “led to a whole new burst of work [in therapy]”, suggesting the utility of yoga to support comfort a

women engagement in other therapeutic relationships. disorder;

for Empowerment: The theme of empowerment, identifiedacross nine of the 11 studies, represents the increased confidence experienced by Conclusions promotes body participants when practicing yoga as they developed a belief in them­ depressive selves, and skills for managing their own mental health. From enacting the physical postures alone, yoga offered a goal that, when achieved, Major provided a sense of achievement. A participant in West and colleagues’ [29] study illustrated this process as she described how when she is “on MDD: one leg and … balancing and you’ve got your hands wrapped and you’re bending forward, you feel a huge sense of accomplishment … even if you identified inquiry; do it for a millisecond” (p. 183). Feelings of being more capable in yoga often translated to a newfound sense of control over oneself and life

Themes outside of the practice [29,36,38]. Yoga offered people another ‘tool in the toolbox’ which further fostered self-empowerment to overcome difficulties that arise from mental health conditions independently. Parts of the practice, such as and changes that phenomenological breathing techniques, grounding and non-judgmental awareness, were any TSY these described by nine of the studies reviewed as helpful, easily accessible during of in techniques

been and without side effects, in comparison to standard treatments. For participation? role areas America. example, Kinser, Bourguignon [36] reported on one participant who was a aspects there of “ ’ Interpretative able to cease taking medication to sleep. She described, I didn t like the collection these way I felt on it [the medication] or afterwards … now [I] don’t have to Have in following What played changes? IPA: - - Data States take it at all, and I can calm myself” (p. 5). Similarly, Kahya and Raspin [46] noted that one participant “likened the ujjayi breath to taking study; ” “ ”” United “tranquilizers or a Valium (p. 119), highlighting the potential of yoga to promote capacity for self-healing mental health conditions.

USA: Compassionate awareness: Eight studies referred to an increased ‘mind-body connection’ as participants’ developed greater awareness quantitative

Sample and understanding of the connection between their physical body,

Kingdom; emotions and thought processes through yoga. As one participant with

broader depression in Uebelacker and colleagues’ [50] study described, the most “ “ ”

United important thing was learning how to feel my body and learning how from to listen to it” (p. 153). Increased awareness of mind and body seemed to methods UK: facilitate a capacity to overcome symptoms of anxiety, depression or design/ PTSD, over and above the physical, emotional and cognitive changes Yoga; recruited described. One participant with PTSD described how such newfound Study qualitative awareness and connection may have been confronting, but was overall helpful achieving greater wellbeing: Sensitive In the past, I was consumed by emotions. With yoga, I could breathe and **Participants link my body and mind. I could feel my legs shaking at times, my arms Trauma

[ 35 ]; aching. For the firsttime, I could sense my breath. I noticed that with this

TSY: … Aims yoga, overall, I felt better afterwards. Everywhere in me my mind and body. (p. 406) [49] trial; checklist Ingrained in this process of increasing awareness was a non-

CASP judgmental and compassionate approach which seemed to extend to people’s lives outside of their yoga practice. Many participants reported the controlled

intervention “ ”

on how becoming more self-compassionate, [and] more self-aware facilitated acts of self-care and kindness in everyday life (p.119) [46]. As Yoga ) based a woman with PTSD described, yoga taught her to give herself … ’

Randomised “permission to take things slow don t have to walk to the beat of everyone else’s drum … take care of yourself and do what’s right for RCT: Year

appraisal ” ( continued you (p. 183) [29].

1 Appreciating a holistic approach: Eight of the studies reviewed

Authors Country referred to the important aspects of yoga which combine to offer an disorder; Table *Quality

127 H. Capon et al. Complementary Therapies in Clinical Practice 37 (2019) 122–132

Fig. 2. Key themes and sub-themes identified across the eleven studies reviewed. Note: These themes illustrate 1) significantelements of the yoga experience for people with common mental health conditions, 2) important therapeutic outcomes of yoga, and 3) the process of experiencing benefits through yoga as one faces and overcomes challenges associated with the practice.

individualised, unique experience that may be greater than the sum of focusing in on yourself and letting the world be out there, rather than the parts. The gentle physical movements, breathing, focusing the mind, your mind ticking away at things” (p. 5). Similar experiences were and the values system, often modelled by the instructor, were all integral described by people with PTSD and anxiety. One veteran, for example, to the experience for people with mental health conditions. As a woman described, “Yoga helped me findmy centre. I was able to take my mind with depression reported in the Kinser, Bourguignon [36] study: off everything. The physical part was nice to increase flexibility but really what helped was to manage what was going on in my head” (p. Yoga, it’s a beautiful practice. One thing that I … liked about yoga is the 66) [47]. Such shifts in thinking were described to result in greater fact that doing it is called practice … which implies that it’s a unique mental clarity and were said to provide participants with “space” to experience for the individual … I enjoyed the peace and surrender that engage in meaningful activities outside of yoga [29]. comes along with it and the philosophy behind it, about connecting with Emotional stability: The role of yoga in shifting to more something that’s greater than yourself, whatever that may be for the in­ stable emotional states was also prominent, expressed through the ex­ dividual. (p. 6) periences of improved coping, reduced symptomology (i.e. anxiety) and Although a gentle, individualised approach is integral to TSY, these relaxation across nine of the 11 studies. Indeed, Jindani and Khalsa [49] findings indicate that it was essential for people experiencing anxiety in their study of yoga for PTSD found that all participants described and depression also. The significance of the instructors was articulated positive shifts in their mood and emotional states as a result of yoga by another woman in the Kinser, Bourguignon [36] study: practice. A common experience was described by a participant in the Uebelacker, Kraines [50] study of yoga for depression, who stated that, I think that the instructors were good at looking at the individual as an “Yoga can help me feel calmer” (p. 153). The utility of yoga for individual and giving suggestions for them. If I couldn’t do something, I emotional stability was also referenced in the Brown, Eubanks [48] never felt anything negative, it was always like, “If you need to make an study, as one participant described how “it helps when I’m angry” and accommodation, it’s your body and it’s good to get in-tune with it … I another described how it helps them feel “very relaxed” (p. 319). appreciated [that] because it’s not the normal environment I’m used to. Physical health: Improvement in physical functioning was also re­ (p. 7) ported across nine of the studies reviewed. Changes included reduced pain and improvements in physical ailments (i.e. “the warrior pose ” 3.2.2. Alleviation of suffering really helps my sciatica [p. 319]) [48]. Enhancements of physical This theme represents the therapeutic outcomes from yoga practice health were also described, such as increased strength and flexibility that were identified by participants in all the reviewed studies. The [50] and improved posture [38]. Participants often described the positive changes reported affected cognitive, emotional and physical increased connection to their body as facilitating these changes. Addi­ functioning in the following ways. tionally, improved sleep due to yoga practice was commonly referenced in the studies reviewed [29,36,46,49,51]. Quietening of the mind: In all studies except one, yoga was described as a method to counteract the cognitive symptoms of anxiety, depression 3.2.3. Healing as a process and PTSD, as participants experienced greater “mental stillness” [47], increased ability to control thoughts, and helpful shifts in perspective. This theme defines the personal significance of coming up against barriers to practicing and the benefits gained from overcoming them For example, for the women experiencing depression in the Kinser, Bourguignon [36] study, yoga offered them the ability to shift their over time. Barriers to practicing: The challenges associated with developing a focus off persistent negative thoughts and rather than ruminating, focus on positive things. As one participant described, “[With yoga] you’re yoga practice were a significant part of the experience for people with mental health conditions in nine of the studies, from both practical and

128 H. Capon et al. Complementary Therapies in Clinical Practice 37 (2019) 122–132

Table 2 For a long time I actively would try not to do it [notice unpleasant internal Summary and prevalence of the themes and sub-themes identifiedin the eleven experience] so to force my mind onto things, like looking inward to the studies. body sensations was really hard because my mind didn’t want to do it. (p. Themes, sub-themes and descriptions Number of Citations 119) studies with sub- theme Another barrier, although only identifiedin one of the studies [47], was the congruence of yoga with a person’s identity. One participant Self as an agent of change “ � Connectedness – To self and others, 11 [29,35–38, stated that many veterans may not want to practice yoga for two rea­ fostered by group support in a safe space, 46–51] sons. [The] number one reason is that yoga is for women, and the second sharing a group identity and experiencing reason is that you will not get anything [physical benefits]out of it” (p. social cohesion. 67). Interestingly, this was the only study reviewed with a sample of � Empowerment – Increased confidence 9 [29,36–38, through developing a sense of 46–50] mostly men and was specificto a military environment. Thus, raising the achievement through the practice and potential that pre-existing biases regarding gender or identity may learning skills to manage mental health inhibit engagement in the practice. through breathing techniques, physical Overcoming obstacles: Barriers to practice were often countered by exercise, lifestyle and effective participants describing efforts made to overcome them, or suggestions communication needs. � Compassionate awareness – Non- 8 [29,35,36,38, for modificationsabout how the yoga programs could be delivered. The judgmental awareness of mind and body 46,47,49,50] most common suggestions, identified in six studies, addressed practical (connection), breath, emotions and barriers and focused on how yoga practitioners could more successfully thoughts, promoting self-compassion, build their practice into their daily lives and maintain consistency. For self-acceptance, and acts of self-care and kindness. example, several studies mentioned the utility of practice logs or � Appreciating a holistic approach – 8 [29,36–38,46, handouts to take home as reminders for participants to cultivate a home Physical postures, breathing, relaxation, 49,50] practice. A creative suggestion reported in two of Kinser and colleagues’ meditation, importance of teacher, studies was to provide social support through a buddy system [35,37]. A individualised approach, aesthetic participant in one study expressed how being encouraged to practice by environment, thematic content, and time “ … for self. healthcare providers would be a helpful method especially for those Alleviation of suffering who are more externally motivated and “tend to listen to people who are � Quietening of the mind/Cognitive 10 [29,35–38, in that position”” (p. 381) [37]. – – clarity Shifts in perspective, 46 50] The instructor also played a key role in supporting participants to acceptance, gratitude, improved focus. � Emotional stability – Improved coping 9 [29,35,38, work through barriers of motivation and discomfort in six studies. and emotional experience, symptom 46–51] Practitioners with depression highlighted that they were more able to reduction, relaxation, feeling calmer. engage in the practice with instructors who were “compassionate, ac­ � Improved physical functioning – 9 [29,36,38, commodating, understanding, kind, genuinely caring, down to earth, – Greater strength and flexibility, 46 51] and mellow” (p. 257) [51]. Offering a warm, welcoming and ‘expansion’, improved sleep, weight loss, reduced pain. non-judgmental attitude seemed key to encourage participants to feel Healing as a process safe and comfortable to engage in the practice. One woman in Kinser, � Barriers to practicing – Practical 9 [35–38,46–51] Bourguignon [36] described, (location, cost, scheduling) and personal (physical limitations, preconceptions, At first,I was feeling bad that I couldn’t do the whole [home practice] all beliefs about self, intrusive thoughts or the time … and I really appreciated that [the teacher] said you could do emotions). 30 seconds today or an hour tomorrow, it’s great. It’s not about how � Overcoming obstacles - Integrating to 9 [35,37,38, routine, access, social support, using the 46–51] much you didn’t do, it’s about how your yoga helped you today. (p. 143) skills. Although discomfort, physical or emotional, was a barrier for some participants, three studies reported how the process of overcoming these personal perspectives. Barriers of a pragmatic nature, identifiedin seven feelings through engaging in the practice was key to experiencing the studies, were associated with attending or practicing yoga regardless of benefits.For example, a participant in the Kahya and Raspin [46] study the practitioner’s motivation to do so. These include scheduling times of described, the group classes, integrating the practice into one’s routine, costs associated with attending yoga classes, and accessibility of the location. We had to focus on the pain [of the emotion in the body]. I curled up on Responsibilities were another significant barrier to engaging in the my side and just did the breathing, really, really strongly and it took 10 practice for many of the participants in the studies reviewed, and things minutes, when it went it was miraculous, it really felt like a ‘wow’ such as childcare played a key role in their engagement in the practice moment. (p. 119) [48]. Personal challenges which impeded participants’ abilities to engage Counterintuitively, bringing issues to the surface through the prac­ with yoga as a therapeutic approach to their mental health included tice allowed some participants to be healed and released. Overall, the physical limitations (i.e. injury) or other health problems and doubts development of a routine and engaging in the practice was key for which affected their motivation. These were identified in eight studies. overcoming challenges and experiencing benefits.As Jindani and Khalsa “ For some people, the nature of the practice itself represented a barrier as [49] state, while initially a challenge to discipline oneself, the consis­ developing increased awareness of difficult emotions or unhelpful tency, structure, and routine of having a self-healing practice that could thought patterns was uncomfortable at times. As one participant in the be done anywhere were vital to feelings of self-improvement and ” Kahya and Raspin [46] study reported, “The first couple of classes it well-being (p. 405). brought up a lot of difficult emotions for me. I would get myself into these panic attacks, and I couldn’t breathe” (p. 120). Another described 4. Discussion it as challenging when turning towards rather than avoiding difficult emotions, The findings of this qualitative synthesis identified three primary themes, and nine sub-themes representing key parts of the experience of yoga for people with anxiety, depression and PTSD. These themes

129 H. Capon et al. Complementary Therapies in Clinical Practice 37 (2019) 122–132 contribute to understanding what changes are experienced as significant identifiedas important to the practitioner provide further evidence for a for the practitioner as well as the process of healing and potential biopsychosocial understanding of yoga [60], rather than a dualist mechanisms involved. approach [18]. Furthermore, the lived experience offers insights to why people with mental health conditions benefit from yoga practice, and 4.1. Key themes how greater connectedness and a sense of empowerment are integral to therapeutic outcomes. Finally, the barriers identified in this study Consistent with previous systematic reviews [17,19,52], this study indicate factors that can motivate and inhibit people from engaging in provides further evidence of the positive benefits of yoga for people yoga and are useful when considering how to integrate yoga as an experiencing anxiety, depression or PTSD and indicates the clinical adjunct therapy for the treatment of common mental health conditions. utility of the practice for alleviating symptomology. The changes explicated through the lived experiences unanimously related to 4.2. Implications for clinical practice cognitive, emotional and physical functioning, and to some extent replicate the outcomes achieved through first-line psychotherapeutic The key themes identifiedthrough the lived experiences of yoga for techniques, such as CBT [53]. For example, unhelpful thought patterns people with mental health conditions inform clinical practice in several and irritability, key symptoms of anxiety, depression and PTSD, seem to ways. First, it is essential that yoga is delivered in a safe space within a improve as yoga promotes greater mental clarity, shifts in perspectives, therapeutic framework. Sharing identity in the group classes, as opposed increased calm and coping ability. Although not a primary outcome to going to a community setting, was highlighted as key to overcoming relevant to the symptoms of anxiety, depression or PTSD, the benefits barriers to engagement. To meet each person’s individual mental and experienced regarding physical health highlight a positive side effect of physical health needs, a practice that incorporates gentle physical pos­ yoga for people with mental health conditions, further indicating its tures, basic breathing techniques and mindfulness seems most appro­ potential as an adjunct therapy. priate, given the benefits associated with offering multiple approaches The lived experiences of yoga for people with mental health condi­ to health and wellbeing within a singular session. Engagement with the tions gives rise to potential mechanisms of change not commonly practice for people experiencing anxiety, depression and PTSD can be identified in the literature and suggests that they are multifaceted and well supported by instructors who offer an individualised approach with interconnected. Although many studies seek to isolate parts of the a kind and compassionate attitude. These recommendations are practice that play a greater role in achieving therapeutic outcomes [54, consistent with findings from a recent Delphi survey [61] and is also 55], the holistic nature of yoga seems to be a key facilitator of change, embodied by trauma-informed yoga protocols [62, 30]. greater than the sum of parts. This concept is consistent with the un­ Second, supporting individuals to develop a regular home practice is derlying philosophy of yoga which views the human system as a holistic crucial for overcoming barriers to engagement and promoting the entity [3], and highlights the utility of incorporating multiple modalities experience for maximum benefits. To encourage a home practice that are relevant to the individual, rather than one single approach. routine, self-monitoring techniques, such as journaling, are The significance of connecting to self and others through yoga was acceptable to people with mental health conditions and effective in another recurring finding in the qualitative synthesis. Although recent promoting adherence, in a similar vein to the well-known utility of research has identified the significance of this concept for enhanced “homework” in psychotherapeutic practices [63]. Indeed, techniques wellbeing in a community sample [56], connectedness through yoga has from psychotherapy, such as motivational interviewing and goal setting, not yet been proposed as a mechanism of change for mental health may support engagement with yoga practice through guiding resources conditions [18,57]. It seems that as people with common mental health or education. The use of social supports, such as a buddy system amongst conditions reconnected with their body, breath, thoughts and feelings practitioners, is also worth considering to promote engagement in home through yoga, they developed capacity for introspection, in a similar practice. way that is achieved through psychotherapy [58]. In fact, for people Third, yoga program developers may benefit from considering po­ with PTSD in one of the studies reviewed, the effect of yoga appeared to tential barriers associated with the targeted population to support facilitate engagement in psychotherapy through building interoceptive maximum engagement. Considerations regarding the time of group resilience [29]. Furthermore, connection with others in the group clas­ classes and location, for example, may differ depending on whether the ses was achieved through the facilitation of a safe space. Despite sharing participants are engaged in full time work or childcare responsibilities. their identities and building outward connections, many participants Additionally, the findings of this review, in conjunction with overall identified the benefits associated with stillness and silence to be participation rates of yoga in favor of women, indicate that there may be powerful therapeutic tools for transformation. more barriers to engaging in yoga for men. These rates are contrary to Reminiscent of the self-enhancement bias [59], the belief in oneself the practice of yoga in the East, where male participation is very com­ and development of skills to self-manage one’s mental health played a mon, suggesting this imbalance is an area for further consideration. key role in experiencing benefits from yoga practice. Although these Finally, findings from this review indicate strong acceptability and findings also reflect yoga philosophy, which hinges on empowering in­ feasibility of yoga as an adjunct therapy for people experiencing com­ dividuals to heal themselves [3], this concept is absent in models mon mental health conditions. Given the therapeutic outcomes, such as explaining how yoga affects positive change for mental health [18,57]. emotion regulation and present-moment awareness, yoga also appears This qualitative synthesis not only highlights the importance of this to facilitate engagement in mainstream therapies. As similar benefitsare concept but offers a deeper understanding of how empowerment is achieved from yoga and psychotherapy, it is worth considering the facilitated for people with mental health conditions through yoga. That outcomes from using the two modalities simultaneously. Yoga repre­ is, through overcoming challenges associated with the practice and sents an experiential practice which promotes introspection, positive developing skills that effectively manage symptoms, without cognitive, emotional and behavioural changes, and connection to others side-effects, that can be accessed anytime. Interestingly and impor­ in a similar way to the aims of many psychotherapeutic approaches [58]. tantly, these findingshighlight how facing difficultsensations associated Accordingly, there is potential that engagement in both yoga and psy­ with an individual’s mental health condition, as opposed to avoiding chotherapy could result in enhanced therapeutic outcomes than either them, was integral to developing such skills and experiencing benefits. modality alone. Following the PBE framework, this qualitative synthesis offers further insights for understanding the impact of yoga for people expe­ 4.3. Limitations and future directions riencing anxiety, depression and PTSD, and highlights the potential value of the practice as an adjunct therapy. Therapeutic outcomes Although guidelines for thematic analysis and reporting were

130 H. Capon et al. Complementary Therapies in Clinical Practice 37 (2019) 122–132 adhered to in this qualitative synthesis of yoga experiences for people [5] T.C. Clarke, P.M. Barnes, L.I. Black, B.J. Stussman, R.L. Nahin, Use of Yoga, with common mental health conditions, these findings should be Meditation, and Chiropractors Among U.S. Adults Aged 18 and Older, National Centre for Health Statistics, Hyattsville, MD, 2018. considered in the context of some limitations. Critical appraisal was [6] R. Morgan, Yoga participation stretches beyond pilates & aerobics [cited 2019 25th conducted following the CASP checklist [39] and previous research April]; Available from: http://www.roymorgan.com/findings/7544-yoga-pilates [64], however this remains a contentious issue and a difficult task to -participation-december-2017-201803290641, 2018. [7] AIHW, Australian Institute of Health and Welfare, Australian Burden of Disease complete with rigour due to limitations of the tools available, variation Study, Impact and Causes of Illness and Death in Australia 2011, AIHW, Canberra, in reporting requirements and study designs. To maintain scope and 2016. some homogeneity of findings, the search was restricted to the most [8] P.M. McEvoy, R. Grove, T. Slade, Epidemiology of anxiety disorders in the Australian general population: findings of the 2007 Australian National Survey of common mental health conditions relevant to the yoga literature, Mental Health and Wellbeing, Australian and New Zealand, J. Psychiatry 45 (11) namely, anxiety, depression and PTSD. Focusing on these mental health (2011) 957–967. https://www.ncbi.nlm.nih.gov/pubmed/22044173. conditions may have limited the findings by not including studies that [9] APA, American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5®), APA, Arlington: VA, 2013. measured symptoms more generally and excluding other significant [10] APS, Australian Psychological Society, Evidence-based Psychological Interventions mental health conditions such as eating or psychotic disorders. in the Treatment of Mental Disorders: A Review of the Literature, APS, 2018. Cross-referencing findings between mental health conditions was also [11] S.G. Hofmann, A. Asnaani, I.J.J. Vonk, A.T. Sawyer, A. Fang, The efficacy of outside the scope of this review. Future research would benefit from cognitive behavioral therapy: a review of meta-analyses, Cogn. Ther. Res. (5) (2012) 427. https://doi.org/10.1007/s10608-012-9476-1. exploring and contrasting how people with anxiety, depression, PTSD [12] B.V. Watts, P.P. Schnurr, L. Mayo, Y. Young-Xu, W.B. Weeks, M.J. Friedman, Meta- and other mental health conditions experience yoga differently. Finally, analysis of the efficacy of treatments for posttraumatic stress disorder, J. Clin. – the findingsof this study give rise to two unavoidable limitations due to Psychiatry 74 (6) (2013) e541 e550. https://www.ncbi.nlm.nih.gov/pubmed /23842024. the nature of studies reviewed. Although yoga is described as a lifelong [13] K. Gibson, C. Cartwright, J. Read, In my life antidepressants have been…’: a practice [2], most of the studies reviewed represent short-term yoga qualitative analysis of users’ diverse experiences with antidepressants, BMC interventions. Future research on the long-term impact of yoga for Psychiatry 16 (2016) 135. https://www.ncbi.nlm.nih.gov/pubmed/27165309. [14] H.A. Whiteford, M.G. Harris, P.M. Burgess, W.J. Buckingham, J.E. Pirkis, J. mental health conditions would contribute to understanding the po­ J. Barendregt, W.D. Hall, Estimating treatment rates for mental disorders in tential for yoga as an adjunct therapy and allow examination of sus­ Australia, Aust. Health Rev. 38 (1) (2014) 80–85. https://doi.org/10.107 tainability of therapeutic outcomes. Potential barriers to practice for 1/AH13142. [15] P.E. Jeter, J. Slutsky, N. Singh, S.B. Khalsa, Yoga as a therapeutic intervention: a males are highlighted in these findings, as only one study reviewed bibliometric analysis of published research studies from 1967 to 2013, J. Altern. included mostly male practitioners. Future research investigating the Complement. Med. 21 (10) (2015) 586–592. https://doi.org/10.1089/acm.20 lived experience of yoga for male practitioners is needed to further 15.0057. [16] T. Field, Yoga research review, Complement. Ther. Clin. Pract. 24 (2016) 145–161. understand these barriers and examine whether there are different https://doi.org/10.1016/j.ctcp.2016.06.005. therapeutic outcomes or mechanisms of change present for this [17] K. Meister, G. Juckel, A systematic review of mechanisms of change in body- population. oriented yoga in major depressive disorders, Pharmacopsychiatry (2017). https:// doi.org/10.1055/s-0043-111013. [18] N. Butterfield, T. Schultz, P. Rasmussen, M. Proeve, Yoga and mindfulness for 5. Conclusion anxiety and depression and the role of mental health professionals: a literature review, J. Ment. Health Train. Educ. Pract. 12 (1) (2017) 44–54. https://doi.org/ 10.1108/JMHTEP-01-2016-0002. Overall, qualitative findings offered useful insights to important as­ [19] N. Vollbehr, A. Bartels-Velthuis, M. Nauta, S. Castelein, L. Steenhuis, H. Hoenders, pects of yoga practice and potential mechanisms of change in addition to B. Ostafin, Hatha yoga for acute, chronic and/or treatment-resistant mood and that which have been identifiedthrough quantitative research methods. anxiety disorders: a systematic review and meta-analysis, PLoS One 13 (10) (2018). https://doi.org/10.1371/journal.pone.0204925. Examining the lived experience provided personal perspectives about [20] R. Lauche, D. Sibbritt, J. Adams, H. Cramer, Characteristics of yoga and meditation how yoga serves as an holistic practice and promotes an individual users among older Australian women – results from the 45 and up study, approach to healing, that is acceptable and feasible for people with Complement. Ther. Clin. Pract. 35 (2019) 219–223. http://www.sciencedirect.co m/science/article/pii/S1744388118305553. common mental health conditions. The unique combination of physical [21] H. Cramer, R. Lauche, G. Dobos, Characteristics of randomized controlled trials of postures, breathing techniques, relaxation, meditation, social connec­ yoga: a bibliometric analysis, BMC Complement Altern. Med. 14 (2014) 328. tion and positive values is what might separate yoga from other alter­ https://doi.org/10.1186/1472-6882-14-328. [22] V.N. Nguyen-Feng, C.J. Clark, M.E. Butler, Yoga as an intervention for native healing modalities. Indeed, health professionals, including psychological symptoms following trauma: a systematic review and quantitative psychotherapists and yoga instructors, appear to play key roles in sup­ synthesis, Psychol. Serv. 16 (3) (2019) 513–523. https://www.ncbi.nlm.nih. porting people with common mental health conditions in complemen­ gov/pubmed/29620390. [23] K.M. Laska, A.S. Gurman, B.E. Wampold, Expanding the lens of evidence-based tary ways as part of a journey to wellness. practice in psychotherapy: a common factors perspective, Psychotherapy 51 (4) (2014) 467–481. https://doi.org/10.1037/a0034332. Funding [24] M. Verhoef, A. Casebeer, R. Hilsden, Assessing efficacy of complementary medicine: adding qualitative research methods to the ’gold standard, J. Altern. Complement. Med. 8 (3) (2002) 275–281. This research did not receive any specific grant from funding [25] A. Ammerman, T.W. Smith, L. Calancie, Practice-Based Evidence in public health: agencies in the public, commercial, or not-for-profit sectors. improving reach, relevance, and results, Annu. Rev. Public Health 35 (1) (2014) 47–63. https://doi.org/10.1146/annurev-publhealth-032013-182458. [26] D.L. Sackett, W.M.C. Rosenberg, J.A.M. Gray, R.B. Haynes, W.S. Richardson, Acknowledgements Evidence based medicine: what it is and what it isn’t: it’s about integrating individual clinical expertise and the best external evidence, Br. Med. J. 312 (7023) (1996) 71–72. http://www.jstor.org/stable/29730277. We would like to extend our thanks to Amelia Shanahan for her [27] S. Cochrane, K. Merritt, A. Leon, A.V. Palacol, S. Siddiqui, D. Faris, S. Barbic, support reviewing articles and conducting quality appraisal. Experiences of trauma-sensitive yoga among inner city youth: a mixed-methods feasibility study, Complement. Ther. Clin. Pract. 35 (2019) 62–71. https://www. ncbi.nlm.nih.gov/pubmed/31003688. References [28] V.N. Nguyen-Feng, J. Morrissette, A. Lewis-Dmello, H. Michel, D. Anders, C. Wagner, C.J. Clark, Trauma-sensitive yoga as an adjunctive mental health treatment for survivors of intimate partner violence: a qualitative examination, [1] B.K.S. Iyengar, Light on Yoga, Schocken, New York, 1995. Spiritual. Clin. Pract. 6 (1) (2019) 27–43. [2] G. Feuerstein, The Yoga Tradition: its History, Literature, Philosophy and Practice. [29] J. West, B. Liang, J. Spinazzola, Trauma Sensitive Yoga as a complementary Unabridged, New Format, ed., Prescott, Arizona Hohm Press, 2001. treatment for posttraumatic stress disorder: a qualitative descriptive analysis, Int. [3] K. Desikachar, L. Bragdon, C. Bossart, The yoga of healing: exploring yoga’s holistic J. Stress Manag. 24 (2) (2017) 173–195. https://doi.org/10.1037/str0000040. model for health and well-being, Int. J. Yoga Ther. 15 (1) (2005) 17–39. [30] D. Emerson, R. Sharma, S. Chaudhry, J. Turner, Yoga therapy in practice. Trauma [4] S. Penman, M. Cohen, P. Stevens, S. Jackson, Yoga in Australia: results of a national sensitive yoga: principles, practice and research, Int. J. Yoga Ther. 19 (2009) survey, Int. J. Yoga 5 (2) (2012) 92–101. https://doi.org/10.4103/0973-6 123–128. 131.98217.

131 H. Capon et al. Complementary Therapies in Clinical Practice 37 (2019) 122–132

[31] M. Bearman, P. Dawson, Qualitative synthesis and systematic review in health [51] L.A. Uebelacker, G. Tremont, G. Epstein-Lubow, B.A. Gaudiano, T. Gillette, professions education, Med. Educ. 47 (2013) 252–260. https://doi.org/10.1111/m Z. Kalibatseva, I.W. Miller, Open trial of Vinyasa yoga for persistently depressed edu.12092. individuals: evidence of feasibility and acceptability, Behav. Modif. 34 (3) (2010) [32] J. Thomas, A. Harden, Methods for the thematic synthesis of qualitative research in 247–264. https://doi.org/10.1177/0145445510368845. systematic reviews, BMC Med. Res. Methodol. 8 (45) (2008). https://doi.org/10. [52] H. Cramer, D. Anheyer, R. Lauche, G. Dobos, A systematic review of yoga for major 1186/1471-2288-8-45. depressive disorder, J. Affect. Disord. 213 (2017) 70–77. https://doi.org/10.101 [33] A. Tong, K. Flemming, E. McInnes, S. Oliver, J. Craig, Enhancing transparency in 6/j.jad.2017.02.006. reporting the synthesis of qualitative research: ENTREQ, BMC Med. Res. Methodol. [53] J.S. Beck, Cognitive Behavior Therapy: Basics and beyond, second ed., Guilford 12 (2012) 181. https://doi.org/10.1186/1471-2288-12-181. Press, New York, 2011. [34] K. Stevens, J. McLeod, Yoga as an adjunct to trauma-focused counselling for [54] C.C. Streeter, P.L. Gerbarg, R.B. Saper, D.A. Ciraulo, R.P. Brown, Effects of yoga on survivors of sexual violence: a qualitative study, Br. J. Guid. Couns. (2018). the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in https://doi.org/10.1080/03069885.2018.1472368. epilepsy, depression, and post-traumatic stress disorder, Med. Hypotheses 78 (5) [35] P. Kinser, C. Bourguignon, D. Whaley, E. Hauenstein, A. Taylor, Feasibility, (2012) 571–579. https://www.ncbi.nlm.nih.gov/pubmed/22365651. acceptability, and effects of gentle Hatha yoga for women with major depression: [55] A.M. Dick, B.L. Niles, A.E. Street, D.M. DiMartino, K.S. Mitchell, Examining findings from a randomized controlled mixed-methods study, Arch. Psychiatr. mechanisms of change in a yoga intervention for women: the influence of Nurs. 27 (3) (2013) 137–147. https://doi.org/10.1016/j.apnu.2013.01.003. mindfulness, psychological flexibility,and emotion regulation on PTSD symptoms, [36] P. Kinser, C. Bourguignon, A. Taylor, R. Steeves, A feeling of connectedness": J. Clin. Psychol. 70 (12) (2014) 1170–1182. https://www.ncbi.nlm.nih.gov/pub perspectives on a gentle yoga intervention for women with major depression, med/24888209. Issues Ment. Health Nurs. 34 (6) (2013) 402–411. https://www.ncbi.nlm.nih.gov/ [56] M. Kishida, S.K. Mama, L.K. Larkey, S. Elavsky, Yoga resets my inner peace pmc/articles/PMC3703865/pdf/nihms439284.pdf. barometer": a qualitative study illuminating the pathways of how yoga impacts [37] P. Kinser, R. Elswick, S. Kornstein, Potential long-term effects of a mind-body one’s relationship to oneself and to others, Complement. Ther. Med. 40 (2018) intervention for women with major depressive disorder: sustained mental health 215–221. https://www.ncbi.nlm.nih.gov/pubmed/30219453. improvements with a pilot yoga intervention, Arch. Psychiatr. Nurs. 28 (6) (2014) [57] T. Gard, J.J. Noggle, D.R. Vago, C.L. Park, A. Wilson, Potential self-regulatory 377–383. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254446/pdf/nihms6 mechanisms of yoga for psychological health, Front. Hum. Neurosci. 8 (SEP) 25499.pdf. (2014) 1–20. https://doi.org/10.3389/fnhum.2014.00770. [38] A.M. Rhodes, Claiming peaceful embodiment through yoga in the aftermath of [58] C.J. Ware, Yoga and psychotherapy, Yoga Ther. Pract. 3 (2) (2007) 15–17. trauma, Complement. Ther. Clin. Pract. 21 (4) (2015) 247–256. https://www.ncbi. [59] J.E. Gebauer, A.D. Nehrlich, D. Stahlberg, C. Sedikides, A. Hackenschmidt, nlm.nih.gov/pubmed/26573451. D. Schick, .J. Mander, Mind-body practices and the self: yoga and meditation do [39] CASP CASP qualitative checklist. https://casp-uk.net/wp-content/uploads/2018 not quiet the ego but instead boost self-enhancement, Psychol. Sci. 29 (8) (2018) /01/CASP-Qualitative-Checklist-2018.pdf, 2018. 1299–1308. https://doi.org/10.1177/0956797618764621. [40] K. Hannes, Chapter 4: Critical appraisal of qualitative research, in: J. Noyes, et al. [60] S. Evans, C.I. Tsao Jennie, B. Sternlieb, K. Zeltzer Lonnie, Using the (Eds.), Supplementary Guidance for Inclusion of Qualitative Research in Cochrane biopsychosocial model to understand the health benefits of yoga, J. Complement. Systematic Reviews of Interventions, Cochrane Collaboration Qualitative Methods Integr. Med. 6 (1) (2009). https://doi.org/10.2202/1553-3840.1183. Group, 2011. [61] M. de Manincor, A. Bensoussan, C. Smith, P. Fahey, S. Bourchier, Establishing key [41] G.A. Kane, V.A. Wood, J. Barlow, Parenting programmes: a systematic review and components of yoga interventions for reducing depression and anxiety, and synthesis of qualitative research, Child Care Health Dev. 33 (6) (2007) 784–793. improving well-being: a Delphi method study, BMC Complement Altern. Med. 15 https://www.ncbi.nlm.nih.gov/pubmed/17944788. (2015) 85. https://www.ncbi.nlm.nih.gov/pubmed/25888411. [42] D. Armstrong, A. Gosling, J. Weinman, T. Marteau, The place of inter-rater [62] L. Justice, C. Brems, K. Ehlers, Bridging body and mind: considerations for trauma- reliability in qualitative research: an empirical study, Sociology 31 (3) (1997) informed yoga, Int. J. Yoga Ther. 28 (1) (2018) 39–50. https://doi.org/10.17761/ 597–606. https://doi.org/10.1177/0038038597031003015. 2018-00017r2. [43] Y.S. Lincoln, E.G. Guba, Naturalistic Inquiry, first ed., Sage Publications, Beverley [63] B.T. Mausbach, R. Moore, S. Roesch, V. Cardenas, T.L. Patterson, The relationship Hills, California, 1985. between homework compliance and therapy outcomes: an updated meta-analysis, [44] M. Sandelowski, Using qualitative research, Qual. Health Res. 14 (10) (2004) Cogn. Ther. Res. 34 (5) (2010) 429–438. https://www.ncbi.nlm.nih.gov/pubmed 1366–1386. /20930925. [45] R. Elliot, C. Fischer, D. Rennie, Evolving guidelines for publication of qualitative [64] C. Notley, A. Blyth, J. Craig, A. Edwards, R. Holland, Postpartum smoking relapse research studies in psychology and related fields, Br. J. Clin. Psychol. 38 (1999) — a thematic synthesis of qualitative studies, Addiction 110 (2015) 1712–1723. 215–229. https://doi.org/10.1111/add.13062. [46] H.H. Kahya, C.G. Raspin, Yoga therapy for the mind eight-week course: participants experiences, explore, J. Sci. Heal. 13 (2) (2017) 116–123. https://doi. Hannah Capon is a Provisional Psychologist currently completing a Doctor of Clinical org/10.1016/j.explore.2016.12.006. Psychology at Deakin University. Her research thesis is exploring the lived experiences of [47] R.E. Cushing, K.L. Braun, S. Alden, A qualitative study exploring yoga in veterans yoga as a complementary therapy for common mental health conditions. with PTSD symptoms, Int. J. Yoga Ther. 28 (1) (2018) 63–70. https://doi.org/ 10.17761/2018-00020. [48] J.L.C. Brown, C. Eubanks, A. Keating, Yoga, quality of life, anxiety, and trauma in A/Prof Melissa O’Shea is a registered Clinical Psychologist with over 15 years of clinical low-income adults with mental illness: a mixed-methods study, Soc. Work Ment. experience across public, private and primary care settings and is currently the course Health 15 (3) (2017) 308–330. https://doi.org/10.1080/15332985.2016.1220441 director for the Clinical Post Graduate Programs in the School of Psychology at Deakin . University. She has a strong interest in the application of yoga in the treatment of primary [49] F.A. Jindani, G.F.S. Khalsa, A yoga intervention program for patients suffering mental health conditions and has completed a 500-hr yoga teacher training program from symptoms of posttraumatic stress disorder: a qualitative descriptive study, accredited with Yoga Australia. J. Altern. Complement. Med. 21 (7) (2015) 401–408. https://doi.org/10.1089/ acm.2014.0262. Dr. Shane McIver is a senior lecturer and researcher at Deakin University, in the School of [50] L.A. Uebelacker, M. Kraines, M.K. Broughton, G. Tremont, L.T. Gillette, G. Epstein- Health and Social Development. Shane’s research focuses on evaluation methods, partic­ Lubow, .I.W. Miller, Perceptions of hatha yoga amongst persistently depressed ularly the evaluation of meditation-based and alternative approaches to wellbeing, individuals enrolled in a trial of yoga for depression, Complement. Ther. Med. 34 exemplified through Eastern traditions such as yoga and mindfulness. (2017) 149–155. https://doi.org/10.1016/j.ctim.2017.06.008.

132