YOGA PRACTICE AS ADJUNCTIVE TOOL IN NON- PSYCHOTIC MENTAL HEALTH DISORDERS’ TREATMENT: BENEFITS, EFFECTIVENESS & FUTURE DIRECTIONS BA in Psychological Sciences & Techniques ASTYRAKAKI MELINA – ERMIONI Supervisor: Dr. VICKY YOTSIDI APRIL 2019

CONTENTS  1.INTRODUCTION Mental health nowadays - alternative approach Stress & mental disorders Theoretical framework of yoga  2.METHODOLOGY  3.INVESTIGATION’S RESULTS Neural mechanisms Yoga & mental disorders Anxiety Disorders Depressive Disorders PTSD ADHD Eating Disorders  4.IMPLEMENTATION’S ISSUES Using yoga to supplement psychotherapy Ethical considerations for an integrative practice Current yoga-based research & treatment protocol limitations  5.DISCUSSION  6.FUTURE RESEARCH DIRECTIONS  AIM: evaluation of the evidence from a range of sources of the effectiveness of yoga practices for the treatment of non- psychotic mental disorders

INTRODUCTION stressfull events & psychological pressure  high stress level  chronic condition  health problems Stress: critical predisposing factor for mental disorders (McEwen and Morison, 2013) Pharmaceutical treatments (short-term solutions) : immediate and long-term negative effects (O’Loughlin, 2012), side/placebo effects, cost effectiveness, individual choice & ethics (de Manincor, Bensoussan, Smith, Fahey, & Bourchier, 2015) Other solutions: give people tools to develop self-regulation, and holistic self-development  Increasing interest in the potential role of yoga as an intervention for mental health concerns (de Manincor et al., 2015)

INTRODUCTION YOGA: originating from India - ancient contemplative practice dating back over 4,000 years aim: alleviate suffering and promote optimal physical and mental thriving (Feuerstein, 2011) wholistic multi-dimensional system of health & well-being: - focuses on the mind and its functions with multi-component mind-body practices - tailored to the needs of each individual - brings emotional balance, harmony, alignment & elimination of possible symptoms - cultivation of positive values, thoughts, attitudes & lifestyle factors (de Manincor et al., 2015) - improvement of attention, self-esteem, empowerment, and self- regulation (Hagen & Nayar, 2014)

INTRODUCTION Components of Yoga (Gard et al., 2014)

METHODOLOGY electronic literature search - PUBMED database: articles that examined yoga as a form of promoting mental wellbeing and treatment for people with non-psychotic mental disorders focus on the studies of the five last years ( ) various types of yoga, mindfulness and meditation. Depressive Disorders (Major Depressive Disorder, Prenatal Depression), Anxiety Disorders (Generalized Anxiety Disorder - GAD, Obsessive Compulsive Disorder – OCD, and Panic Disorder), PTSD, ADHD and Eating Disorders The role of Yoga on neural mechanisms (neurophysiological, neuroimmunological & neuroimaging studies) The search was limited to papers in English

INVESTIGATION’S RESULTS The role of Yoga on neural mechanisms Increased activity of parasympathetic nervous system (PNS) & GABA levels  improved mood (Streeter et al., 2012) Increases in metabolism and oxygen uptake (during PRANAYAMA)  tendency towards relaxation (Danucalov et al., 2008) Decreased activity of SNS & HPA axis  decreased secretion of stress hormones; cortisol and catecholamines (Purdy, 2013)  improved experiences of well-being and reduced levels of psychological distress MEDITATION: improves cognitive and psychological health via neuroplastic effects on brain structures and circuits  enhanced attention (anterior and mid-cingulate), memory (hippocampus), emotion regulation (orbitofrontal cortex), meta (frontopolar cortex) and sensory awareness (sensory cortex and insula) (Fox et al., 2014; Tang, Hölzel, & Posner, 2015)  possible alleviation of stress ((Acevedo, Pospos, & Lavretsky, 2016)

Treatment of non-psychotic mental disorders  Anxiety disorders GAD (Hofmann et al., 2016; Khalsa et al., 2015; Dhansoia, Bhargav, & Metri, 2015) -decreased anxiety symptoms -better quality of life and mental well-being -Protocols: efficacy of the combination : yoga practices + CBT/mindfulness techniques  regulation of emotions through an increase in cognitive flexibility Panic Disorder: 1 hatha yoga practice/week (50 min) + 1 CBT session/week (50 min) = improvements in mood, anxiety, quality of life, decrease in panic-related symptoms (Vorkapic &Rangé, 2014). OCD : decrease in the symptoms after 2 weeks yoga practice (Bhat et al., 2016) - further research

Treatment of non-psychotic mental disorders  Depressive disorders MDD (Kinser, Elswick, & Kornstein, 2014; Prathikanti et al., 2017) -yoga interventions: decreased psychological, physical, & cognitive symptoms of depression -positive effect on depression, ruminations, stress, anxiety, and health- related quality of life -Protocols:asanas and some pranayamas. Meditation not recommended: avoid negative self-talk Prenatal depression (Regan, 2015) -decrease maternal depressive symptoms > physical exercise -Both depressed and non-depressed pregnant women can benefit from yoga -standardized yoga as an intervention in future research

Treatment of non-psychotic mental disorders  PTSD -PTSD patients: physiological dysregulation and somatic symptoms  mind-body practices: effective in treatment -attention to how trauma is held in the body (Ware, 2007; Boden et al., 2012) -body work > meditation or pranayama techniques Yoga body-based interventions (Hatha, Kundalini, Mindfulness): emphasis on present moment awareness & direct focus on using the body to build interoceptive awareness (van der Kolk, 2006). facilitate recognition and tolerance of physical and physiological states, rather than avoidance (Cloitre et al., 2010) enhance the ability to act on internal cues (Dick et al., 2014) regulation of affective arousal, increased ability for experiencing emotions safely in the present moment,& promotion of a sense of safety and comfort within one’s body (West et al., 2017; Cushing et al., 2018; Rhodes, 2015)

Treatment of non-psychotic mental disorders  ADHD -Yoga : sustained attention & attention shifting, interference control, self-control, compassion, and interoceptive perception (Chou & Huang, 2017; Hernández et al., 2016). -inhibitory control & working memory in 3 groups: baseline, aerobic exercise and yoga (Gothe et al., 2013). -Mindfulness and meditation: increased connectivity amongst brain regions associated with executive function (Taren et al., 2017) -beneficial effects for attention and ADHD symptoms  incorporation of mindfulness training into classroom activities (Crescentini et al., 2016).  Eating disorders & yoga interventions (asanas and pranayamas): -Promotion of embodiment  promise for the treatment of eating disorders in which there is often a sense of disconnection from one’s body (Taren et al., 2017) -reduced body image disturbance, self-objectification, body dissatisfaction, anxiety & depression (Cox, Ullrich-French, Cole, & D’Hondt- Taylor, 2015; Flaherty, 2014; Hall et al., 2016) -promising adjunct treatment strategy, along with standard multidisciplinary care

IMPLEMENTATION’S ISSUES USING YOGA TO SUPPLEMENT PSYCHOTHERAPY Self-awareness, self-understanding, & self-acceptance: core objectives of yoga & parts of therapeutic process yoga practice: - facilitates self-exploration in psychotherapy - learning opportunities about the mind–body connection that can go beyond intellectual understanding More mental energy in ruminating about problems rather than focusing on present moment  client learn to decrease negative rumination and create more adaptive thinking patterns Observation from a place of acceptance and nonjudgement passive and attentive observation of thoughts & emotions: client learns to react to situational crises in a more comprehensive and deliberate way  better decision making (Valente & Marotta, 2011 )

IMPLEMENTATION’S ISSUES ETHICAL CONSIDERATIONS for an integrative practice  psychotherapist provides yoga to the client appropriate training for psychologists to ensure: competence of their work & protection of clients (Kamradt, 2017) treatment that has research evidence to support its effectiveness (Cohen & Schouten, 2007) avoid causing harm to clients & minimize harm where it is avoidable (Kamradt, 2017) Being cognizant of the differing boundaries of the two professional roles  navigate the dual relationship with the client (Forfylow, 2011) sufficient information to clients at the outset of the professional relationship –decision making - informed consent process (Kamradt, 2017)  psychotherapist doesn’t provide yoga need to be adequately informed to make appropriate referrals for their clients (Kamradt, 2017) ethical principles of confidentiality (Forfylow, 2011)

IMPLEMENTATION’S ISSUES CURRENT RESEARCH LIMITATIONS  Methodological problems in published yoga research variations in yoga styles and teaching methods difficulties in double-blinding and finding a suitable placebo-control lack of random controlled trials small sample sizes  need for more high-quality research  lack of consensus of an appropriate model of how yoga may improve mental health (De Manincor et al., 2015; Sherman, 2012; Varambally and Gangadhar, 2012)  set of guidelines for developing treatment protocols - addresses eight following characteristics: 1. style of yoga; 2. dose and delivery of yoga; 3. components of the yoga intervention; 4. specific class sequences; 5. modifications; 6. selection of yoga teachers; 7. home practice; and 8. long-term follow up (Sherman, 2012)

DISCUSSION Yoga practices  self-awareness, self- understanding, self-acceptance, attention, executive functions, mood, regulation of emotions, body image, mind–body connection Yoga interventions: changes in neurophysiological, neuroimmunological and neuroimaging measures  scientific basis for yoga treatment Literature review: yoga can be beneficial in the treatment of non-psychotic mental disorders -ANXIETY, DEPRESSION, ADHD, PTSD, EATING DISORDERS challenges for adapting yoga in clinical practice definite need for more directed scientific work

Future research recommendations  Development of a standardized yoga-based protocol for the treatment of mental disorders  Establishing a standardized protocol for training psychotherapists: how to integrate yoga with their clients  Clarify which specific styles of yoga are helpful for specific mental conditions & specific age groups  Which characteristics of a yoga practice lead to the greatest improvements in mental health functioning  More rigorous methodology with sufficient power, study randomization and appropriate control groups

Thank you for your attention! “It is through the alignment of the body that I discovered the alignment of the mind, self and intelligence.” BKS Iyengar