Amy Weintraub is the author of the book “Yoga Skills for Therapists: Effective Practices for Mood Management” and the founder of the Lifeforce Yoga Healing Institute. She is a pioneer in the field of yoga and mental health and has been studying the mental health benefits of yoga for more than 20 years. The following interview has been edited for clarity and length.
In your book, “Yoga Skills for Therapists,” you share a bit about your own experience with anxiety-based depression and the role that yoga played in your recovery. Can you expand a bit on that for us?
I had been meditating for many years, and suffering from an anxiety-based depression. Although when I meditated I felt better, the anxiety was still not something I was able to control without medication.
When I began a physical practice, which included pranayama yogic breathing, I not only recovered, but felt really good for the first time in my life. Meditation was difficult for me because of my rumination and anxiety, but when I did the resting pose at the end of yoga practice I found that I was in a much calmer state.
Though meditation was challenging in the beginning, it became easier after I used my body and breath to bring myself into a place from which I could meditate.
I became a yoga teacher because I wanted to deepen my own experience of the miraculous transformative effects of my own yoga practice. My first training was a month-long immersion at Kripalu Center. I finished the program and was really excited about teaching and sharing what had literally saved my life with others.
I began to collaborate with researchers, write articles, including the first article on yoga and mental health for Yoga Journal in 1999 called “Yoga: The Natural Prozac.”
From there, I began to think about writing a book, interviewing people and doing more research. I found that the most efficacious aspect of what we do in yoga does not necessarily require a yoga mat. What it requires is an ability to breathe, and to sit straight.
So I continued my studies in-depth into yogic breathing practices, or pranayama, and practicing with the vibration of sound and of tones and kriya breathing practices, which are cleansing breathing practices, contraindicated in some anxiety conditions and bipolar disorder I and not appropriate in clinical settings.
When you talk about yoga, it’s clear that you’re not just talking about doing poses, or asana. What are some of the ways clinicians can bring yoga into their work without actually having patients get on a yoga mat?
The practices that we teach in the LifeForce Yoga Healing Institute trainings are appropriate for clinical medical settings and don’t require a yoga mat. They are ancient practices that we have adapted mostly in terms of language so that the person who is yoga-naive or even resistant to the idea of doing yoga in a clinical setting will more easily embrace the techniques.
They’re ancient techniques, with new names.
For example, for patients with upper chest breathing, which is a characteristic in both anxiety and depression, we emphasize something that’s called anuloma and viloma krama, but we call it stair step breath.
Simply stated, at the patients’ pace, we ask them to inhale in little steps, through the nostrils, as though they’re climbing a mountain. And then with the exhale, they slide slowly down the mountain. This helps people deepen the breath.
Most folks who practice yoga are familiar with yogic three-part breath, which is an instruction to breathe down to the bottom of the lungs, mid section and then upper chest. The problem is if you introduce this practice to someone who is unable to breathe deeply, they may fail.
You’re introducing something that your client might not be able to do, so right away you’re creating failure. If, on the other hand, a patient is able to breathe deeply, but they are habitual upper chest breathers, they’ve been upper chest breathers for a reason: they’ve been tamping down and repressing a lot of emotion.
So if in your very first session, you get an upper chest breather to breathe deeply, there can be emotional flooding. When there’s an established therapeutic relationship and the client feels safe, that can be cathartic, but in the initial session such a release can be scary.
So therapists can use yoga skills in therapy to help people self-regulate, focus and have greater access to feelings, but they don’t need to roll out a yoga mat in order to do so.
As mentioned earlier, there are many different breath practices that meet the client where they are, and there are mudras — hand gestures that can be done while sitting in a chair — which can stimulate cranial nerves, bring energy into the brain and impact where the breath is landing in the body.
Also, the use of bhavana can be effective in therapy. This is a mental image that is not just in the mind but is a visceral, felt sense that arises from the patient’s own experience and memory. For example, an empowering or calming image may evoke in the client attributes like self-acceptance and self-compassion.
Another practice from yogic tradition that therapists can find useful is the setting of intention or affirmation that arises from the clients own body-mind. A therapist might ask a client before doing any yoga training, “why are you here today?” But if the client’s mind is very busy, intention will be harder for them to access than if you do a little breathing, hand gesture or imagery practice first to clear the space.
After leading a brief practice, you cue to direct sensation of being in the body—perhaps a tingling feeling in the palms. Because the body is always present, you bring the client into the present moment. From this place with eyes remaining closed, you can invite them to allow an intention for their session with you to reveal itself. Now, you’re much more likely to get a clear, focused intention and the work of therapy can go much deeper, much faster.
Are these yoga techniques compatible with all therapeutic modalities?
Regardless of the modality of psychotherapy you are practicing, these tools will help you develop a stronger therapeutic relationship with your client. As most therapists know, it’s not the modality that makes a difference for the most part. Rather, the most important element of a positive outcome in therapy is the quality of the therapeutic relationship.
When you’re teaching these techniques to your client, you’re practicing with your client, creating a sense of connection, and giving them tools that they can use on their own—tools for not only self-regulation, but self-empowerment.
Research among people who are depressed has shown that when self-efficacy goes up, depression goes down. So if you give a client a tool for self-empowerment, that process can strengthen the connection between the two of you.
Can you expand a bit more about how the therapeutic relationship is enhanced through the use of yoga in sessions?
When you offer a yogic tool or skill, you are creating a sacred space; a kind of safe container. You’re doing something that allows you and your client to experience something together that clears away the constrictions and tensions in the mind, body, and spirit.
In doing so, the oxytocin and prolactin — the feel good hormones — are elevated. So you, the clinician, are going to feel more connected and your client is going to feel more connected, both to you and to a sense of themselves. They are going to feel more connected with what might be true about themselves beneath the story or beneath the mood.
Through these practices, you give the client a moment, a glimpse, a window through the story with which they’ve come in. You give them a glimpse through the dark mood or the anxious mood, and even if just for a moment, you give them a sense of hope that they are more than that story and that mood.
In that moment, the client experiences a sense of connection to themselves as being whole and healed. They may have touched some very deep, dark material, and may have had some insight that was painful, but they leave the session knowing that they now have the tools to find their way into a larger space–a space where they are deeply and intimately connected to their true nature, their wholeness, something bigger than the pain with which they arrived.
Can you talk a little bit about the slumped over posture, the psoas muscle, the trembling that often occurs when doing yoga postures, and how this is all connected with depression and anxiety?
The posture associated with depression is kind of a compression, in which the shoulders are slumped over and the belly is dormant. When we begin a yoga practice, through breathing practice and also posture, we’re increasing lung capacity, we’re opening the lungs.
What happens in depression, anxiety, and trauma, is that the psoas muscle — the only muscle that goes from the front of the body to the back, and the top to the bottom — constricts, it clenches, and when that happens, that impacts the diaphragm in such a way that the diaphragm is now constricted.
A constricted diaphragm is one of the reasons why we aren’t able to breathe deeply. So when we do the heart opening postures and the breathing practices, we are able to relax the psoas, to deepen the breath, and to counter the effect of trauma.
Somatic psychotherapy modalities, developed by people like Peter Levine and Pat Ogden, are based on getting the body to tremble at the psoas muscle. When the body trembles, there’s often a release of constriction in the psoas that is a release of that holding pattern that trauma and loss have structured in the body.
Because this occurs in the body, the release can come without the story attached, so people can ultimately feel lighter, brighter, less constricted, less gripped by this trauma story simply because they’ve had release through the psoas.
The benefits of deep breath are often taken for granted, but what are the benefits? What is the function of breathing deeply and how does it affect our mental health?
Diaphragmatic breathing, or being able to breathe to the bottom of the lungs, has a calming effect on the autonomic nervous system. The breathing practices that we teach in yoga stimulate the vagus nerve, which then deactivates the sympathetic nervous system so that the parasympathetic system takes over. That’s the calming, cooling, rest and digest side of the nervous system.
Deep breathing practices also create an increase in heart rate variability, which is the balance and the ease in which we go from sympathetic activity to parasympathetic, both of which are needed. If we were only in the parasympathetic, we’d be couch potatoes. If we were only in the sympathetic, we’d be hyper-aroused all the time, anxious, and our responses would be trigger responses that are not necessarily appropriate to the situation.
Mindfulness meditation and mindfulness-based exercises have become extremely popular and the research has supported this growth. When it comes to meditation without an element of breath work, is there something missing?
Yes. The problem with instructing only mindfulness with someone who has a lot of rumination and negative self-talk is that when you’re watching the breath and the negative thoughts arise, unless that patient has already developed the skill of witnessing and not being caught up in her thoughts, she is likely to spiral into a darker place as she sits in meditation.
These yoga tools, things like pranayama and mudra, give the mind a bone. They anchor it with a technique that allows the mind to focus and draws the senses in. These practices are a more effective portal into meditation for someone with a mood disorder than the technique of simply watching the breath.
In the popular press, mindfulness is shown to work so well with depression and anxiety and it does. But mindfulness-based stress reduction (MBSR), the specific modality that is used in many of these studies, is not just mindfulness meditation. It includes yoga, and it includes a body scan.
So in fact, when you hear that mindfulness is effective, you’re not just seeing results of mindfulness meditation, but also body scan and yoga.
For therapists who wish to incorporate yoga practices into their clinical work, how necessary is it for them to have their own personal practice?
A therapist doesn’t need to necessarily take a 200-hour teacher training to introduce yogic strategies or skills to clients in sessions, but just reading a book may not be enough. I would suggest workshops or trainings that are specific for those who work in medical/clinical settings and that give them clinical applications of yoga skills, as well as practice facilitating those skills in a supervised setting.
In such a training, a mental health professional can learn the subtleties of language in introducing the practices, how to effectively monitor the client and how to help the client develop a home practice, tailored to help them self-regulate and manage mood.
There are also safety precautions — there are certain practices that are appropriate in a yoga studio setting that are not appropriate in a clinical setting. We need to be careful that clients don’t leave the session too revved up or overstimulated or so meditative that it might not be safe to drive home.