Does Yoga Have A Place In CBT?

Yoga’s value in significantly improving mental health is increasingly appreciated by the health services; this includes both yoga therapists working in mental health care, and mental health professionals integrating therapeutic yoga in their work. There is growing recognition that a greater emphasis on body awareness and bottom-up regulation skills can enhance traditional psychological therapies, providing clients with a broader emotional regulation skill set and enhanced capacity for executive functioning. Cognitive Behavioural Therapy (CBT) is one of the most popular forms of mental health therapy offered in much of the world, and there is growing evidence from research and clinical reports that CBT enriched by yoga improves mental health outcomes via distinct neurological mechanisms of change. The integration of yoga practices and CBT therefore offers significant opportunity, not only to improve the lives of many people but also for yoga to be integrated with mental health care.

History of Yoga & Psychology

The amalgamation of yoga and CBT may well be recent, but the idea that yoga might offer psychological benefits is not new to the field of psychology. Carl Jung is widely regarded as the first psychologist to examine yoga philosophy and relate it to western psychological thinking (Douglass, 2007), during his series of public lectures at the Swiss Federal Institute of Technology between 1938 and 1940. Jung viewed the psychological themes within yoga as tools for self-study, describing yoga as a “natural process of introversion” (Yung, 1932), through which one could reflect on and more deeply understand the psyche (both personal and collective). Nevertheless, he actively discouraged the practice of the full range of yogic techniques (Jacobsen, 2008), perhaps stunting the integration of yoga and therapy for years to come.

In more recent years, as the popularity of yoga has grown, the focus has shifted; there is now a growing interest amongst psychologists as to how practical yoga techniques can enhance psychological wellbeing and complement psychological therapy, reflected in a growing trend for the integration of yoga into mental health care (Novotney, 2009). Whilst the evidence base is in the early stages, there is encouraging research indicating that yogic techniques can be helpful in a range of mental health conditions, including depressive disorders (Balasubramaniam et al., 2013), anxiety conditions (Hofmann et al., 2016), PTSD (Telles et al., 2012), and eating disorders (Neumark-Sztainer, 2013).

Why Integrate Yoga & CBT?

Studies have examined both the impact of yoga as a standalone intervention and as an adjunct to psychological therapies, and there is reason to believe that integrating the two provides an augmented effect when it comes to improving mental health. Interestingly, CBT appears to be uniquely complementary; a 2022 review of yoga as an adjunct intervention for a variety of common treatments found the highest efficacy when added to CBT (O’Shea et al., 2022). This is in-part because the self-regulation skills and enhanced interoception afforded by yoga seamlessly align with and support the CBT process. Additionally, bottom-up approaches bolster the pre-frontal cortex (PFC, the part of the brain understood to be the seat of executive functioning), thereby enhancing traditional cognitive-behavioural change strategies by supporting clients’ capacity to consider alternative ways of interpreting and responding to their experience.

The yoga tradition also explicitly focuses on psychological wellbeing as a key purpose of practice, offering a range of ‘limbs’ or tools to navigate this endeavour. A major appeal of yoga is that its holistic approach to mental cultivation fits neatly into a biopsychosocial approach to mental healthcare, with improved physiological health and social relationships also being actively addressed (Evans, Tsao, Sternlieb, Zaltzer, 2009). There is growing awareness within healthcare that mental and physical health go and in hand, reflected in shifting healthcare policy in recent years; NHS England’s Five Year Forward View emphasises the need for better integration of the physical and the mental in healthcare, paving the way for integrated approaches such yoga and CBT.

Yoga, CBT & The Brain

Underlying the emergent appreciation for the integration of body-based techniques into mental health care is a corpus of research demonstrating that they support enhanced brain functioning, most importantly, in structures associated with cognitive reappraisal and emotion regulation. The PFC is understood as the seat of executive functioning and when robust, affords us an opportunity to shift attention, reappraise and alter our habitual responses, and appropriately manage competing goals (Siddiqui, 2008). There is overwhelming evidence that mental health disorders are correlated with attenuation in the PFC (Drevet, 2008), while effective therapeutic interventions are associated with an increase in activity and volume in this structure (DeRubeis, 2008).

In his 2007 publication in the Annals of Science, Bessel Van der Kolk, an eminent psychiatrist specializing in PTSD, expresses that effective cognitive therapy of any kind necessitates a certain level of pre-existing capacity to activate the PFC. Healthy functioning of the PFC is required to reconsider one’s world view, to use interpersonal therapeutic dynamics to modify one’s responses and experience, and to invoke alternative responses or behaviours. As such, substantial down-regulation or under-development of the PFC is an obstacle to successful treatment. Van der Kolk proposes that body-based interventions such as yoga (in which physiological mechanisms influence neurological ones) help to bolster PFC functioning, enhance psychological well-being and support a more effective therapeutic encounter.

Further support for the use of yoga in CBT comes from psychiatrists Patricia Gerbarg and Richard Brown, who are renowned for using mind-body techniques in clinical practice. They suggest that through controlled breathing and movement, various bottom-up pathways act in unison, collectively promoting neuroplasticity which leads to improved executive functioning and consequently more effective therapy (Brown, Gerbarg & Muskin, 2012). Afonso’s research lends credibility to their hypothesis; his study found that older females with a long-term yoga practice exhibited greater cortical thickness in the PFC when compared with those naïve to yoga (Afonso et. al, 2017).

If the theory that yoga, as a body-based intervention, is positively impacting the functioning of the PFC, how might it be having this effect? One interesting line of research has focused on the impact of the planned movements involved in yoga asana practice; Diamond’s paper on the impact of planning new movements on the cerebellum and PFC indicated that the process of planning a non-automated movement resulted in greater upregulation of both structures and their shared pathway. Yoga asana offers a huge range of postures and movement, and for many practitioners the process of learning how to enter, exit, and properly position oneself is likely to offer ample opportunity to support this mechanism of change within the brain (Diamond, 2000).

The idea that yoga movement into and out of postures may galvanize executive functioning is further supported by Gard’s study, which found a much higher level of functional connectivity of the caudate in those who practice yoga than in those who don’t (Gard, 2015). The caudate is part of a group of subcortical structures that are collectively known as the basal ganglia, which interact with the motor networks of the brain to support fine movements. There is evidence to suggest that the caudate is also implicated in cognitive flexibility (Klanker, 2013), and may enhance our ability to inhibit specific thoughts and purposely evoke others. Schmalzl’s research attempted to unpack the mechanism behind this neurological signature, with the hypothesis that the constant planning that takes place during yoga practice to move from one position to another with control and mindful attention would naturally enlist the prefrontal-cortical regions, thereby reinforcing their relationship with the caudate (Schmalzl, 2015). This theory suggests that entering and exiting yoga postures might be a complementary means of helping a client to develop their ability to shift attention, thereby facilitating the therapeutic process of CBT.

The Vagus Nerve & GABA

Another neurological mechanism through which yoga may confer support to CBT is via the impact of slow controlled breathing and physical posture on the vagus nerve⁠—the main nerve of the parasympathetic nervous system. Dr Chris Streeter, one of yoga’s most eminent researchers, has focused on the relationship between yoga practice, the vagus nerve and neurochemical changes which strengthen PFC functioning (Streeter, 2012). According to Streeter, activation of the vagus nerve results in an increase in GABA, the brain’s main inhibitory neurotransmitter.

GABA is well-known for inhibiting fear-based circuits in the brain, while simultaneously allowing for the activation of alternative neurological pathways that correspond with shifts in mood. High levels of GABA are therefore associated with well-being, while low levels are found in many mental health conditions such as depression, anxiety spectrum disorders and PTSD. Streeter suggests that if GABA regularly floods the PFC, it can change this structure’s circuitry, increase its efficiency and thereby improve client well-being. Her research trials have shown support for yoga’s potential to increase GABA; in two separate trials she found that a one-hour yoga intervention led to statistically significant increases in GABA (Streeter, 2007; 2010), highlighting the potential for yoga to improve mental health via the vagus nerve.

With practice, regular activation of the vagus nerve over time is believed to lead to a greater level of tone and strength, heralding heightened parasympathetic dominance, increased PFC activity, greater resilience and improved social connection. Stephen Porges’ ground-breaking Polyvagal theory suggests that greater vagal tone is associated with additional social benefits that may further support well-being, providing additional support for the use of yoga practices alongside CBT. According to Porges, the vagus nerve plays a vital part in our capacity for social engagement, through mechanisms such as voice modulation (allowing us to effectively empathise with others) and control of facial muscles (affording us the ability to attune to others and respond with signs of visual resonance) (Porges, 2011). The enhanced capacity for social interaction afforded by vagal activation not only supports wellbeing via improved relationships with loved ones, but may also support therapeutic relationship dynamics within CBT.

The Future of Yoga & CBT

The more research is conducted into the benefits of yoga the clearer it becomes that yoga can support mental well-being on many levels, whilst giving rise to the neurological changes necessary for even more effective psychological interventions. There is huge potential for CBT therapists to offer basic yogic breathing and mind-body techniques in their existing clinical practice, or to train more comprehensively in yoga therapy in order to offer sessions within their services. As the evidence base supporting yoga as an adjunct therapy to CBT continues to grow, it is important to clarify both the range of ways in which yoga can be safely applied within mental health care, and the possible contraindications, especially given that not all yoga practices are appropriate for certain mental health populations. For yoga to have a place in CBT, those pioneering this work will need to have an embodied understanding of what practices work for whom and why, knowledge of possible precautions and the ability to adapt these interventions with accessibility in mind. Since 2007, The Minded Institute has led the way in educating mental health practitioners as to what type of yoga might be appropriate for different clinical populations, in addition to supporting other yoga teachers and yoga therapists in disseminating this knowledge within mental health care. In January 2023, our training in Integrating Yoga Therapy Skills with CBT will support clinicians in effectively integrating yoga practices into their work, providing them with the skills and knowledge they require.

Whilst caution is prudent, this should not overshadow the huge potential that yoga has to offer in augmenting the mental health benefits of CBT. As Murali Doriswamy, professor of psychiatry and behavioural sciences at Duke University, has said: “The search for improved treatments, including non-drug based, to meet the holistic needs of patients is of paramount importance and we call for more research into yoga as a global priority. If the promise of yoga on mental health was found in a drug, it would be the best-selling medication world-wide.”

References

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