Defining Yoga Therapy
Many people ask me, what’s the difference between a yoga teacher and a yoga therapist? Experienced yoga teachers are often exposed to people with differing needs in their classes, and they may point to their excellent ability to individualise within a group setting and say, ‘Isn’t any good yoga class also yoga therapy?’ Well it’s something of a long story so my initial response might be to agree that yes, skilful yoga teachers are able to make classes suitable for a wide range of student needs. I’d also agree that yoga in itself is therapeutic, in that it brings physiological and psychological benefits and moves people towards balance, strength and flexibility in mind and body. So where’s the complexity? I’ll see if I can walk you through some of the key areas of debate and diversity in the ongoing effort to define the emerging health field of Yoga Therapy.
Therapeutic Relationship and Person-centred care
At the heart of yoga therapy is the relationship between therapist and client. It is typically more personal, nuanced and sensitive to individual needs than the teacher-student relationship. In most modern postural yoga classes the teacher-student ratio is between 1:15 – 1:50 and many studios and venues allow drop ins. This means that while teachers might strive to know student’s names and remember their back grounds, old injuries, and current concerns, it is likely to be limited to a brief check in before class with perhaps 5 minutes to understand the student’s situation.
In yoga therapy the intake process varies but is typically a multi-page intake form, followed by or along with, an in depth interview, observation and assessment. Initial consultations take between 60 – 90 minutes. This allows the therapist and client to start to develop rapport, and yoga therapists will skilfully use coaching and goal setting techniques to draw out the motivations of their clients. Anatomical assessment and movement observation forms just one part of this intake and assessment process, just as yoga asana forms just one part of yoga as a whole system.
The yoga therapist then creates a personalised yoga therapy management plan or protocol for the client that suits their lifestyle, constitution, physical, mental, emotional and spiritual needs and goals. A clear home practice is provided using learning resources suited to the client, and opportunities for clarification or check ins with the therapist may be available between sessions.
Over a series of consultations, the client can feel supported to try a variety of practices, including asana, pranayama, mudra, mantra, dharana,dhyana, held safely in a therapeutic space where their feedback is welcomed and responded to kindly. Unlike general yoga classes, there tends to be more discussion, and verbal feedback from the client is prioritised. However silence is still valued and clients typically respond to the one on one environment with an internalised awareness and quiet focus that allows them insight into their own practice and life. In this environment of sadhana (spiritual practice), wisdom is unveiled, and clients may see their health situation differently. It’s important to note that yoga therapy doesn’t claim to cure or treat any disease or injury, instead it allows the client to develop their wisdom through suitable yoga practices, some of which may then prevent future suffering.
Scope of Practice and Other Professions
Yoga Therapy certainly draws from the fields of Ayurveda, psychology and to some extent physiotherapy or manual therapies. However yoga therapy focuses on an empowerment model with an emphasis on strengths rather than pathology. We do not treat using any internal medicines such as herbs or drugs, we do not seek to alter the body through manual manipulations, nor do we wish to psychoanalyse or relive any trauma experiences. You can download the International Association of Yoga Therapists Scope of Practice document here http://www.iayt.org/page/IntroScope. It seeks to allow diversity of practice approaches in this emerging filed while also reassuring clients and health professionals of the limits of yoga therapy professional practice. Humility is encouraged, and a measure of a good yoga therapist might be one who avoids any temptation to diagnose or prescribe in a way that places them as the knower and the client as ignorant. Referral to medical practitioners is the recommended way to have conditions diagnosed when relevant, while the yoga therapist can continue to act as a complementary therapist or supportive care modality.
Lineage Based Yoga Therapy
Yoga has a long and diverse history. Depending which scholars you read, the age of yoga and the approaches may differ. What we currently accept as yoga includes all eight limbs described by the sage Patanjali, with emphasis in most classes on asana, pranayama and relaxation. In the works of the modern yoga lineages which branched out from the teachings of Krishnamacharya, there are claims made about the benefits of certain practices for organs, systems and specific health conditions. If one flips open Yoga Makaranda by Tirumalai Krishnamacharya, translated into English by TKV Desikachar, you can see that Caturanga-dandasana (something like a bent elbow plank, common in modern vinyasa yoga sequences) is said to ‘Remove toxins from bone joints and nerve joints very quickly’. Other mudras and asanas are described as being beneficial for people with asthma, tuberculosis or heart conditions.
There is great authority in the teachings of experienced yoga gurus, they may indeed remove ignorance and allow space for healing to occur. Having seen many students over many years, in some cases working with individuals extensively, their recorded insights are certainly valuable. However they may also have been influenced by the time, place and students before them and so the modern reader might be advised to exercise caution in taking the prescriptive teachings of the various lineages as gospel. It is easy to find contradictions between the various styles of yoga which may cloud rather than clarify the yoga therapists’ work. The current approach to yoga therapy might be to integrate the traditional lineage based ideas with modern evidence based knowledge, and most importantly, apply it to practice with the unique individual before us.
The Language of Evidence Based Medicine
A yoga teacher who has not done further training in a health science or related field, may read such an authoritative text and take it as fact, especially if they are devoted to a lineage which upholds the teachings of the guru. However that kind of knowledge will not hold up in a modern medical setting. A yoga teacher could not adequately converse with a student’s doctor and say, ‘I have prescribed maha mudra and ten rounds of 8 breaths duration of chaturanga dandasana for this student’s health issues in order to reverse the problems I perceive with ama accumulating in the joints and nerves’. While the practice may be well indicated, the language of energy flows, prana, vayus, toxins and claims of cure are likely to raise red flags amongst conventional practitioners. If a reliable form of evidence is not there to support the practice then trust with the health professional may be damaged or lost. This is very confusing for the student who feels sure that yoga is helping, and frustrating for the teacher/therapist who is genuinely seeking to offer help from a yogic framework.
Thankfully there is a growing body of literature published in peer reviewed journals to support the role of yoga therapy in the management of numerous chronic diseases. Dr Timothy McCall has done much work in the field of yoga therapy or as he calls it Yoga as Medicine, and has recently updated the list of conditions where sound evidence exists to support yoga as a therapeutic modality. His downloadable pdf has 28 pages of references so you can search the original journal articles for yourself, or you can use the one page list of 101 conditions as a handout for interested people, including medical professionals who will want to know what evidence exists. This link can take you to McCall’s website and the single-page PDF with just the list of 101 conditions.
Conditions with high level evidence include cancer, arthritic conditions, anxiety and cardiovascular disease management. This does not mean that yoga therapy cures or treats those conditions, however it means we can confidently say there is evidence behind the use of yoga therapy to support an individual living who is experiencing these conditions. For acute conditions conventional medicine is rightfully the primary intervention. Yoga therapy is increasingly proven to improve quality of life for people living with a range of chronic diseases.
Integrating Tradition and Science
Yoga therapy remains respectful of tradition, very much valuing the direct experiences of practitioners and teachers, while blending that experiential insight with scientifically sound knowledge. Yoga therapy goes beyond yoga teaching to embrace the evidence based paradigm which is the dominant health paradigm. Yoga teachers embarking on yoga therapy training in accredited courses will become very familiar with evaluating peer reviewed research, searching through academic journals for studies which can inform a yoga therapy management plan. They are then skilled at communicating in the language of evidence based health to other health professionals so that yoga therapy can be part of a multi-disciplinary effort to support the well-being of the client. In this way the client feels held safely and is reassured that all their health care team are working for their best interest. The healing space can remain sacred without the conundrum of paradigm clashes between practitioners.
Individual rather than Protocol Driven Management Plans
The art and science of yoga therapy requires practitioners to integrate internally, and to be long term students with committed sadhana, in order to accurately perceive their own biases. While some of the traditional yoga texts prescribe certain practices for certain conditions, the medical paradigm is moving towards a patient centred, sometimes genetically tested, individualised treatment model, at least in some settings. Yoga therapists must carefully assess each case as a multi dimensional being on a unique path, with their own deeply held values, goals, suffering and strengths. This means that even while articles, trainings and classes called things like ‘Yoga for Cancer’, or ‘Yoga for MS’ abound, yoga therapists understand that people are not defined by their diagnosis. In a small group yoga therapy class each participant should be assessed individually and practices crafted to suit their present condition and future goals. So there is not a set sequence that can heal everyone with lower back pain, cancer or diabetes. In fact, as a complementary therapy, yoga therapy cannot directly heal any condition.
The Yoga Alliance Position Statement
The professional registration body Yoga Alliance in the US has stated that any yoga teacher registered with them cannot use the term ‘healing’ or ‘yoga therapy’ in their bio and must remove such terms and statements to similar effect from their marketing materials. It was clearly a legal move to prevent any claims in a litigious environment, despite the relative safety of yoga as a movement modality. Yet it paved the way for some greater clarity around who is a yoga therapist and who is a yoga teacher. The flaw in the foundational concept though is the idea that yoga might be used to treat disease. At it’s essence yoga therapy is designed to improve wellness in the whole person, not to target disease or disorder. Hopefully the discussions which have been stimulated by Yoga Alliance’s statement have begun to articulate this crucial difference.
As health modalities evolve so too do their educational standards and levels of registration with professional bodies. Yoga therapy has moved from being a sub group of yoga teachers to a distinct field over the last twenty years. led by professional bodies such as International Association of Yoga Therapists, Australasian Association of Yoga Therapists and the British Council for Yoga Therapy, the bar for training has been set high. While yoga teachers typically undertake 200 – 350 hours training (many do much more as part of ongoing professional development but this is the entry point for membership to professional bodies), the minimum standards for yoga therapists are now 650 – 800 hours yoga therapy specific training. It’s been developed as a post graduate qualification for experienced yoga teachers, akin to a Masters degree or at least a Grad Dip. This is similar to the increasingly high standards set for Naturopaths, and Exercise Physiologists. While there will always be an unregulated area in these fields, and many less qualified practitioners do provide excellent services due to their unique personal qualities and perhaps more practical than theoretical training, comparing yoga teachers to yoga therapists is like comparing natural therapists with a weekend workshop under their belt with Bachelor of Health Science qualified practitioners. The level of background knowledge and ability to source evidence based information to inform their prescription is world’s apart. Perhaps even more accurate is to compare Personal Trainers with Exercise Physiologists. For a well person the exercise program from their PT is fine and certainly beneficial in all the ways that exercise can be wonderful for mind and body. For the client who is recovering after treatment for cancer though, the PT may not have the necessary depth of understanding, or flexibility of response to safely and effectively guide them with their non standard needs. An accredited EP can assess, tailor and gradually rebuild all the areas required, informed by the latest science and supported by a body of professional peers and mentors. Cancer survivors should certainly find yoga classes in their community and often this will be beneficial, but if they feel they need to tell their story, describe the lasting effects of treatment, and have a yoga practice designed for them rather than the mixture of needs in a general class, they are best served by seeking an accredited yoga therapist.
Yoga Therapists as Health Literacy Educators
The majority of my work in recent years has been integrating yoga and complementary therapies in cancer care settings. Medical oncologists, haematologists, cancer nurses and radiation oncologists have all become increasingly happy to refer patients to yoga, meditation, mindfulness and counselling when they are reassured that the people delivering these services are also working in an evidence based model. They are not comfortable at all with their patients trying unproven ‘alternative’ healing methods especially when they hear language that contrasts with the dominant paradigm.
While patients/clients are always free to do whatever they want with their own health, it is important that they receive unbiased information based on real evidence so that they can make informed choices. When underqualified though well -meaning people give unfounded advice it can be very confusing. Yoga teachers are often perceived to be wise health leaders by their students and many teachers report being asked for advice on health issues well beyond their training.
Yoga therapists recognise and are clear on their own scope of practice and will comfortably say when they don’t know the answer and the client/student should see a suitably qualified professional. It tends to be the case though that less experienced, perhaps less educated yoga teachers may give their own personal opinions, possibly based on reading lay literature and the internet, and clients/students are not able to discern between the fondness and respect they have for the teacher, and the difficult truth that they are not all knowing.
Despite the many flaws in conventional health systems, informed consent is generally adhered to. In the cancer field that means oncologists explain risks and benefits of treatments in terms of statistics. It’s complicated at times and difficult to decide, so when someone speaks with confidence about having a clear solution with no negative side effects, it’s very appealing. However it’s not truly helpful, especially if it causes the person with the health issue to delay other treatments, or gives false hope. Chaturanga is powerful but it is not a cure for cancer. So the language that a yoga teacher/therapist uses is crucial to giving the client/student accurate information from which to make an informed decision. Yoga Therapists are well placed to build relationships between clients/patients and their health care teams when they are able to support the client in increasing health literacy.
Equally some yoga teachers may be very cautious in their approach to people with health conditions. Sometimes they err on the side of caution and prevent their students with pain, cancer, a non conventional body or a hip replacement from attempting anything in class. It’s understandable, no-one wants to hurt their students, however it may be disempowering to someone who is mostly well but living with a disease or condition. Yoga therapists are able to focus on what the person can do, rather than trying to keep them safe in a general class. That means the language used can be more encouraging and less fearful, which allows the client to thrive and grow within their own capacity.
Training Levels and Yoga Therapy Accreditation
I don’t think that anyone is claiming that a 200 hour trained yoga teacher should be well versed in medical literature. Nor should they be expected to give out health advice. That’s why the recent statement from Yoga Alliance regarding claims yoga teachers make about being yoga therapists is important. It clarifies what has been a grey area in a rapidly evolving industry. If you are a yoga teacher, you instruct yoga classes, doing your best to make them safe, accessible and inclusive for the population that presents to you. As you become more experienced, your ability to adapt and personalise may also develop. You can teach private yoga classes that are suited to the person in front of you and gain valuable experience in doing so.
If you are calling yourself a Yoga Therapist you will be cultivating therapeutic relationships with clients in a variety of settings including hospitals, palliative care units, homes and studios. To ethically claim to be a yoga therapist, you must have undertaken suitable training, and/or have extensive experience that brings your skill set in to the evidence based paradigm of modern health. As is common in emerging health fields, generous grand parenting clauses will help those practitioners who have been leading the field before accredited training courses existed.
The prerequisites for yoga therapy professional bodies are high and represent a global effort to set and maintain high standards for yoga therapy. All accrediting bodies describe yoga therapists as experienced yoga teachers with additional yoga therapy specific training of between 550 hours (BCYT British Council for Yoga Therapy) and 800 hours (IAYT International Association of Yoga Therapists). IAYT, AAYT (Australasian Association of Yoga Therapists) and Yoga Australia also advocate ongoing mentoring under experienced yoga therapists to ensure the ongoing professional development of graduates of accredited programs.
The International Association of Yoga Therapists is the global peak body which recently began to certify individual yoga therapists who may use the nomenclature C-IAYT. Yoga Australia and AAYT also register yoga therapists in Australia, New Zealand and Australasia.
The Future of Yoga Therapy
As more graduates come through the rigorous training courses accredited by the professional bodies, we will see a rise in awareness in the broader community about yoga therapy as distinct from yoga teaching. As these skilful yoga therapists work with clients in various settings, the health community is likely to embrace yoga therapy even more. Much as physiotherapy and exercise physiology moved from fringe health professions quite rapidly into mainstream healthcare, yoga therapy looks set to do the same. With respect for holistic multi-dimensional traditional models, blended with evidence based practice and the language of scientific health care, yoga therapists will be welcomed by GPs, surgeons, specialists, allied health professionals, treatment centres, nursing homes and hospitals to deliver personalised, safe, effective, measurable yoga therapy management plans to people with diverse needs.
See www.livingyogatherapy.com for accredited training programs delivered by C-IAYT experienced yoga therapist Chandrika Gibson, co-directed by Dr Jean Byrne PhD and available in modular formats and online throughout Australia and Asia.