shapeimage_1 Yoga for Depression and Anxiety
By Lauren Rose, lcsw, ryt
“I tell you, deep inside you is a fountain of bliss,
a fountain of joy.
Deep inside your center core is truth, light, love,
there is no guilt there, there is no fear there.” [i]

Very few people are unfamiliar with the feelings of depression and anxiety.  They are two of the many mood disorders that impact the lives of most people.  The majority of us have been anxious or sad on occasion.  Quite a few have been affected more deeply.  Whether we experience a passing sadness or a chronic major affective disorder, we can all benefit from insight into our minds and bodies and techniques to move beyond these states and back to a place of balance and contentment.  Both yoga and psychotherapy offer techniques to accomplish this result.  These methods will be described in detail below. By integrating yoga practice and philosophy with traditional psychotherapy, Yoga Therapy is an exciting treatment approach.
As a psychotherapist practicing for two decades I have discovered that I have been using many of the philosophical principles and mindfulness techniques of yoga within my practice without appreciating their origins in Eastern beliefs and yogic teachings.  I have found myself drawn to yoga not only as a tool for clients to learn relaxation and stress reduction, but also as a method to connect to their inner selves in a different way.  In my experience, many people, especially those suffering from depression and anxiety, tend to judge themselves in harsh, self-critical ways.  I have often struggled to help these particular clients learn to observe and relate to themselves in compassionate, non-judgmental ways. The combination of yoga and psychotherapeutic techniques used in Yoga Therapy can lead clients to a deeper understanding of themselves and their core issues.  With this improved self-awareness, work can begin to develop improved self-esteem, coping mechanisms and patterns of behavior.
Yoga is a union of the mind, body and spirit.  It is a practice of attention, loving kindness and honor toward oneself.  People begin a yoga practice for many different reasons.  Whether they seek a challenging form of exercise, an aid in recovery from physical injuries or illnesses or a philosophical exploration, devotees of yoga frequently come to think of it as more than a form of exercise, often they think of yoga as a way of life.  While the benefits of yoga on the body and mind can be experienced by all practioners, they can be especially remarkable for those suffering from mood disorders. BKS Iyengar stated: “The impact of yoga is never purely physical.  Asanas, if correctly practiced, bridge the divide between the physical and mental spheres.  Once we become sincere practitioners of yoga, we cease to be tormented by unhappy and discouraging thoughts.”[ii]
Dedication to yoga including attention to the details of alignment and breathwork; acceptance of oneself in the asanas; and quieting the repetitive, distracting and often destructive thoughts of the mind are critical to developing a successful yoga practice. As the practitioner begins to increase self-awareness of his own physical alignment and sensations as well as the thoughts and feelings of the mind, he can begin to find greater self-acceptance and inner balance.  Slowly, he can begin to make peace with the realities in his life.  
Methods for stilling the agitated mind are widely considered as important as the physical yoga practice. Dedicated practitioners find that over time with a regular practice, good instruction and the development of mindfulness they are able to learn techniques for dealing with sensations in their mind and bodies and make connections that lead to better emotional and physical health.  Through yoga, individuals suffering from depression or anxiety can learn to consider their feelings as momentary and passing rather than permanent, unchangeable conditions.  They may begin to think of these periods as temporary states rather than as a definition of themselves.
Traditional yoga’s definitive text, Pantanjali’s Yoga Sutras, written approximately two thousand years ago, describes the mechanisms of the human mind and suggests methods of living life with a goal of achieving inner peace and freedom from suffering through self-awareness.   The second line of this sacred text states that yoga is controlling and stilling the mind so an individual can experience his own spirit.   At the core, this system recognizes the destructive emotions that interfere with self-realization and encourages transformation of this negative energy into a more productive force. 
We are the heirs of our actions.” (Buddha)
Mood Disorders
Mood or affective disorders are disturbances in a person’s emotional state. Often those who suffer with affective disorders maintain a negative belief system about themselves and the world.   They frequently dwell upon events in the past and worry about the future.  Difficulty accessing positive emotions and beliefs can interfere with therapeutic improvement. Two of the more commonly diagnosed disorders are depression and anxiety.
During a state of depression, an individual may experience a deep sadness affecting enjoyment of all areas of his life.  For some these feelings are fleeting and mild, whereas those suffering from a major depression may experience feelings of hopelessness, worthlessness and despair for long periods with debilitating results. Studies suggest as many as 20% of the population has dealt with feelings of depression at some point in their life.  In addition to feelings of sadness or emptiness, other symptoms of a major depression include sleep and appetite disturbances, concentration difficulties, low energy level, physical ailments, and feelings of guilt, shame and worthlessness.  The intense emotional pain felt by some individuals can lead to suicidal thoughts or attempts. Job performance, social relationships and even physical health can suffer as a result of depression. 
Though depression and other mood disorders cannot be attributed to one specific factor, many believe depression results from an interaction between life stressors and biological and psychological vulnerabilities.  One of the prevailing theories is that depression is an overactivation of the stress-response mechanisms of the autonomic nervous system and the underactivation of the parasympathetic part of the nervous system, which aims to return the body to it’s resting state. In less technical terms, the brain recognizes something associated with upsetting thoughts and emotions in the past and launches previously established mechanisms to counter these feelings (for example avoidance, withdrawal and isolation).  However, in a major depression, the brain’s response is stronger than necessary and does not cease once the situation is resolved.  The mind’s continued negative thought patterns reinforce and deepen this cycle, becoming increasingly difficult to break. Depressive episodes have a very high level of recurrence with some studies suggesting that each depressive episode increases the likelihood of recurrence by 16%.[iii]
Anxiety often involves intense worries and fears, rapid thoughts and difficulty concentrating.  Approximately 40% of the population may have experienced anxiety. Sleep disturbances, depression, excess physical and emotional tension and fatigue can all accompany chronic anxiety.  Like depression, anxiety disorders can significantly interfere with functioning in all areas of life. 
Depression and anxiety often occur simultaneously, referred to as a comorbid or mixed mood disorder.  The symptoms are not always similar or complementary.  For example, the mind can be either anxious or overstimulated while the body may be lethargic or depressed.
Treatments for Mood Disorders
In our society, traditional treatments for mood disorders are psychotherapy and medication. Psychotherapy is a treatment process involving examination of an individual’s thoughts, emotions, values and perceptions in an atmosphere of acceptance. In psychotherapy the client “tells his story” and works to understand how past and present relationships and patterns of behavior may be contributing to his symptoms.  The goals of psychotherapeutic treatment include recognition of the ways in which past experiences and feelings as well as present misperceptions impact a client’s current emotional state, satisfaction and understanding of him or herself; decreased symptomatology; improved self-esteem; enhanced communication skills and healthier social relationships,
Psychiatric medications, such as antidepressants, antianxiety and mood stabilizers are another effective method of treatment for mood disorders. They are not cures.  While these medications can help clients feel better by controlling symptoms, they will not solve the underlying problems. Therefore, psychiatric medications are generally recommended in conjunction with psychotherapy.  Antidepressants work by restoring the brain’s chemical balance thereby lessening the symptoms of depression and their impact on daily functioning. Medication for anxiety often effectively calms the stress-response system and lessens the symptoms that interfere not only with daily functioning, but also with psychological treatment necessary to make changes.
Psychiatric medications, however, can also cause side effects, be quite expensive, further reinforce the notion that “something is wrong with me” and mask the core issues underlying the depression creating a situation where relapse likely.  Some people (quite often those who improperly medicated) report feeling numbness and disconnection when on medication.  Without feeling the emotions, one cannot expect to resolve them.  Further, this disconnection reinforces the feelings of separation from themselves and others that many clients report during depressive episodes.  A negative cycle ensues where the client may then avoid the very people and activities would give him pleasure and a sense of connectedness.
Psychotherapy or a combination of psychotherapy and medication can be tremendously effective for some people, but not for everyone. Some psychotherapists focus narrowly on the client’s emotions and mind using one particular treatment method without consideration of the whole person.  Alternatively, yoga reflect upon the complete individual and their needs in all areas when designing a practice, rather than focusing on the particular presenting symptom.  An individual may come to recognize concerns and areas of difficulty, but may need more guidance in resolution of the issues than a yoga teacher is able to give.  Here, a synthesis of the yoga and psychotherapy can be an invaluable tool.
Yoga Therapy
Yoga Therapy is an emerging school of treatment offering clients the opportunity to participate more actively in their treatment, healing and personal growth. Treatment can be effective in both individual and group settings for clients with affective and other types of emotional disorders. It has been used to treat many issues including:  stress management, anxiety, insomnia, post-traumatic stress disorder, depression, dysthymia, seasonal affective disorder, body image issues, eating disorders and the emotional effects of illness or Infertility.  Like all therapeutic practices, there are many different foundations and techniques.  As described here, Yoga Therapy is intended for use in conjunction with more traditional psychotherapy and/or medication management, not as a replacement.  Collaboration and partnership with treating therapists or doctor can be an important component of care. 
Within a safe environment filled with warmth, compassion and acceptance, the client, under the guidance of the yoga therapist, can begin to recognize the issues interfering with happiness without feeling judged. Clients are encouraged to explore being present in the moment and the physical and emotional feelings and sensations that arise during treatment.  Integrating insight-oriented counseling techniques, mindfulness training, breathwork and postures, yoga therapy facilitates the exploration of the underlying thoughts, emotions, bodily sensations and reactions to past experiences in a safe, supportive environment. Traditional psychotherapeutic treatment explores why we react to situations the way we do, but it is only in the breaking of our physical, emotional and thought patterns that we gain the ability to respond differently.  The insight gained through psychotherapy aids in the restoration of a comfortable balance in our bodies, minds and our lives, but often is not enough to effect true “change” for many clients.
“Change” is often quite complicated as we experience emotions not just with our minds, but also with our bodies.  An abundance of information about our earliest experiences, memories, patterns and emotions, often from periods in life prior to language acquisition, as well as more current events and thoughts are stored within our physical bodies.  Depressive and anxious symptoms can become engrained in our daily lives and our very being. Experiences and thoughts in our lives become charged with positive and negative associations. When we listen to our bodies, we are listening to the messages in our minds. With increased repetition of certain thoughts and behaviors comes increased development of the parts of the brain associated with these emotions and actions.

“The mind, much like the physical body, is subject to the gravitational pull of repetitive patterns of thought, emotion or behavior (known in Yogic terms a samskaras). From this perspective, anxiety, depression, and mixed affective disorders are neuro-emotional patterns or samskaras that may have at one point been adaptive coping mechanisms but that currently prevent people from realizing their full potential.”
If we accept that certain movements are a reaction to specific thoughts and emotions, it would follow that altering the movement patterns through a program like Yoga Therapy would create change in thought patterns as well. By decreasing internal and external stresses and increasing internal physical and emotional awareness, physical and psychological tensions release and change of physical and emotional patterns and improvement of overall health and vitality may follow.  Through mindfulness and conscious awareness of our emotional triggers, the client is able to interrupt this “chain of reactivity” earlier allowing thoughts, feelings and the physical body to settle.  Therefore, one of the many roles of the yoga therapist is to help the client to break free of these negative cycles and develop new, positive and more functional patterns.
Physical practice with emotional insight and support facilitates the release of the emotional tension that is held in the body bridging the gap between intellectual insight and actual change. The physical body is used as an instrument to change thoughts, emotions and physical issues that interfere with an inner sense of balance and happiness.  This is one of the foundations of Yoga Therapy.

“Yoga in the form of asana, pranayama, and relaxation techniques, has been shown to reduce both situational and chronic anxiety within a period of 10 days...practicing Yoga postures resulted in significant changes in brain levels of the neurotransmitter gamma-amino butyric acid after just one hour of Hatha Yoga....both depression and anxiety are associated with lower levels of GABA. Another study measuring the effects of Iyengar-style asana practice among individuals with depression reported significant reductions in depression, anger, and anxiety, as well as changes in heart rate variability. While research concerning Yoga’s effects on anxieyt and depression is in its beginning stages, there is a much larger body of evidence supporting the beneficial effects of meditation, relaxation, and mindfulness for mood disorders.”
A therapeutic yoga practice differs from a typical yoga class or psychotherapy session as it recognizes and focuses upon both the physical and emotional experiences simultaneously. The yoga therapist should be both a trained psychotherapist and yoga instructor.  Through integration of the philosophy and practice of these two different schools, an individualized program can be created to address the needs of both the body and the mind.  In addition to the traditional structure of a hatha yoga class that can lead to improvement in general health and alignment, a yoga therapy class may be designed to include particular asanas, sequences and adjustments of speed and intensity to address particular issues. The ability to recognize what the mind and body require to come into balance is one of the most important skills to be gained through yoga therapy.  These needs are not permanent and may change from day to day or even hour to hour.  Therefore, the process of self-study and self-observation is critical to self-realization.
Due to the many different needs of the various individuals encountered in treatment, assessment is a necessary initial step.  This includes evaluation of strengths and weaknesses in the client’s mental state, emotional connections and physical body as well as any physical ailments (past and present), symptoms and medical limitations that might impact development of a therapeutic plan.  Many different asanas and sequences can be recommended for addressing mood disorders.  It is my belief is that best practice in Yoga Therapy requires an approach individualized for each client recognizing and addressing all of the areas of the physical body, emotions and mind, clearing blockages to progress and establishing balance.  For some this may mean a vigorous practice featuring rapid sequencing of poses with periods of reflection or introspection limited maintaining the flow of energy and breath in the body without distracting thoughts.  Others may benefit more from a slower pace of more restorative sequences with a detailed focus on alignment and transitions.  Some may benefit from repetition and familiarity to calm the anxious mind, while others may need the stimulation of an ever-changing series to energize the lethargic mind.
Asana, the physical practice, can be useful in developing a sense of body awareness and relaxation.  Freeing the body and mind to “flow” through a sequence can be liberating and calming simultaneously.  The ability to allow thoughts, feelings and physical sensations to move through body without attachment often needs to be learned. Certain poses can be invigorating and revitalizing to the lethargic body and mind, while others are more calming and grounding to those experiencing anxiety. The same postures and practices may even have positive effects on people with different issues, as one of the goals of the practice of yoga is to bring the body and mind into balance. 
Tension in the body, created by anxious thoughts, can be released through deeply held postures. Frequently props such as bolsters, blankets, blocks and eye pillows are used to calm the nervous system and facilitate relaxation.  Forward bends and supportive restorative poses are considered soothing and reassuring and therefore recommended for work with clients with anxiety disorders. Practice is generally quite slow with precise focus and mindful recognition of the presence of physical and emotional resistance without allowing the over-identification with and grasp upon feelings. 
Depending on circumstances, clients may be encouraged to describe the emotions that arise while holding a pose for an extended period of time.  They are encouraged to frequently return to awareness of their own body and release of poses slowly noting where their body takes them.  These thoughts and sensations lead to greater awareness and must be permitted to arise and worked through.  Clients with depression benefit from a restorative practice for similar reasons; however, the pace is generally faster to energize the lethargic body. To counter the physical and emotional effects of depressions chest and heart opening poses such as gentle or full backbending poses are often recommended. 
Mindfulness is a method of observing and quieting the overly active mind, a process critical to yoga. Pranayama, also known as breath control, is often one of the first methods used in teaching mindfulness as it can be quite effective in quieting the mind, enabling further development of self-reflection and self-awareness.  An individual’s heart rate and overall steady and deep breathing has been shown to directly impact one’s sense of calmness.  In their research, Dr. Richard Davidson and Jon Kabat-Zinn have shown that clients’ mood and energy levels improved while their anxiety decreased following mindfulness training.  Brain scans showed increased activity on the left side of the brain, which has been shown to correlate with happiness.  Therefore, they believe we can actually change our brains programming them to be less anxious and depressed and more positive instead.  
Another significant mode of mindfulness training involves the practice of meditation. Techniques, which cultivate concentration and a focus of our senses, may be the most efficient means of returning the mind to a calm and focused state.  During meditation, we clear away the information overload that is building each day and contributing to our level of stress. Thoughts and feelings are observed without judgment.  Meditation helps in focusing on the present, reducing negative beliefs, building skills to manage stress and gaining new perspectives on life.  “One word for meditation in Tibetan means familiarization.  Meditation is a process of getting to know the mind. …This ‘knowing’ itself interrupts these chains of reactive thoughts and feelings.”[vi]  When one is mindful, his yoga practice is more effective for the body and psyche.
Guided visualization and other imagery based meditation techniques help clients move beyond self-fixating, negative thoughts by choosing to focus on positive, nurturing and energizing thoughts instead.  Meditation and pranayama will not make the painful feelings disappear, but they can assist in understanding of feelings and provide comfort knowing that the feelings are temporary and will pass.

“The mere act of trying to hold the mind to a single point, an act with which higher forms of meditation begin, teaches the beginner in a radically concrete and experiential way that he or she has little or no control over the mental flow. All attentional training starts with this failure. This is the great step in the work of objectifying the mental flow, that is, of seeing it not as something that ‘I’ am doing, but something that is simply happening. WIthout this realization no progress can be made, for one must first know one is in prison in order to work intelligently to escape.”
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Therapist and client work together to help the client gain increased self-awareness and insight leading to changes in physical, emotional and thought patterns. The psychological insight developed through working with a trained Yoga Therapist can break the vicious cycle of thoughts influencing emotions and emotions influencing thoughts.  The client comes to learn that the layers of armor he created for protection has ultimately left him feeling disconnected from himself and others.  Through use of the techniques learned in yoga therapy, new, more functional coping mechanisms can be created.  Clients can learn to gaze inward and recognize what their mind and body needs at any given moment.  This may be different today than yesterday and it may change again tomorrow.  This experience, the ability to transform one’s life from the inside out, is the essence of yoga therapy and its goal.
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[i] Sri Sri Ravi Shankar as per Weintraub, A.  Yoga for Depression:  A Compassionate Guide to Relieve Suffering Through Yoga.  Random House; 2004; p. 26
[ii] Weintraub, A.  Yoga for Depression:  A Compassionate Guide to Relieve Suffering Through Yoga.  Random House; 2004; p.103
[iii] Williams JM, Teasdale J, Segal Z, Kabat-Zin J, The Mindful Way through Depression:  Freeing yourself from Chronic Unhappiness.  Guilford Press.  2007.  p.16
[iv] Forbes B, Arkturk C, Cummer-Nacco C, Gaither P, Gotz J, Harper A, Hartsell K.  Yoga Therapy in Practice:  Using Integrative Yoga Therapeutics in the Treatment of Comorbid Anxiety and Depression, International Journal of Yoga Therapy.  2008 (18): 90
[v] Forbes B, Arkturk C, Cummer-Nacco C, Gaither P, Gotz J, Harper A, Hartsell K.  Yoga Therapy in Practice:  Using Integrative Yoga Therapeutics in the Treatment of Comorbid Anxiety and Depression, International Journal of Yoga Therapy.  2008 (18): 89
[vi] Cope, S.  The Wisdom of Yoga; A Seeker’s Guide to Extraordinary Living.  Bantam Books; 2006; p. 106
[vii] Novak, P.