An increasing use over time [1] suggests that popularity of yoga is on a rise in the US. Moreover, this steady increase in the interest in popular mind is dwarfed by the fascination of researchers and scholars with yoga, which is reflected in 1,483 journal articles found on yoga between 2002 and 2012 in a PubMed search. Additionally, there is a current trend to medicalize yoga, thereby raising it to the status of therapeutic modality rather than a spiritual, health promotional preventative practice. Against this background, it is not surprising that yoga is used as a part of psychotherapy [2,3] or sometimes even as a stand-alone psychotherapeutic tool [4,5]. Parallel to this inclusion in practice, literature is emerging to justify it [6-8]. Many would see this as a part of welcome natural progression in the evolution of modern yoga.

However, integrating yoga with psychotherapy needs a reflective critical evaluation. The field of yoga is already inundated with the practice of putting the cart before the horse. Efficacy (or effectiveness) is being tested without defining Yoga. Incentive bias and publication (file drawer problem) bias are making the panacea projecting yoga research look suspicious. To make matters worse, when the utilization of yoga is predominantly occurring in a highly selective subpopulation- typically, young educated well-to-do healthy Caucasian white females [9], sweeping generalization are being made about its universal applicability. Specialist credentialing like “Children’s yoga teacher” or “Prenatal yoga teacher” by Yoga Alliance USA, and a push by International Association of Yoga Therapists to tout yoga as a therapy are vivid testimonies to an incautious unsubstantiated haste. While it might be interesting, timely, and important to conduct a critical analysis of the whole yoga exhilaration, this paper is to critique the issue whether yoga and psychotherapy can be combined, and if so, what are the caveats in doing so.

Health care is getting costlier [10]. While the need of time might be simplification & generalization in health care, addition of one more modality when similar ones are already existent can become a cost burden. Therefore, the pros and cons must be weighed carefully before implementing any reforms. The following discussion may help mental health and yoga community to decide what might be the best approach to this challenge.

Increase in the prevalence of mental health issues and stress in the society

In 2014, 18.1% adults in the US had ‘any mental illness (AMI) in the past year’ compared to 17.7% in 2008 [11]. The percentage of adults who had ‘serious psychological distress in the past 30 days’ rose from 3% to 3.4% between 2005 and 2013 [12]. A 2014 survey by American Psychological Association (APA) found that the stress gap was widening between men & women, and women experienced higher stress than men and got more adversely affected than men on different dimensions of stress. The same report also showed that the stress level is much above the national average level for millennials and generation Xers [13]. A recent National Center for Health Statistics data brief reported that the suicide rate in the US increased by 24% between 1999 and 2014 with the pace accelerating after 2006, and that most people who committed suicide were suffering from mental health or substance use disorder [14].

Workforce shortage in the mental health field in the US

A 2013 Substance Abuse and Mental Health Services Administration (SAMHSA) report to congress noted that “shortages of qualified workers, recruitment and retention of staff and an aging workforce have long been cited as problems” [15]. Similarly, a 2015 Merritt Hawkins review states: “The United States is currently facing a mental illness coverage crisis” [16].

Above data show that there is an unmet need in the mental health field in the US and the existing workforce cannot adequately fulfill it. This might provide a reason why yoga is being sought as and can serve as an adjuvant to psychotherapy.

Yoga is about exercising mind

The modern western yoga is seen as primarily a physical exercise (postures or asana). This wrong image, an artifact of history, happens because of lack of knowledge that meditation and modulation or control of mental activities and or processes was and is the only matter that the core of yoga philosophy (even including those historical yoga scriptures like Gherand Samhita or Hathayoga Pradipika that first introduced postures into the body of yoga practice) concerns itself with.

Unlike modern yoga, which is hard to define due to its diverse practices, ancient texts define yoga unambiguously. In at least two of its most respected books, it is clearly stated that the focus of yoga is only on mind and its activities. For example Patanjali’s aphorisms on yoga, in the second verse of the treatise says: “Modulation of mental processes is (defined as) yoga” [17]. Similarly Bhagwad Gita, another treatise on yoga philosophy (Karma Yoga) in chapter two, verse 50 defines yoga as: “The craft or art of behaving wisely is (defined as) yoga” [18]. It also states further in the same chapter: “The one who has acquired the control of one’s mind, their mind becomes happy, peaceful, and tranquil…and all their mental anguish disappears.”

The purpose of this article is not to catalogue or discuss in detail similar numerous references scattered abundantly in the ancient yoga literature. Many scholars have expounded on this topic before and discussed how yoga can be used as psychotherapeutic tool [6-8,19]. It is sufficient to say that ancient yoga literature has a plethora of techniques that can be harnessed to modern psychotherapeutic practice.

Reduction in disease burden and utilization of health care resources

Mental health issues often go hand in hand with chronic diseases. Yoga and other mind body techniques have shown to substantially reduce the utilization of healthcare resources and therefore the cost of care [20]. Integration will create synergy to more successfully address one of the most daunting challenges of the modern health care system.

Integrated therapy may have more appeal and use for the increasing elderly population

According to the W.H.O. about 15% of adults > 60 years suffer from a mental disorder. Furthermore it is projected that between 2015 and 2050, the proportion of the world’s population > 60 years will nearly double [21]. It is a truism that people tend to get more spiritual as they get older. Yoga has a strong spiritual base. Integrating yoga with psychotherapy may appeal and help older population better [22].

However, before one can haste to conclude that therefore yoga should be included in modern western psychotherapy domain, careful note should be made of the reasons elucidated below as to why integration of yoga might pose challenges and why great caution must be exercised before such inclusion.

Yoga is a spiritual practice not a mental tool or technique

It has been debated whether spiritual practices can be considered as psychotherapy [23]. After all, spiritual experience is highly subjective and individualized experience, which cannot fit into ‘two persons interaction’ model of psychotherapy. Yoga has many intermediate mental activities that can be taught by a therapist to a patient. However, yoga leaves cognition behind and transcends into spirituality- its central theme, where it claims its true benefits lie. Furthermore, the biggest challenge related to using yoga as psychotherapy is related to regulatory issues. All health care services are sooner or later regulated by state. If yoga is a spiritual practice, can its transactions be regulated by the state? Spirituality is the last bastion of human freedom. Regulation of yoga by state subsequent to declaring it a therapy, may it ever be little and partial, can be and would be seen tantamount to regulating spirituality, and this can open a floodgate for constitutional litigations, and rightfully so.

Lack of training to therapists

Forbes et al. in their 2011 paper “Training Issues in Yoga Therapy and Mental Health Treatment” have discussed the issue of training of psychotherapists in yoga philosophy & of yoga therapists in psychotherapeutic fundamentals [24]. While former may be doable, the latter is difficult to achieve in current scenario. According to APA: “after graduating from a four-year undergraduate college or university, psychologists spend an average of seven years in graduate education and training to earn a doctoral degree” [25]. It is not possible that existing yoga-teachers-training programs, given their constraints about finances and time, can impart adequate training to prospective yoga teachers in fundamentals of psychotherapy and then make equally intensive efforts to further educate them about the philosophy of yoga, which is extremely dense and involved to say the least.

Lack of service delivery infrastructure

Currently most yoga services are offered in yoga studios. Conversations between yoga teachers and students occur informally and in relatively open spaces, lacking office setup, which is essential for yoga-based psychotherapy. Notion of group therapy can apply to postural yoga; it is unlikely that it can serve for spiritual-mental counseling. If yoga has to be used as a psychotherapy tool, then the operational model of yoga service delivery (or conversely of psychotherapy) needs to be reconfigured.

Fundamental differences in the philosophies of yoga and psychotherapy

It was mentioned previously that yoga training might not be easy for psychotherapists. The reason is more than merely pedagogical. At core, yoga philosophy is exactly opposite of the philosophical foundation of western psychotherapy, even including most branches of humanistic psychologies. Psychotherapy accepts “I” of an individual as something real and tangible, and therefore manageable and accessible to manipulation. Antithetically, yoga philosophy denies the existence of “I” and considers it as an illusion, and strives to dispel the ignorance through spiritual enlightenment to subsequently deny and dissolve the notion (of “I”). This is a radically different approach compared to the western approach. Intactness of “I” is essential for western psychotherapy. Dissolution of “I” is the motive of yoga philosophy. Western psychotherapy tries to solve the problems of “I” whereas yoga tries to eliminate “I” to make the problems irrelevant. This fundamental disagreement can make mixing of yoga and psychotherapy and its techniques almost impossible.

Yoga practice is incompatible with any institutionalized religion

The debate whether yoga is Hindu has been ongoing for a while [26]. Recently the supreme court of California ruled that yoga is not Hindu [27]. However, this is a naïve view of the issue. What is overlooked is a more fundamental question whether yoga is compatible with any institutionalized religion. Unlike the question whether somebody practicing yoga practices Hinduism or not, the question is, while practicing yoga (its mental component) can someone still retains their original faith. Unfortunately, yoga at its core clearly negates faith of any kind in the end [28]. Yoga’s meditative prescriptions, if followed faithfully, eventually lead to transcendence of faith & embrace of abstract and non-iconized spiritualty. Furthermore and to complicate matters, transit of a seeker to enlightenment sometimes happens via faith, but the texture of those faith based nuances are aligned to Hindu faith, which is innately distinct from other western faiths. In the practice of postural yoga, faith does not play a significant role. In that sense postural yoga is closer to modern medicine, which is secular (a person of faith can have the medical services while retaining their faith to a reasonable extent). However, mind related activities of yoga could have implication for psychotherapy. In those cases, if the patient adheres to some faith [22], meditative practices of yoga can generate added mental stress rather than alleviate it.

In this small overview, the paper has delineated the various issues associated with the integration of yoga with psychotherapy. It appears that the reasons for integration are convincing but the challenges are more daunting. Therefore it is necessary to take a very cautious path to such an endeavor.

Yoga originated in ancient India to illuminate a path for the ultimate peace for human mind. It is possible that if it has the potential to deliver its bigger promise of salvation, it might also have smaller benefits for mental issues as byproducts. However, using yoga for these purposes is laden with risks and consequences that must be borne in mind before decisive steps are taken.

In the view of the author, today’s meteoric rise of modern yoga is not so much a result of a healthy desire for better enlightened living, but a subtle panic response to various global crises that threaten world societies; terrorism, obesity, chronic diseases, increased longevity of life without added quality, wealth and opportunity disparities, to name a few. This panic is precipitating a sense of urgency and haste. If history is any witness, haste invariably has unfortunate consequences. In the matters of integration of yoga with psychotherapy or medicalization of yoga in general, rather than a sentimental and over optimistic celebratory approach, a prudent well thought out strategic approach might serve better. For example, the process can begin with an effort to create a universal definition of yoga fashioned after that component of yoga, which enjoys the most health benefit evidence. Further, yoga should be segmented using a new ‘health oriented typology’ rather than a history-market-generated (for example Iyengar, Bikram) or socio-anthropological one [29]. This will help research as well as integration. Additionally, the spiritual component should be sorted out from the mental tools or techniques of yoga. These tasks will not be easy practically as well as politically. Moreover, following these, the measurable impact of yoga outcomes will appear to look smaller. However, to maximize the utility of yoga, this needs to be done. The author will elaborate on these issues in a separate article.

I wish to thank Swati Patwardhan, my wife, for serving as a sounding board, a reviewer, and a proofreader throughout the development of this paper. The research presented in this paper is that of the author and does not reflect the official position or policy of his employer.