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Cognitive and Behavioral Practice 16 (2009) 59–72

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Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice

Paul Salmon, Elizabeth Lush, Megan Jablonski, and Sandra E. Sephton
Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY 40292

The use of Yoga and other complementary healthcare interventions for both clinical and non-clinical populations has increased
substantially in recent years. In this context, we describe the implementation of Hatha Yoga in the Mindfulness-Based Stress Reduction
(MBSR) program of Kabat-Zinn and colleagues. This is embedded in a more general consideration of Yoga’s place in complementary
healthcare. In providing this overview, we comment on the nature and quality of current research on Yoga, summarize current
physiological and psychological explanations of its effects, and discuss practical issues related to teacher training and experience.

A. Introduction and Overview about the implementation of these practices – particularly

There is a long-standing interest in the health benefits
of Yoga in India and other non-Western cultures. Yoga is
currently experiencing a marked increase in popularity in
the West, primarily in health clubs and wellness centers.
One program which has advanced the status of Yoga in
clinical settings is the mindfulness-based stress reduction
(MBSR) program developed by Kabat-Zinn (1990) and
colleagues. This work has stimulated extensive clinical
practice and research in acceptance-based psychological
interventions in recent years (Germer, 2004; Hayes and
Feldman, 2004). Outcome studies reviewed elsewhere
(Baer, 2003; Salmon, Sephton, Weissbecker, Hoover,
Ulmer, & Studts, 2004) attest to its promise as a clinical
intervention. A meta-analysis of health benefits associated
with MBSR (Grossman, Niemann, Schmidt, & Walach,
2004) reached a similar conclusion, but noted a relative
absence of methodologically rigorous studies, and a lack
of detail concerning intervention specifics.
Indeed, much of the writing about mindfulness
interventions to date has focused on conceptual defini-
tions and broadly-defined outcome measures, to the
relative neglect of the program’s content and structure,
particularly with respect to Yoga. Kabat-Zinn has written
extensively about the nature of the original MBSR
program (Kabat-Zinn, 1996, 2003b) and described three
key components – sitting meditation, Hatha Yoga, and
body scan (a sustained mindfulness practice in which
attention is sequentially directed throughout the body) –
at great length. However, little has been written elsewhere
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Yoga – in either clinical or research contexts. Concerning
clinical research, studies generally provide little detailed
information about specific intervention elements in terms
of either content or process factors, and instead focus
attention primarily on outcome measures.
Yoga as discussed here refers to an integrative physical/
spiritual practice which developed in ancient India. We
capitalize the word ‘Yoga’ throughout in recognition of its
historical stature as a highly evolved cultural system of
beliefs and practices, even though clinical applications
tend to ‘de-contextualize’ it from its cultural and spiritual
roots. The word ‘Yoga’ means ‘yoke’ or ‘union’ and
connotes the interconnection of mind, body, and spirit.
Yoga practice in Western contexts involves sequences of
postures, called asanas, that incorporate regulated breath-
ing and focused attention. Ongoing practice is reported
by practitioners to promote psychological well-being and
a variety of physical benefits. Although the focus in
Western Yoga practices is usually on the asanas, they
comprise only the most basic of what are characterized as
the ‘Eight Limbs of Yoga,’ a cumulative series of stages
embodying ethical principles of behavior and meditative
states compiled by the Indian sage Patanjali in a collection
of aphorism known as sutras (Desikachar, 1999). There
are different paths that Yoga practitioners may follow, the
most widely practiced being Hatha Yoga (physical devel-
opment); Gnyana Yoga (developing the intellect); Bhakti
Yoga (spiritual devotion); and Karma Yoga (practical
action; Patel, 1993). The form practiced in the MBSR
program, and indeed in most Western healthcare
contexts, is Hatha Yoga.
The inclusion of Yoga in the MBSR program is
interesting and warrants detailed consideration. Aside
60 Salmon et al.
from a mindfulness-based program for depression (Wil-
liams, Teasdale, Segal, & Kabat-Zinn, 2007), Yoga has
received little attention in clinical psychology, despite an
extensive research literature documenting its benefits in
stress reduction and other contexts (Khalsa, 2007). One
obvious reason for this omission is that few psychologists
have much experience or training in Yoga and other
physical disciplines. A second possible reason for a lack of
attention in clinical contexts is that Yoga is associated by
many more with fitness and health than as a treatment for
illness, despite its historical roots in Indian Ayurvedic
medicine.
Yoga has generated considerable empirical research in
other contexts, especially Indian medical practice, which
we comment on below. Its comparative exclusion from
clinical psychology is something of an anomaly, and this
article is an attempt to rectify this oversight. In discussing
the program which he formulated, Kabat-Zinn (1990)
notes that Yoga was originally included for the practical
purpose of helping medical patients overcome disuse
atrophy – deterioration of muscle tissue due to lack of
activity – that frequently accompanies illness. In addition,
however, and perhaps of even greater importance, Yoga
provides an opportunity to practice mindfulness. Yoga is
introduced in the program once participants have been
exposed to the Body Scan, a physically static exercise in
which attention is systematically directed toward internal
sensations emanating from different regions of the body,
beginning with the feet and progressing to the head. The
Yoga movement sequences have been formulated with the
intention of encouraging mindful awareness: they are
done slowly and gently and are not overly physically taxing.
Much of the attention directed at the MBSR program
focuses on sitting meditation, a predominantly cognitive
practice that has its roots in Buddhist meditation practices.
Hatha Yoga, on the other hand, draws on related but
somewhat distinct cultural and philosophical traditions
that employ physical activity in the context of meditation
practice. That the two elements have been juxtaposed in
the same program, along with the body scan, is something
of an anomaly, reflecting the particular experiences and
training of those who originated the program.
B. Clinical Research
In recent years, a substantial body of clinical research
has accumulated attesting to the health benefits of Yoga. It
is not the purpose of this article to review the extant
research literature; a recent comprehensive analysis of
published studies by Khalsa (2004), and more selective
reviews by Innes and Vincent (2006), Innes, Bourgignon,
and Taylor (2005), and Raub (2002) do this admirably.
More recently, Yoga is included in an exhaustive review
and critique of health-oriented meditation studies invol-
ving mantra and mindfulness meditation, Tai Chi, and Qi
Gong (Ospina et al., 2007). Our intention is to highlight
recent findings from methodologically rigorous studies,
which until recently have been relatively few in number.
As is the case with meditation research as recently noted
by Walsh and Shapiro (2006) many studies involving Yoga
as both a lifestyle and clinical practice have been
conducted over the years. Unlike meditation research,
however, much of the research on Yoga originated in
Indian research institutes, beginning in the early 20th
century. Few of these early studies employed research
methodologies now taken for granted, but they did serve
the important function of signaling a new view of Yoga as a
form of health and medical care, rather than an
exclusively spiritual practice (Khalsa, 2007).
Currently Yoga is among the 10 most widely practiced
forms of complementary healthcare in the U.S. (Barnes,
Powell-Griner, McFann, & Nahin, 2004). Yoga practice is
linked to demographic variables including gender
(female), education level (high), age (post-WWII birth),
and lifestyle (urban; Saper, Eisenberg, Davis, Culpepper,
& Phillips, 2004). As a result of its growing popularity, Yoga
is becoming a focus of increasing clinical research in this
country.
Results of well-designed recent randomized trials
employing Yoga as a clinical intervention report promis-
ing results. For example, Yoga has been shown to improve
management of Type II diabetes mellitus (Innes and
Vincent, 2006), relieve chronic low back pain (Sherman,
Cherkin, Erro, Miglioretti, & Deyo, 2005), improve quality
of life in patients with chronic pancreatitis (Sareen,
Kumari, Gajebasia, & Gajebasia, 2007), reduce gastro-
intestinal symptoms in irritable bowel syndrome (Kuttner,
Chambers, Hardial, Israel, Jacobson, & Evans, 2006), and
improve the physical capabilities of healthy senior adults
(Oken et al., 2006). A recent article reviewing the impact
of Yoga interventions on risk factors for chronic disease
found evidence that Yoga elicits favorable changes in body
weight, blood pressure, cholesterol, and blood glucose
levels (Yang, 2007). Studies have also shown that Yoga
interventions are beneficial to emotional wellness, with
improvements demonstrated in stress management
(Granath, Ingvarsson, von Thiele, & Lundberg, 2006)
and depressive symptoms (Pilkington, Kirkwood, Rampes,
& Richardson, 2005). Research studies vary in the degree
to which the Yoga practice is described in detail, and it is
quite evident from those that provide detailed informa-
tion that there is considerable variation in how it is
implemented.
Two recent research studies employing randomized
control designs are especially noteworthy in terms of
methodological rigor and detailed descriptions of the
Yoga practice. In one study, 38 patients with lymphoma
were randomly assigned to a seven week Tibetan-based
Yoga program or a wait-list control group (Cohen,
 Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice
Warneke, Fouladi, Rodriguez, & Chaoul-Reich, 2004).
The Yoga intervention incorporated regulated breathing
and imagery, mindfulness practice, and sequences of
postures (asanas) appropriate for individuals receiving
cancer treatment. The sole area of improvement con-
cerned sleep quality; changes were noted in depression,
anxiety, or fatigue. The significance of this study lies in its
robust experimental design, clear description of the
intervention, and demonstration that Yoga can fruitfully
be practiced by medical patients receiving taxing treat-
ment regimens. Yoga was employed in another rando-
mized controlled study (Moadel et al., 2007) involving a
multi-ethnic sample of breast cancer patients. The
intervention consisted of twelve weekly 90-minute sessions
incorporating sequences of poses (asanas), meditation,
and regulated breathing. This study was especially notable
for the positive outcomes reported (improved quality of
life and emotional well-being, reduced distress), and
acceptance by ethnically diverse participants.
More generally, the therapeutic significance of move-
ment-based interventions including Yoga, Tai Chi, and
others was recently emphasized by van der Kolk (2006) in a
discussion of neuro-cognitive aspects of PTSD. He pre-
sented compelling evidence that regulation of physical
movement is a fundamental priority of the nervous system,
perhaps from an evolutionary standpoint even more
important than regulation of emotional functions. Physical
therapies may benefit from ‘pre-wiring’ that augments their
impact on patterns of behavioral reactivity commonly
associated with various clinical conditions. In addition,
physical activity provides a rich source of present-moment
interoceptive cues that can serve as a focal point for mindful
attention that is comparatively well tolerated by trauma
victims, who may otherwise feel overwhelmed by inner
sensations. Van der Kolk notes however, that aside from
mindfulness-oriented intervention models such as those of
Kabat-Zinn (1990) and Linehan (1993), few Western
psychological models – even those that ascribe to a
mind/body perspective – make systematic use of body-
centered or movement-based interventions.
The absence of movement therapies in Western
psychotherapy and clinical practice is notable but
certainly understandable, given that what Freud termed
the ‘talking cure’ has historically placed more emphasis
on cognitive factors than on physical aspects of
behavior. It also reflects in part the mind/body
dichotomy that has traditionally characterized Western
health and medical care. In addition, relatively few
somatically-based practices have been thoroughly
empirically validated, despite their broad popularity.
This is the case, for example, with methods such as
those developed by Feldenkrias, Alexander, and Pilates.
In contrast, Yoga attracted considerable research
interest, beginning early in the 20th century. However,
61
although voluminous, much of this early research on Yoga
was hampered by a range of methodological problems
that detract from its empirical foundation and conse-
quently limit its clinical utility (Khalsa, 2007). For
example, a recent systematic review by Innes and Vincent
(2006) evaluated the methodological rigor of 70 studies
published between 1970 and 2004 assessing the effect of
Yoga on insulin resistance and cardiovascular disease. In
terms of experimental design, the majority were observa-
tional (1), non-controlled (26), or controlled but non-
randomized (21); in contrast, only twenty-two studies
(31%) employed a randomized controlled design.
Methodological problems enumerated by these and
other authors have included: lack of statistical power,
small sample sizes, substantial variations in Yoga interven-
tion protocols, failure to control for possible explanatory
confounds, questionable statistical analyses, and lack of
specificity concerning randomization procedures. They
also pointed out that many of these studies were
conducted in non-Western clinical research contexts,
primarily in India, where Yoga is widely accepted within
the prevailing culture. Of the shortcomings noted above,
the most problematic from a research standpoint is the
current lack of specificity or standardization with respect
to the Yoga practice itself. Yang (2007) recently under-
scored the difficulties inherent in evaluating and replicat-
ing interventions without having detailed descriptions of
the Yoga postures and their sequence, urging the
development of a more standardized intervention that
could be replicated for research purposes. These meth-
odological concerns and contextual factors need to be
addressed in designing future Yoga-based intervention
research and clinical practice. In general, the entire field
of meditation-oriented research is in need of much grea-
ter methodological rigor and consistency (Ospina et al,
2007). The fact that a relatively standardized approach to
Yoga practice has already been developed in the MBSR
program is a promising development in this regard.
C. Underlying Physiological Processes
Yoga – Hatha Yoga to be specific – involves physical
activity, and in general both physical activity and exercise
have been linked to a variety of neurophysiological effects
including β-endorphin release and altered brain neuro-
transmitter levels, especially dopamine and serotonin,
which have emotion-enhancing effects (Buckworth and
Dishman, 2003). However, many of these changes occur
in the context of relatively high intensity activity, which
involves heightened activation of the sympathetic nervous
system (SNS). In contrast, most forms of Yoga (excluding
high intensity, aerobic variants such as Ashtanga Yoga)
elicit the ‘relaxation response’ described by Benson
(1975), a state of physiological de-activation reflecting
dominance of the parasympathetic nervous system (PNS).
62 Salmon et al.
Yoga is commonly practiced in a focused, yet relaxed
manner. It shares in common with meditative/contem-
plative practices an emphasis on focused attention,
reduced extraneous external stimulation, controlled
breathing, and relaxation; thus, it has much in common
with stress reduction practices eliciting the relaxation
response. Such practices have been found to have
measurable effects on brain function assessed by imaging
techniques (Lazar, Bush, Gollub, Fricchione, Khalsa, &
Benson, 2000), attention-related cognitive processing
(Galvin, Benson, Deckro, Fricchione, & Dusek, 2006)
and cardiorespiratory function (Danucalov, Simoes,
Kozasa, & Leite, 2008; Dusek et al., 2006), although the
strength of such effects varies depending on the specific
practice (Peng et al., 2004). A growing body of research
on biological and psychological correlates of movement is
revealing new ways in which simple behavior patterns, for
example walking, interact reciprocally with cognitive and
emotional states (Acevdeo and Ekkekakis, 2006). Walking,
Yoga, and other repetitive motion patterns appear to
restore and entrain the rhythmicity of biological functions
that are often disrupted during periods of stress.
A two-part physiological model has recently been
proposed (Innes, Bourguignon, & Taylor, 2005) to
account for the relaxation-inducing effects of Yoga. First,
it may help balance the reactivity of endocrine stress
responses, perhaps ameliorating hyper- or hypoactivation
of the SNS and the hypothalamic-pituitary-adrenal (HPA)
axis. Frequent stress-related activation and/or chronic
suppression of the SNS and HPA results in altered
catecholamine (epinephrine and norepinephrine) and
cortisol secretion. Both SNS and HPA activation are
associated with heightened arousal and reactivity states
that are normally balanced by parasympathetic activation,
which exerts a restorative, energy-conservative effect.
Chronic stress may lead to imbalances in stress-related
versus restorative neural responses, with damaging effects
on other body systems including regulatory mechanisms
(McEwen, 1997; McEwen & Lasley, 2003; McEwen &
Seeman, 1999). Yoga may curtail chronic stress-related
activation, and potentially reduce allostatic load, the
cumulative impact of chronic HPA and SNS activation
(McEwen, 1997).
The second part of the hypothesis suggests that Yoga
enhances PNS activation through relaxation-inducing slow
movement patterns that reduce heart rate and blood
pressure via stimulation of the vagus nerve, which
connects cardiac control centers located in the brain
stem with the heart’s intrinsic pacemaker, the sino-atrial
node (Powers and Howley, 2006). In addition to altered
autonomic and HPA function, Khalsa (2007) recently
highlighted additional physiological mechanisms by
which Yoga may exert its effects. These include: reduced
metabolic rate and lower oxygen consumption; improved
respiration and neuromuscular function; and altered
cognitive and neurophysiological status. It is also possible
that Yoga has direct beneficial effects on health that are
mediated through other pathways related to neurological
approach rather than avoidance (stress) mechanisms. It
may be fruitful for research to explore effects of Yoga on
serotonergic, dopaminergic, and endogenous opioid
pathways.
The physiological effects of relaxation have been
thoroughly documented in broad-based, clinical research,
beginning with the work of Benson (1975). However,
comparatively few recent studies have examined the
physiological effects of Yoga practice per se, and more
methodologically rigorous studies are needed. Among the
handful of studies that have been conducted, one study of
35 male volunteers showed that heart rate and skin
conductance decreased after a guided relaxation based
on Yoga (Vempati and Telles, 2002), and another
demonstrated reductions in heart rate and blood pressure
among Type II diabetics after 40 days (Singh, Malhotra,
Singh, Madhu, & Tandon, 2004). Benefits in autonomic
function have been noted among samples of refractory
epilepsy patients (increased parasympathetic function;
Sathyaprabha et al., 2007) and in Type II diabetic patients
(reduced allostatic load parameters of glycemic load and
cardiac activity; Singh, Malhotra, Singh, Madhu, &
Tandon, 2004). To the extent that Yoga is linked to
attention-focusing mindfulness, it is likely to reduce
sympathetic over-activation associated with PTSD symp-
toms. Yoga may also be effective in reducing physiological
symptoms of PTSD, particularly when pronounced
autonomic hyperarousal is involved either directly
(Gupta, Lanius, & Van der Kolk, 2005), or in the context
of attention-focusing mindfulness (van der Kolk, 2006).
Despite these promising findings, more research on the
effects of Yoga on autonomic balance, HPA, metabolic,
neuromuscular and neurocognitive functions is needed
before its specific effects can fully understood.
D. Clinical Implementation
One of the most obvious challenges facing greater
acceptance of Yoga within mainstream Western health-
care has to do with its cultural, spiritual and social origins
in India, where it flourished for centuries without the level
of empirical validation and scientific verification required
for widespread acceptance in contemporary biomedical
settings. As is the case with meditation, another
‘imported’ complementary health care practice, Yoga
has in recent years been transplanted into Western
culture and healthcare, where the enthusiasm of its
practitioners has been countered by the skepticism of the
biomedical community due to the lack of strong valida-
tion data. Validation studies are needed oriented toward
the pragmatics of Western healthcare that value
 Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice
interventions primarily to the extent that they reduce
pain and suffering associated with illness. Clearly, there is
a need to develop more systematic means of specifying
the nature of Yoga-based interventions in clinical research
and practice. This is especially important owing to the
popularity of Yoga and the degree to which it is making
significant inroads into clinical healthcare. Establishing
research guidelines for study design, intervention speci-
fication, and teacher training are among the most
pressing needs, all of which would contribute substantially
to controlling confounding variables that detract from the
rigor of most extant research. Complete and accurate
intervention descriptions could allow researchers to
further uphold the standards necessary for maintaining
accuracy, reporting and corroborating results across
studies. Providing the critical information necessary for
accurate replication and implementing stricter protocol
control across clinical trials may further substantiate the
use of Yoga as a treatment option among clinical
populations. In this context, it is important to be able to
evaluate both positive and negative outcomes and other
manifestations of individual differences.
To date, there does not appear to be widespread
agreement in this regard. There are several possible
reasons for this. First, the term 'Yoga' encompasses many
different forms of practice, of which perhaps the most
widely practiced is Hatha Yoga, which as noted emphasizes
physical development. But even within the domain of
Hatha Yoga there are variations, including Bikram,
Iyengar, and Ashtanga Yoga. Second, Yoga has been
implemented primarily in private studios and health clubs
which do not share in common standards of practice.
Third, virtually all schools of Yoga emphasize the
importance of individualized instruction and personal
adaptation, a perspective that runs somewhat counter to
the idea of standardization. An exception to this is Bikram
Yoga, which consists of an invariant sequence of asanas
that has been patented by its founder, and which is taught
by certified teachers specifically trained to conduct the
classes. A practical problem with Bikram Yoga, however, is
that it is taught in a very hot environment that limits its
application, especially with respect to medical patients. In
addition, several of the poses themselves are quite
challenging from a physical standpoint, and not well
suited to beginning practitioners unless they are carefully
and individually supervised.
The MBSR-based Yoga sequences comprise one of the
few relatively replicable models in this regard. Hatha Yoga
is practiced as part of an eight-week meditation-based
program comprised of weekly 2.5-hour sessions con-
ducted in a group format. Historically, most participants
were referred to the program by physicians at the medical
center, but self-referrals have increased significantly in
recent years. As already noted, Yoga is one of three
63
practices that form the core of the MSBR program, along
with sitting meditation and the body scan. Each of these
practices, described in greater detail below, is taught
during program sessions and then done at home using
narratives on tape or CD for guidance. To date, more than
15,000 patients and participants from a variety of referral
sources have taken the program. The evolution of a
consistent sequence of asanas in the MBSR program,
practiced by thousands of medical patients, provides a
relatively standardized, field-tested intervention that is
worth consideration by anyone contemplating research
on the clinical benefits of Hatha Yoga.
E. MBSR-based Yoga
In the context of the MBSR program, Yoga provides a
means of practicing 'mindfulness in motion.' Practically
speaking, it also addresses the problem of ‘disuse atrophy’
common in medical patients as a result of reduced physical
activity. The structure and underlying philosophy of the
MBSR program are described in detail by Kabat-Zinn
(1990). The basic premise underlying mindfulness practice
is that living 'in the present' can be an effective antidote to
the myriad stressors people experience as a result of
cognitively-based projections into the past or future often
marked by regret, fear, or apprehension. The Yoga practice
consists of two separate sequences of asanas, performed in a
state of focused, yet relaxed, awareness. Each sequence lasts
approximately 45 minutes, and is practiced using an
accompanying audio tape/CD for guidance. Participants
are expected to devote between 45 and 60 minutes most
days of the week to various combinations of Yoga, the Body
Scan and Sitting Meditation.
A recent study by Carmody and Baer (2008) attests to
the impact of this component of the MBSR program.
These authors reported results from a large (n = 172)
within-subjects MBSR trial conducted among patients
with varied medical conditions at the University of
Massachusetts Medical School. Because they carefully
gathered patient home practice logs and assessed mind-
fulness skills before and after the intervention, the
authors were able to document the importance of home
practice in cultivating mindfulness skills and the con-
sequent decrease in psychological symptoms. Signifi-
cantly, the Yoga practice (vs. Body Scan and Sitting
Meditation) was clearly most strongly associated with
improvements in psychological well-being, and reduction
of both perceived stress and psychological symptoms. It is
especially noteworthy that Yoga – involving movement
and physical activity – was most effective in reducing
psychological symptoms, a finding consistent with a
previous study by Kabat-Zinn, Chapman-Waldrop, and
Salmon (1997).
Given the apparent impact of Yoga on MBSR out-
comes, a more detailed analysis of this aspect of the
64 Salmon et al.
program is warranted. To date, however, neither of the
two asana sequences have been systematically analyzed
either descriptively (i.e. in terms of the movements
involved) or functionally, in terms of possible reasons
for their positive impact. Since physical inactivity is a
common problem, both within the medical and general
population, it would be helpful from both a clinical and
research standpoint to know more about the potential
benefits and possible liabilities of this intervention
element. However, relatively few clinicians with tradi-
tional academic programs have any experience from Yoga
practice, and fewer still have pursued formal study and/or
certification. And even for those who have such back-
grounds, working with diverse patient groups comprises a
particular challenge. And yet, simply as a form of physical
activity, Yoga offers sufficient benefits to those with both
physical and psychological health problems to warrant
taking time to acquire firsthand knowledge and experi-
ence with it. As summarized by Buckworth and Dishman
(2003), physical activity is low in cost and can be done just
about anywhere; is essentially devoid of adverse side
effects and negative social stigmata; and has well-
documented effects on health and disease risk reduction.
Our discussion of the MBSR Yoga sequences is
conducted with these issues in mind. We address the
following questions: First, how does the Yoga component
correspond to generally accepted practice standards?
Second, are these sequences designed in such a way that
they can be practiced safely by patients with a wide range
of medical conditions? Third, what would be the
minimum amount of training and experience needed
by clinicians who want to incorporate Yoga into mind-
fulness-based interventions?
Several excellent texts are available as background re-
ferences, among them works by Desikachar (1999),
Coulter (2001), and Iyengar (1997). Although differing
considerably in detail and teaching approaches, the views
of these tend to converge on several key points. First,
focused attention is a key aspect of effective Yoga practice.
Second, beneficial effects of Yoga depend on careful,
deliberate, and persistent practice, emphasizing correct
form and breathing, and attention to moment-by-moment
sensations as they arise in the course of sequences of
postures. Third, Yoga has more to do with exploring capa-
bilities and limits in a non-judgmental way than perfor-
mance of physically challenging poses. In fact, a guiding
principle articulated by Desikachar (1999) is to qstart
where you are,q which is intended to convey the import-
ance of working within existing physical boundaries, which
tend to broaden and become less confining over time.
Yoga is generally practiced in systematic sequences of
asanas based on five 'families' of physical movements.
These include a) forward bends; b) backward bends; c)
side twists; d) lateral (side) flexion; and e) axial extensions
(lengthening the spine; Coulter, 2001). All of these
movements involve the spine, the key component of the
axial skeleton. Yoga sequences typically consist of asanas
incorporating all of these movement patterns throughout
a full range of spatial planes and physical orientations.
Focused attention and controlled breathing are essential
to proper practice. Attention – mindfulness – helps keep
one anchored in the ‘here and now’ and also enhances
processing internal (proprioceptive, kinesthetic) and
external (visual, auditory/vestibular) cues that contribute
to physical alignment and posture. Controlled breathing is
important for several reasons. First, it provides an anchor
point for attention, as is also true in sitting meditation.
Second, it helps regulate the pacing of asana movements
to keep them from becoming either too fast or slow. Third,
conscious regulation of breathing helps control the
balance of sympathetic and parasympathetic activation,
the latter increasing in prominence as the breath deepens
and slows. Finally, learning to ‘breathe into’ asanas –
especially physically challenging ones – often enables one
to move deeply into physical configurations that are
inaccessible when breathing is shallow and tense. These
general principles are embedded within the MBSR
program, within the broader context of mindfulness.
Hatha Yoga is introduced at two points in the MBSR
program: During the third of eight weekly sessions, then
again two sessions later. The first sequence is intended not
only to encourage physical activity for its own sake, but
also to promote 'mindfulness in motion,' the idea of
bringing focused attention to slow deliberate movements.
Participants are encouraged to do each sequence in a
deliberate manner, focusing on physical sensations
associated with moving into, through, and out of each
asana. This is potentially helpful for several reasons: it
provides a focal point for one's attention, and it allows
moment-by-moment exploration of integrated movement
patterns involving many different muscle groups impor-
tant in everyday activities such as walking, lifting,
balancing, and turning.
The first sequence involves a series of prone and
supine positions beginning and ending with participants
lying on their backs in savasana, the ‘corpse’ pose. (Yoga
poses have descriptive and often highly evocative Sanskrit
names. Entering into a pose, one is encouraged to
embody characteristics of the object represented by the
name.) The second sequence is a series of poses that
begins with a fundamental standing pose, tadasana
(‘mountain’ pose) and ends with savasana. Each
sequence is approximately 45 minutes in length. In both
sessions, the poses are demonstrated by the instructor
while participants do them as best they can, making
allowances for whatever physical limitations may interfere
with range of motion, balance, strength, or mobility.
Given that the average class size of some MBSR programs
 Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice
is between 25 and 40 participants, it is not possible for
instructors to provide individualized feedback to partici-
pants. Instead, program instructors consistently empha-
size the importance of working within one’s particular
physical capabilities and limitations, using the experience
as an opportunity for mindfulness practice. This tends to
defuse any tendencies to treat the Yoga as a purely
physical practice or as an offshoot of the unfortunately
prevalent “no pain, no gain” school of thought.
The instructor provides an ongoing commentary
throughout the duration of the session, describing the
movement into and out of each asana in detail, and
commenting frequently on the importance of moment-
by-moment attention. In general, the poses are not
especially challenging from a physical standpoint, and
have much in common with what one might expect to
find in a very basic Yoga class. In fact, the asanas which
comprise MBSR Yoga are in some ways preparatory to a
regular class, since they consist primarily of extremely
basic standing, sitting, prone, and supine postures.
Nonetheless, even such apparently simple postures can
pose extreme physical challenges for certain individuals,
and it is important to keep in mind that they were selected
to begin with as being relatively accessible to a wide range
of medical patients in a hospital setting.
Participants are encouraged to 'work at their own
level,' relying essentially on internal proprioceptive feed-
back to gauge the suitability and safety of doing the
various poses. They are also encouraged to notice, and be
respectful of, physical 'boundaries' or limits that arise in
the course of doing the asanas as a result of one's
particular degree of flexibility and mobility. The idea that
is conveyed is to work within safe boundaries, but at the
same time allow oneself to 'move up to' and explore
sensations denoting a level of physical intensity that may
signify a beneficial degree of stretching or movement that
goes somewhat beyond one's habitual level. This emphasis
on inner-directed attention is in fact a powerful and
important aspect of the practice because it helps
participants become increasingly familiar with their own
physical capabilities and limitations.
Although instructors are expected to provide general
oversight as to correct and incorrect ways to do each Yoga
sequence, participants are actively encouraged to work
within personal limits to minimize risk of over-stretching.
It should be pointed out in this context that instructors
make a point of saying that doing the Yoga poses entails a
personal decision that takes into account one's knowledge
of the potential risks and benefits of doing so. It is
recommended as part of the pre-program screening that
participants confer with a physician or physical therapist
about any back or neck problems prior to starting the
practice and medical authorization is a required pre-
condition for participation in the program.
65
Following the instruction session during the third class,
participants are asked to do the Yoga on days that
alternate with the body scan, using an audio tape or CD
which provides guided instructions. Unlike some Yoga
practices (Iyengar Yoga in particular), MBSR-based Yoga
does not make use of any special props or ancillary
equipment. It is recommended that home practice be
done in a safe area on a soft, non-slip surface (for which a
Yoga mat would be ideal). The poses themselves have
been selected so as to minimize inordinate physical
demands. The rationale behind such a 'minimalist'
approach is threefold: first, it helps avoid establishing
perceived barriers to practice by emphasizing simplicity.
Second, it characterizes the Yoga as an opportunity for
mindfulness practice, where perceptual clarity is of
greater importance than physical activity itself. Third, it
minimizes physical demands in order to create a safe
environment for program participants and instructors
alike.
The second Yoga sequence is traditionally introduced
during the fifth week of the program. Doing so provides an
expanded repertoire of asanas, providing participants with
an alternative sequence that can subsequently be incor-
porated into one's personal mindfulness practice.
Although there is some overlap between the two
sequences, they are sufficiently distinct to expand the
range of stretches to incorporate a wide range of physical
capabilities and inclinations. As is true with the first
sequence, the emphasis is on doing the practice in a
focused, deliberate, mindful manner. Each sequence ends
with a quiet rest period – savasana, the 'corpse' pose –
done in a supine position, with the focus of one's attention
on the breath. The Yoga sequences are illustrated in Kabat-
Zinn (1990), and we recommend that they be studied in
detail by anyone considering incorporating them into an
MBSR-based intervention. Our purpose in describing the
two sequences here is to point out general characteristics
and qualitative aspects of the practice. For readers who
may be interested, we have prepared an analysis of both
sequences in tabular form that lists the common asana
names and types of movement involved (see p. 9).
Sequence I
The first sequence begins and ends in a quiet resting
pose known as savasana, the ‘corpse’ pose. This is
intended to encourage focused attention and relaxed
awareness prior to and following active movement. Both
MBSR Yoga sequences end with a period of sustained rest
in savasana. Beginning the Yoga practice this way links it to
the preceding body scan, which involves selectively
directing attention throughout the body while in a
prone position, assisted by a guided narrative that
encourages both awareness and acceptance of any
physical sensations as they arise.
66 Salmon et al.
From savasana the sequence evolves into a sequence of
asanas that is smooth and well integrated, in the sense that
there is no need for major postural shifts when moving
from one position to another. The fact that all are done
on the floor, in either a prone (lying on the belly) or
supine (lying on one’s back) position avoids radical
postural changes. Moreover, since in either orientation
much of the body’s weight is supported by the floor,
physical exertion is comparatively minimal. A number of
the poses in sequence I involve bending forward by
hinging at the hips while lying on one’s back. We refer to
these as ‘forward bends,’ even though posturally these
movements are quite different from bending forward
while standing erect, the usual way to teach forward
bends. Perhaps the term ‘upward bends’ would be a more
apt description, since the direction of movement in either
upper or lower body is away from the floor and against
gravity. This is an excellent way to build both strength and
flexibility in core (mid-section) musculature, in prepara-
tion for doing standing forward bends, which are
introduced in the second Yoga sequence.
If there is any major obstacle to doing this sequence, it
primarily involves the ability to safely get down on and up
from floor level, something that many people are
physically unaccustomed to. Shifting from an upright to
a horizontal position can also cause a sudden alteration in
blood pressure, resulting in dizziness or light-headedness,
if the transition is too sudden.
This Yoga sequence incorporates all five of the
standard families of Yoga poses: forward bends, back
bends, axial extension, lateral bends, and side twists. In
keeping with good Yoga practice, it makes systematic use
of ‘counter poses’ – asanas involving movement in a
complementary, often opposing direction to a primary
pose. For example, forward bends are generally coun-
tered with back bends, whereas back bends (as well as
axial extension, lateral bends, and side twists) are
normally countered with forward bends. The purpose of
including counter poses is to achieve balance and
symmetry in movement, strength, flexibility, and range
of movement. Sequence I is most heavily weighted with
poses that involve flexing at the hips, (as in standing
forward bends), followed by axial extensions, back bends,
and twists and lateral bends (one each). Since flexing at
the hips is a standard counterpose for the other categories
of asanas, it is not surprising that movements of this
nature are most prominent. This sequence helps foster
strength, flexibility, and range of motion in the central
core area of the body, where weak low back and
abdominal musculature create postural and musculoske-
letal problems for medical patients and non-patients
alike. Emphasizing these areas to begin with, in a way that
utilizes the floor to provide supportive stability and reduce
weight bearing, is an important feature of this sequence,
because it provides a solid foundation for the second Yoga
sequence which emphasizes standing (upright) positions.
In keeping with the underlying theme of the MBSR
program, this Yoga sequence is done slowly and mindfully,
with emphasis on noticing sensations that arise and
diminish throughout the sequence of movements.
Sequence II
Much of what has been said about the first MBSR Yoga
sequence applies to the sequel, except that many of the
poses are done while standing, emphasizing extension of
the spine and upright posture. Assuming an upright
posture places added demands on abdominal muscula-
ture in terms of both postural stability and weight bearing,
so it makes sense that this sequence follows the first, which
emphasizes asanas that help develop the core area.
Moving from a horizontal to vertical orientation provides
new opportunities to practice mindfulness in motion –
noticing, for example, the sensations associated with
standing upright and maintaining one’s balance while
moving in a deliberate manner. This sequence ends with a
progressive series of asanas that culminate in lying on
one’s back in savasana, which, like its predecessor, is
followed by a period of quiet rest and mindful breathing.
Both Yoga sequences emphasize movement in and out
of each pose done in a slow, deliberate, and continuous
manner, establishing a constant smooth ‘flow’ that
promotes effective blood circulation and minimizes risk
of over-exertion that can develop when poses are held
for an extended period of time (i.e., ‘static’ poses).
Although there is no clear demarcation between a ‘warm
up’ phase and the remainder of the session, the most
challenging poses occur toward the end of the sequence,
preceded by preparatory asanas that engage the neces-
sary musculoskeletal structures. The continuity achieved
by this pacing is somewhat attenuated by frequent
instructions to rest between postures, either by lying on
one's back or in another comfortable position, and focus
on movement of the breath. On balance, the fact that
this sequence is taught to medical patients who may be
severely limited not only posturally but also in terms of
endurance, to some extent overrides concerns about
sequencing ‘flow.’
Overall, our experience teaching this program to
medical patients is that it provides a useful introduction to
Yoga that is generally safe and satisfying. Participants are
encouraged to practice mindfully, carefully observing how
their bodies respond to moving and stretching. However,
when teaching these sequences in a group setting, it is
important to know that there are marked individual
variations in strength, balance, posture, flexibility, and
range of motion that need to be taken into account.
Experienced teachers frequently suggest ‘release valves’ –
less demanding but related postural variations of specific
 Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice
poses – as alternatives for individuals who find the regular
poses unduly challenging. Severely deconditioned indivi-
duals often require additional preparation with respect to
range of motion, strength, and balance before under-
taking this sequence, which can be daunting to someone
who has never done Yoga before, despite the overall mild
intensity of the poses that comprise the sequence.
Perhaps the most important principle with respect to
teaching either sequence is taking nothing for granted in
terms of the physical capabilities of program participants
to perform even very basic asanas.
Those who work their way through both Yoga
sequences develop an appreciation for subtle aspects of
carefully regulated movement and breathing, and as a
result show an interest in further developing their
practice after the program concludes. We maintain a list
of experienced teachers whom we recommend for this
purpose, in much the same way that anyone wishing to
deepen their meditation practice can be referred to
appropriate teachers. This is especially important in light
of the fact that deepening a Yoga practice typically
progresses into increasingly challenging inner landscapes
of physical sensations and cognitive reactions necessitat-
ing great patience and a tolerance for postural novelty to
work through. In the MBSR program, participants are
advised to ‘work within their own perceived limits’ when
practicing asanas, a prudent recommendation given the
lack of individual attention that is possible in this context.
Going into, and perhaps even beyond such perceived
physical boundaries, is a task better left to practice with a
skilled and experienced teacher.
The MBSR program provides a safe and effective
introduction to Yoga, which if practiced regularly can
provide a good foundation for further refinement.
We have prepared a table of both MBSR Yoga sequences
that identifies and describes the individual poses, provides
their Sanskrit names, and identifies the type of movement
involved (forward bend, backward bend, axial extension,
twist, lateral bend). Interested readers are invited to
contact the corresponding author for a copy. Overall,
the sequence of asanas employed in this program
incorporate a number of positive features, along with
areas of possible improvement. To place the MBSR-based
Yoga practice into a broader context, we propose a
framework developed by well-known teacher and writer
T.K.V. Desikachar (1999). His influence on contempor-
ary Yoga practice is substantial, and notable for a down-
to-earth orientation making it accessible to a wide range
of practitioners. His recommendations are helpful in
structuring one’s Yoga practice, and may be useful as well
in terms of providing general guidelines for use in
clinical research applications. Both MBSR-based Yoga
sequences implicitly incorporate these 5 straight-forward
recommendations.
67
1. ‘Start where you are’ (vinyasa krama): Program
participants are encouraged to be accepting of their
current mind/body state and to work patiently
within whatever limitations they experience. Both
in-class and home practice sessions are treated as
opportunities to qbe where you are,q which further
implies the importance of present-moment, focused
attention when doing Yoga.
2. Begin by ‘loosening’ the body: Virtually all forms of
Yoga practice begin with preparatory, or 'warm up',
asanas that prepare body and mind for more
challenging work. This practice is akin to warm-
ups in preparation for any type of physical activity,
the purpose of which is to establish a coherent and
integrated psychological, physical, and metabolic
preparatory context. In the MBSR program, the
sequence begins with positions that are not overly
challenging, then move on to somewhat more
demanding poses, none of which however go
beyond the level of a typical introductory Yoga
class. There is a sufficient amount and variety of
movement to engage most of the major musculos-
keletal units in both sequences.
3. Incorporate counter poses into Yoga sequences:
Counter poses are described by Desikachar as
helpful for counteracting the effects of certain
strenuous poses (Desikachar, 1999, p. 26). The idea
of a 'counter pose' is that movement in one plane or
direction should be counteracted by movements in
the opposite direction. For example, forward bends
complement back bends, and vice-versa. Given that
relatively few asanas in either sequence are highly
strenuous, there may not be as great a need for
counter poses, but both Yoga sequences make
liberal use of forward (upward, if supine) bends,
which comprise the most common form of counter
poses.
4. Practice dynamic (moving) poses prior to doing
static poses: The rationale for this recommendation
is that static poses are more demanding from both a
physical (strength) and metabolic standpoint. Static
poses entail supporting partial or total body weight
without movement, similar (though not identical)
to isometric exercises. Static poses entail reduced
circulation because of the absence of the pumping
action of muscles that are necessary for venous
return, especially from the lower extremities. In
general, it is recommended that beginners hold
static Yoga poses for only a few seconds, a practice
followed in the MBSR Yoga sequences. In fact, the
MBSR sequences in general have dynamic qualities:
few poses are held for any length of time, seldom
more than two or three breaths. The overall pace is
slow, however, as far as movement in and out of
68 Salmon et al.
poses is concerned. Perhaps in recognition of the
fact that most program participants have little
experience doing Yoga, the sequence has been
developed in such a way that it does not place
inordinate demands on postural or circulatory
capabilities, while at the same time offering a
degree of challenge that can help sustain motiva-
tion and interest.
5. Balance major poses with simpler counter poses:
This recommendation is intended to complement
the effects of doing asanas in any given direction or
plane of movement via movement in an opposing
direction. Because of the overall low demand
characteristics of the MBSR sequence, this does
not appear to be as much of a potential problem as
might be the case with a more challenging
sequence. But it is worth pointing out that both
MBSR Yoga sequences include requisite counter
poses that appear to provide a good balance of
opposing movement and stretching patterns.
F. Yoga and Mindfulness: Clinical Significance
Yoga is an integral element of the MBSR program.
Because the program originated in a medical setting, Yoga
was originally incorporated as a gentle means of counter-
acting disuse atrophy prevalent in patients and more
generally in our sedentary culture. As described by Kabat-
Zinn (2003a) this characteristic complemented the known
ability of meditation to reduce autonomic nervous system
reactivity. These two ‘ancient consciousness disciplines’ (p.
86) were united through the common link of mindfulness.
Kabat-Zinn is careful to emphasize mindfulness in Hatha
Yoga practice, clearly differentiating it from “physical fitness
dressed up in spiritual clothing,” (p. 87). He places less
emphasis on precise form and technique than on a sincere
intention to be present and awake to oneself on a moment-
by-moment basis, regardless of one’s physical capabilities.
“Mindful Yoga is a specific attitude and attentional stance
that we bring to our practice, both on the mat and in daily
life: namely, a refined, moment-to-moment non-judgmen-
tal, non-striving attending to the entire range of our
experience” (p. 89).
From this perspective, Yoga is clearly well characterized
as ‘mindfulness in motion,’ an opportunity for sustained
attention to body and breath during a progressive
sequence of postural configurations. Attention may be
directed as well to thoughts and emotions that accom-
pany, and are often stimulated by, movement, an
important manifestation of the mind/body connection.
Yoga practice centers on a tangible, physical base for
exploring physical capabilities and limitations. It gener-
ates a steady stream of proprioceptive and interoceptive
cues that collectively contribute to a felt sense of move-
ment in space, demarcated by the particular physical
capabilities and postural boundaries of each individual.
Making these sensations the focus of one’s undivided
attention is the embodiment of mindfulness practice. An
added benefit of this style of practice is that it can help
lessen the likelihood of injury or overuse, given that
participants are encouraged to work very deliberately to
stay within boundaries they sense or know to be safe.
It is interesting to think in terms of how Yoga and other
movement practices could form the foundation of a
psychological developmental progression leading
inwardly toward cognitive refinements that are depen-
dent on earlier stages, analogous to how Piaget's stages of
cognitive development begin with overt physical activity.
Movement-based interventions have been implemented
for victims of torture (Harris, 2007), and could potentially
serve as here-and-now ‘grounding techniques’(Crosby,
Mashour, Grodin, Jiang, & Osterman, 2007) for PTSD and
other trauma patients. In the context of the MBSR
program, Yoga may serve as a catalyst or foundation for
subsequent cognitive processes related to meditative
awareness. At the very least, Yoga may become the salient
focus of attention because of the way that movement is
intrinsically interesting – many people who find sitting
meditation too formal, boring or forbidding take quickly
to movement patterns that are done with care and
attention. Movement itself seems to have a stimulating
effect, both in terms of the body’s involvement and
perhaps also in terms of certain cognitive processes of
awareness that are stimulated – increased alertness,
awareness, etc. which has obvious survival value.
Movement has a way of capturing present-moment
attention in a manner that static, sitting meditation does
not. When you are sitting still, it is easy to let your mind
wander because of the fact that you do not have to keep
track of your body’s position in space or of the
environmental context in which behavior is occurring.
Sitting promotes resting, and perhaps a relaxation of
focused attention, unless one is deliberate about engaging
it. On the other hand, movement often sharpens sensory
awareness, especially when one is doing things for the first
time, or engaging in behavior patterns that involve skilled
activity. Even something ‘simple’ like tying one’s shoe can
become the center of focused attention. Of course, many
behavior patterns and sequences become automated over
time, leaving the mind free to wander, as is the case when
one is ‘just sitting.’ But engaging mind and body is
relatively easy in the practice of Yoga, which continually
offers new challenges and possibilities in the sense of a
practically infinite number of asanas and development
levels that can be experienced.
G. Final Issues: Clinical Practice & Research
One of the main reasons that Yoga should be of interest
to MBSR-oriented clinicians is that it offers an especially
 Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice
compelling opportunity to practice mindfulness. This
distinguishes it from both purely physical activity or
exercise (somatic interventions) and cognitively-oriented
practices such as relaxation, and more traditional stress
reduction practices. Conceivably, almost anything that
one can do presents an opportunity to practice mind-
fulness, but there are several aspects of Yoga (and related
somatic activities including Tai ‘Chi and ‘Chi Gong) that
represent a unique convergence of beneficial therapeutic
elements, as suggested by La Forge (2005, p. 5). Among
these are: a) present moment, process-oriented focus; b)
awareness of inner states (i.e. proprioceptive and inter-
oceptive cues); c) using the breath as an anchor point; d)
specific patterns of postural alignment; and d) sensitivity
to the flow of movement-based energy (prana, ‘chi’). All of
these factors emphasize awareness and focused attention,
the essence of mindfulness.
The structural properties of the two Hatha Yoga se-
quences in MBSR appear to be well thought out and
generally safe for a wide range of medical patients. The
asanas employed are in general neither overly strenuous,
nor done in a static manner likely to over tax either the
cardiovascular or musculoskeletal systems. The sequences
evolve in a way that promotes smoothly integrated
movement, breathing, and relaxed, yet focused attention.
However, further refinement of MBSR-based Yoga is
needed for clinical research purposes. First of all, the
comparatively limited range of asanas, done at low
intensity levels, may limit potential clinical improvements
in strength, balance, mobility, and range of motion. At
minimum, careful specification of asana sequences,
verification that program participants are actually doing
these sequences correctly, as well as pre- and post-
intervention assessment of specific outcome parameters
would all be necessary to ensure adequate evaluation of
the intervention. Moreover, since MBSR-based Yoga
emphasizes mindfulness to a greater degree than physical
changes, consideration should be given to developing
movement-oriented mindfulness measures. In addition,
despite the relative safety of MBSR-based Yoga and its tight
integration with the overall program, one currently
unresolved issue has to do with teacher training and
experience. At the present time, there does not appear to
be a clear consensus as to whether MBSR teachers need to
be certified as Yoga instructors; in all likelihood, most are
not, nor was the program really designed with this
requirement in mind. Only very general guidelines have
been proposed; for example, Brantley (2005, p. 138)
simply advocates “…significant personal experience with
Yoga practice…” to complement more formal MBSR
training.
One option would be to incorporate certified instruc-
tors in MBSR program classes to teach that element of the
program, but this would detract from the continuity that
69
comes from having a single instructor who is well-steeped
in the conceptual model underlying the program. More-
over, even among certified Yoga instructors, formal
experience with mindfulness is rare. On the other hand,
requiring MBSR instructors to become professionally
credentialed as Yoga instructors with one of the various
accreditation groups is equally problematic and probably
needlessly complicated.
A reasonable middle ground is to recommend that
current or aspiring MBSR teachers acquaint themselves
with basic principles of Yoga through any number of
helpful texts (Coulter, 2001; Iyengar, 1997; Lasater, 2003).
Of particular note in this regard is a recently published,
beautifully illustrated text (Kaminoff, 2007) on the
anatomical basis of Yoga movements. Furthermore, they
should obtain first-hand experience with Yoga by enrol-
ling in classes taught by skillful teachers. Experienced
Yoga teachers are highly sensitive to how individual
students respond to their directives, and it is clear that
MBSR teachers need to have some background and
experience with body-oriented practices in order to know
something about how to work with person-by-person
variations. Such exposure could also be achieved by
incorporating more detailed information and instruction
about Yoga as part of MBSR training programs by
instructors who are steeped in both traditions. This
approach is consistent with the professional training
model proposed by the Center for Mindfulness in
Medicine, Health Care, and Society for those who wish
to become MBSR teachers: Included in the minimum
qualifications are three years experience with Hatha Yoga
and/or body-centered awareness disciplines (Santorelli
and Kabat-Zinn, 2007).
For clinicians willing to invest the time and energy to
become immersed in Yoga practice and philosophy, the
potential payoffs are substantial. Yoga incorporates
elements of traditional psychological relaxation techni-
ques that elicit the Relaxation Response. It provides an
alternative means of achieving this state, adding flexibility
to one’s clinical repertoire of relaxation practices. Slow,
repetitive movement patterns help entrain physiological
factors (breathing synchrony, heart rate, etc.) easily
disrupted by stress, creating a satisfying sense of physical
integration. The deliberate, slow pacing of Yoga as
practiced in the MBSR program provides a wonderful
setting for mindfulness practice, offering a wealth of
kinesthetic, proprioceptive, and interoceptive cues for
focused attention. For many people (clients and clinicians
alike!), Yoga offers an accessible means of cultivating
physically graceful movement patterns that not only feel
good, but can help bolster feelings of well-being,
particularly among medical patients who often discover
that they possess physical capabilities not previously
utilized. And as a means of providing a unified body/
70 Salmon et al.
mind experience, Yoga has few equals. The combination
of deliberate movement and inner-directed attention can
be quite powerful in creating a sense of being really
‘grounded’ in present-moment experience. And in
contrast to static relaxation techniques, Yoga offers certain
potential benefits associated with physical activity, includ-
ing improved flexibility, balance, range of motion, and
strength. And finally, clinicians who cultivate Yoga
practice may discover that it provides them with a way of
connecting with clients that minimizes extraneous verbal
interactions and instead uses the shared experience of
calming and centering movement patterns to build
rapport and enhance therapeutic communication. Even
brief periods of Yoga can help create an atmosphere of
relaxed congeniality that enhances the quality of ther-
apeutic interactions.
A second issue for further consideration concerns the
potential of the MBSR Yoga program as a reference point
for future research studies. To our knowledge, it is the
only extant Yoga program incorporating a standard
sequence of asanas that has been systematically adminis-
tered to and practiced by literally thousands of medical
patients and other MBSR participants. Moreover, the
asanas are embedded in a cognitive framework emphasiz-
ing mindfulness, which helps to unify mind/body aspects of
the practice. Use of this protocol as a starting point for
Yoga interventions is attractive, because it provides a
useful working model that can be adapted for specific
clinical and research applications, as recently endorsed by
Yang (2007). We recommend that researchers and
clinicians alike give serious consideration to using
MBSR-based Yoga as a foundation for their work.
There are promising signs that MBSR-based Yoga is
beginning to be systematically implemented in specific
clinical settings: For example, the Mindfulness-Based
Cognitive Therapy (MBCT) for Depression protocol
developed by Segal et al (2002) incorporates Yoga
sequences in a consumer-oriented book that includes a
CD for guidance. This is a promising start, one that would
lend itself well to empirical investigation. However, new
studies that specifically address physical, physiological,
and mindfulness-related aspects of Yoga are needed as
well. Measures of flexibility, joint mobility, strength,
balance, and range of motion could be used to assess
changes over time in key parameters of movement and
posture. The hypothesized effect of Yoga on vagal tone is
in need of empirical verification, via measures of heart
rate, heart rate variability, and blood pressure. Alterations
in breathing patterns commonly associated with Yoga
could readily be documented via basic psychophysiologi-
cal instrumentation. Cardiac and respiratory measures
could be combined to assess respiratory sinus arrhythmia
(Porges, 1995), a pattern in which heart rate increases
slightly on the in-breath and decreases slightly on the out-
breath, that may be useful as an index of vagal tone
(Grossman and Taylor, 2007). Additionally, to the degree
that Yoga practice may foster mindfulness and attention,
measures of mindfulness should be incorporated into
outcome studies.
Yoga adds a contemplative element to physical activity,
and is an integral component of the MBSR protocol
because of its natural affiliation with mindfulness. Based on
documented success rates, low attrition rates, and lack of
resultant physical injury, it appears that MBSR is a relatively
safe intervention when used as described in MBSR program
documentation. Eventually, outcome studies will begin to
appear that employ a relatively consistent format for the
practice of Yoga, and perhaps the MBSR program could
serve as a model. As far as health-related applications are
concerned, emphasis should be on sequences that can be
practiced by relative beginners who are facing often
significant physical challenges. Potential benefits of Yoga
practice for such individuals include the following: 1)
manageable physical challenges that should help build
confidence along with improvements in physical status; 2)
reduction of stress reactivity associated with the impact of
illness on both the autonomic nervous system and HPA axis;
3) an opportunity to learn about one's personal physical
capabilities and limitations in a relaxed, supportive atmo-
sphere. From a motivational standpoint, these positive
characteristics are likely to encourage participation as well
as ongoing adherence. Ultimately, however, the acceptance
of Yoga as a viable intervention in the context of
contemporary healthcare systems will depend on clinical
outcome research using methodology that permits valida-
tion and replication through careful specification of
practices and procedures.
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Address correspondence to Paul Salmon, University of Louisville,
Department of Psychological and Brain Sciences, University of
Louisville, Louisville, KY 40202; e-mail: psalmon@louisville.edu.
Received: December 13, 2007
Accepted: July 27, 2008
Available online 17 December 2008