Safe or Unsafe? Yoga and the Medical Establishment

Looking at Yoga from a feminist perspective, we can gain more in our understanding of its effectiveness when we consider it as a system or a science, as well as shine a light on the inadequacy of allopathic medicine and science to fully articulate the holistic base of practices on which Yoga’s therapy relies. This blog article analyzes some questions and controversies concerning Yoga as a medical treatment. In my book in Chapter 2, I discuss how women’s bodies have historically been under the control of science and medicine, and how in the women’s liberation movement, they sought greater self-knowledge, control of, and to care for their bodies. By looking at some of the misunderstandings surrounding the effectiveness of Yoga practice, as well as some of the important legal considerations, my hope is that others will be more informed and able to participate in further discussions of how Yoga, along with other CAMs (complementary and alternative medicines), will be utilized and disseminated therapeutically in the future.

The integrated approach to Yoga (sadhana, abhyasa) is supported by several classical texts and the teachings of modern gurus, and holds sway in Yoga communities and studios today. However, Yoga often looks very different when it is put under the research microscope–it “may help” migraines, or your lower back[1]. Scientific researchers have tended towards viewing Yoga’s practices in an isolated manner, rather than as a system or family of practices; when these studies fail to prove Yoga’s effectiveness, I put forth it is not Yoga which is to blame, but rather research frameworks and the medical establishment itself, which ignores research that is perhaps not so well known. A well-publicized 2011 study was conducted by the Group Health Research Institute in Seattle, Washington, and funded by the National Institute of Health’s Center for Complementary and Alternative Medicine. In the project, which observed 228 adults with chronic low back pain, it was found that Yoga is indeed effective on relieving back pain. However, in numerous articles reported in the mainstream media, they pointed out that attitude/mental effects of Yoga had very little effect, and that it was only due to exercise.

Consider the headline of the Wall Street Journal reportage—”Yoga May Help Low Back Pain. Mental Effects? Not So Much” (2011). Also consider that, as a medical study, the control group was a group who did stretching exercises, while the other group did Yoga. The researchers concluded rather miraculously that stretching was equally good for the body in both settings, and so their conclusion was that Yoga’s benefits are due purely to the stretching. Finally consider that the people in the study who were “doing Yoga” were not exposed to the full menu of Yoga practices and teachings that are available to those who study with a teacher at a studio. The study did not reveal what kind of practice the Yoga entailed, who the teachers were, what their training was, or how they employed philosophical teachings from Yoga which are meant to accompany exercise. Yoga has for years been considered a mind-body practice, and yet science is still grappling with whether there are any attitudinal effects of its practice.

Have all forms of Yoga practiced in the United States completely removed its meditational and philosophical components? The sample sizes of studies on Yoga exercise and meditation may be statistically significant, but the research design is fundamentally flawed, in that it fails to examine how Yoga exercise cannot be separated from its other practices and/or mental and emotional benefits. In many cases, researchers claim, as Australian medical researcher Hylton Menz admits, that “it is just that there isn’t a lot of research to go on” (Wehrwein 2011), or more than likely, that the medical establishment has not informed themselves on the relevant studies on Yoga. When asked about non-medicated or “alternative medicine” for migraine problems, Boston-based Dr. Paul Rizzoli, who co-authored The Migraine Solution published by Harvard Health Publications and St. Martin’s Press, communicated that “Yoga is a personal favorite of his for his patients… because it is widely available, affordable, and very likely has benefits beyond migraine” (Wehrwein). A simple search on PubMed or other medical databases returns at least 2-3,000 peer-reviewed articles on Yoga-related medical studies, two to three hundred on women and Yoga specifically, and yet the medical establishment persists in backing the dominant viewpoint that Yoga’s claims may be ineffective both physically and mentally. In the medical studies involving women, over two hundred peer-reviewed studies indicate that Yoga was found to help with: decreasing pain of all kinds in elderly patients, helping breast cancer survivors with conditions such as lymphedema and chronic fatigue, alleviating insomnia, lessening anxiety, reducing stress, lowering cortisol, lessening fibromyalgia, helping with menopause, increasing positive body image, decreasing eating disorders, along with many others.

Some of the earliest Western medical and scientific experiments on Yoga were conducted in the 1960s, when Swami Rama (founder of the Himalayan Institute of Yoga Science and Philosophy in Honesdale, PA) submitted himself to study by the Menninger Clinic, a psychodynamically-based psychiatric institute in Topeka, Kansas, on several bodily processes (such as breathing and heart rate) that were considered by the West to be autonomic, but which he could control himself. One of Rama’s senior students, and in many ways his successor, Tuganait, shared in his keynote speech at the Yoga Journal Conference 2010 in San Francisco how this kind of experimentation and public display of Yoga’s benefits was very popular in the United States during the 1960s, when several events were held that featured yogis from India demonstrating their physical and spiritual feats.

Swami Rama, along with researchers Ballentine and Weinstock (1976) drew connections between Yoga’s relaxation techniques and those used in modern psychoanalytic therapy; Yoga could provide a progressive relaxation that would be used to open patients up to introspection and reveal what bothers them. “Postures are thought to gradually help those muscles which are tense to relax, which withdraws the energy bound up in rigid musculature making it available for other uses. Moreover, when the voluntary muscles become quiet, one becomes more clearly aware of internal states” (10). They draw parallels to other therapies for which Yoga could be a replacement: autogenic training in Europe used to treat psychosomatic illness, Freud’s couch relaxation for which he abandoned hypnosis, and behavior therapy.[2]

Naturopathy and other alternative healing systems are still vying for recognition by the mainstream and insurance coverage for patients. Yoga, while not covered by health insurance, is still one of the major alternative healing modalities employed. In fact, the way that today’s practitioners relate to and believe in Yoga was heavily influenced by the birth of natural medicine in the early 20th century. Elizabeth DeMichelis describes in A History of Modern Yoga, the importance of Yoga intersecting and developing with the fields of alternative medicine and New Age healing and personal growth (181). Yoga is intimately connected to the rise of natural and alternative medicine; it has been referred to as “complementary medicine” since the 1970s and “integrative medicine” since the 1990s. DeMichelis observes that the changing of the terms over time indicates that these practices are seen as “progressively more acceptable and compatible with mainstream medicine” (183). What she terms “Modern Postural Yoga” falls within one of the five major trends of the New Age movement previously outlined by Hanegraaff—that of “Healing and Personal Growth.” (The other trends are: Channelling, New Age Science, Neopaganism, and the general concept of New Age) (184). DeMichelis notes that “healing” and “health” are described in different ways by different types of medicine. Medical anthropology uses the term “bio-medicine” to refer to allopathic medicine, and “holistic medicine” to indicate non-mainstream, folk, and religious healing, and pre-modern approaches to health and well-being (184).

De Michelis points out the medicalization of Yoga itself, and scientific research in “the health sciences, including areas of (bio)medical research, clinical applications, and sports-fitness disciplines” (25). She writes about how Yoga practitioners increasingly tout it as a “therapeutic” and “holistic” tool to cope with life[3], while at the same time having a history of what Joseph Alter describes as magic, alchemy and sex. Thus, in Modern Yoga, everything from stress reduction, to esoteric models of relaxation (what Mark Singleton calls “relaxationism”) and mystical awareness, have begun to influence and interact with the bio-medical and psycho-therapeutic realms of treatment. De Michelis writes of how Yoga’s modern themes incorporate both of these mystical and more scientific approaches: “Eminently psychosomatic in scope, they also act as “bridges” between strictly biomedical, the psychological, and the more holistic aspects of the contemporary therapeutic explorations of Yoga” (25). Therapy has become a central concept to Yoga in the 20th century, and she notes how in a sense, this emerged from the New Age idea of metaphysical health, promoted from as early as the 1920s.

Yoga’s struggle to prove itself is part of a wider initiative to understand the renewed growth in complementary and alternative medicine (CAM). In 2000, the federal government commissioned the White House Commission on Complementary and Alternative Medicine to research this area and submit relevant policy recommendations to the federal government and Congress. Over 18 months, commissioners (including both CAM and allopathically trained professionals) listened to and read, over 14 meetings, the testimony of over 700 individuals and organizations, as well as over 1,000 written submissions. (I have put a copy of the report in Dropbox. Download here.)

One of the main concerns of the commission is that over the past thirty years people have increasingly started to seek out answers from alternative medicine and that “they are exploring these approaches without valid scientific information to guide them” (White House Commission xi). The people are seeking treatments that are more helpful and have fewer side effects, healing partnerships with care providers rather than a brief consultation, as well as the ability to participate in their own healing. Self-care, prevention, prayer and spirituality were some of the complex topics that were difficult for the committee to address, as they often straddle both traditional and alternative medicine and are difficult to quantify.

The report emphasized the need for information, people’s need to know, and advocated for much more research in this field for the future. Though it opened the door for more holistic approaches to healing, the rather cautious tone of the report seems to emphasize the professional healthcare provider as the one who “knows,” who can distribute information to patients, and there is a huge emphasis on making sure CAMs are “safe and effective,” in spite of thousands of years of evidence in cultures around the world which vouch for both safety and reliability. Thus, while the report’s first of ten concluding points emphasizes the importance of “A wholeness orientation in health care delivery,” the second point requires “Evidence of safety and efficacy” (xvi). The refrain is that “the commission recognizes that most CAM modalities have not yet been scientifically studied and found to be safe and effective” (xvii). The commission is vigilant about the fact that not all treatments can be included in the category of CAM: “It is essential to begin separating the safe from the unsafe and the effective from the ineffective” (xvii).

But just exactly who is to do that separating? The government? The scientists? Or the practitioners and teachers of CAMs with a lifetime of experience and a lineage of teachers that is thousands of years old? The commission claims it is difficult due to the myriad of trainings and certifications. In the view of the government and medical professionals, heterogeneity is dangerous, and standardization is best. CAM cannot be included in the “mainstream health care system” (their words) until more research is done and members of the public get involved in advising federal advisory committees. At the same time, “many people expressed a desire for increased access to safe and effective CAM… Equally important, access is limited by income, since most CAM practices and products are not covered under public or private health insurance programs. Moreover, access is more difficult for rural, uninsured, underinsured, and other special populations” (xxv). And yet, the commission concludes that access cannot improve until scientific research increases. In this paradigm, all successes hinge upon an increase in scientific research rather than looking at research that has already been done by CAM practitioners through experience and/or alternatively documented studies.

While repeatedly emphasizing the need for more scientific evidence, the commission also legitimately attempted to take a holistic approach in its recommendations, acknowledging the person in “biopsychosocial” terms “shaped by attention to the mind, body, and spirit of each person, and to the social and ecological world in which we all live” (xii). On the whole, it uncovers at a deep philosophical level the difference with which CAMs approach healing and people’s inborn capacity for healing. The commission emphasizes information, education, health promotion and self-care, in addition to the individuality, preferences, and even dignity, that different persons require. Additionally, from a practical standpoint, it recommends that the National Center for Complementary and Alternative Medicine should collaborate with various federal agencies and organizations such as the Institute of Medicine, National Science Foundation, National Institutes of Health, and the World Health Organization and that dialogue and interaction with conventional medicine should be increased.

Allopathic medicine has made it very difficult for people to find the holistic healing that they speak of, its chemicalization of treatment, its focus on disease rather than health (allopathic over vitalistic or osteopathic), and compounded by its collusion with insurance companies. “The allopathic premise of confronting and excising disease co-opted scientific medicine prior to its full maturation, thus distorted its evolution. Pure technology could equally have been informed by vitalistic or osteopathic principles” (Grossinger 473)[4]. The current “questionable” status of CAMs and Yoga from the viewpoint of the medical establishment (and its so-called lack of valid scientific information) must be seen in the context of the historical erasure of traditional systems of knowledge of all forms (not only medical), in favor of promoting the scientific, technological, and modern. In the view of the commission, it is the CAM which must “measure up”—get IRB approvals, get published in peer reviewed journals, and meet state standards—and though they mention that conventional doctors should get an education in CAM and curricula should be developed to that effect, there does not seem to be any implication that conventional medicine needs to change. Progress is seen in terms of referrals and collaborations, but in this proposal, the two fields remain separated. CAM appears to have a lower status than conventional medicine, and the barriers listed to incorporate it into a standard medical curriculum are steep and numerous.

The report also says that CAM education and training should also develop curriculum that “reflect the fundamental elements of biomedical science and conventional health care,” though this idea sidesteps an elemental quality of CAM, which is that its base very often lies in cultural traditions that are rooted in a worldview which is altogether different from modern-day medicine. It is difficult to discern whether more recognition of Yoga by the medical profession, insurance companies, and scientists is a good thing or not, especially if they are the ones leading this grand “collaboration.” If it means changing the underlying belief structure that Yoga is practiced as a lifestyle or lifepath, which comprises an important cosmological and ethical difference from modern medicine, then maybe it is not such a good thing. It is certainly territory that should be covered, but it will be the willpower, knowledge and strength of the practices that will prove themselves, as CAM practitioners take a stronger role in defining how their teachings benefit practitioners.

Within the past fifteen years, Yoga professionals themselves have taken a more aggressive stance in solidifying its worth as a medical treatment for ailments of all kinds. The International Association of Yoga Therapists (IAYT) is documenting and demonstrating Yoga’s medically therapeutic effects. By creating a new field called Yoga Therapy, they emphasize using the whole system of Yoga for therapeutic purposes. Since most people today tend to think of Yoga in terms of “going to Yoga class,” the IAYT is one avenue through which the Yoga community would like to preserve its holistic nature and disseminate the impacts of a systematic approach to practice. They have organized meetings, offered guidelines on Yoga Therapy certification, and created a list of approximately 200 bibliographies which document studies, research and information from both the medical field and practitioners regarding the use of Yoga for particular ailments. The status of “Yoga Therapist” is an additional certification which Yoga teachers (usually designated by “RYT”-registered Yoga teacher) must obtain and for which they have published guidelines.

In the Yoga Therapy setting, students are “clients” and the Yoga teachers are “therapists” who develop an in-depth treatment plan for them to develop an ongoing practice, more effectively heal with physical problems, and move toward a place of “health and wellbeing.” IAYT has developed and disseminated educational standards for the training of Yoga therapists. The recommended training is informed by Ayurveda (the training seems to be in part based on the already established and extensive training of Ayurvedic specialists) but also teaches an understanding of a wide array of illnesses from an allopathic standpoint, and how to diagnose the specific needs of the patient. Special attention is also paid to the therapeutic relationship, and responsibilities of those involved, so that “appropriate practice strategies” can be deployed (IAYT 2012). This kind of development builds on the level of instruction that is available to students in Yoga classes, deepens their relationship with their Yoga “guide,” and provides a space for monitoring ongoing healing and progress.

At the same time, there are also legal implications to consider, as Yoga is a specific certification, and it can be inadvisable for teachers to administer recommendations for wider health ailments. Lawyer Michael H. Cohen teaches at Harvard Medical School and publishes the Complementary and Alternative Medicine Law Blog;[5] he has listed guidelines for Yoga teachers to keep in mind concerning the legal parameters of their teaching. Cohen’s suggestions (collected from several articles on the matter) are as follows:

  • Acknowledge the limitations of yoga teaching
  • Emphasize the role of licensed health professionals in dispensing health advice
  • Beware of nutritional recommendations, especially involving dietary supplements
  • Appropriately acknowledge students’ health concerns
  • Limit claims to those backed by current medical and scientific evidence
  • Be clear about potential contraindictions [of poses]
  • Stay modest about potential benefits

Since the late 1800’s, medicine in the United States has been governed by licensing laws, and so, while Yoga teachers may feel the urge to recommend a therapeutic approach to illness, they are still beholden to the legal regulations of medicine that are currently in place.

Another important research project is the Yoga Genome Project (YGP), initiated by the Yoga Care Foundation of Austin, Texas, which seeks to gather information from 100,000 Yoga practitioners, in order to “describe different styles of Yoga as effective health interventions” (YGP 2012). Their aim is to utilize a website and survey to collect the information, modeling a nationwide study on a local study they conducted on 519 practitioners in Austin. The research rationale is to create better descriptions of particular styles of Yoga practice, by asking Yoga teachers to describe their practice in exact detail (down to the minutes). From the Austin study abstract:

“We move closer to getting Yoga incorporated into the health care system as we build the evidence base substantiating Yoga as a therapeutic modality that includes a broad spectrum of diverse interventions. The goal of this study was to build a reliable scheme by which different Yoga styles can be categorized and compared, thereby providing an entry point for health care professionals to prescribe Yoga as a lifestyle intervention. This is the first phase of a large-scale survey of Yoga practitioners at studios across the country.”

One of the main goals of the Yoga Genome Project is documentation, and the other is educating health care professionals who may not be familiar with Yoga. With their tag line “Doctors can’t prescribe until yogis describe,” it seems that they are also campaigning to have Yoga be a therapy that insurance will pay for. Though I try to emphasize that environment, study, and growth with Yoga practice over time are the pertinent factors that must be studied to comprehend the full range of its efficacy, this project promises to be a great step for the community itself to document how Yoga is being taught at studios across the country.

There have been major strides in research on meditation, especially in the field of neuroscience, with conferences and organizations built around the intellectual project of discerning meditation’s benefits. Many of these studies are focused on the effect of mindfulness on the brain, and some researchers at the Stanford’s Center for Compassion and Altruism Research and Education have also started to look at how compassion and selflessness function on the neural level in meditating monks. Over 300 scientific papers on mindfulness have clearly demonstrated that those who meditate can reduce chronic pain and stress, and feel safer in the world. Researchers at the UC Davis Center for the Mind and Brain have conducted studies in which chemical changes in meditators presented the potential for repairing cells better (through telomeres) and potentially contributing to longevity (May 2012).

However, every single one of these studies has a significant downfall: isolating Yoga asana and meditation practice in a controlled scientific study does not at all, nor will it ever, account for the myriad of lifestyle choices, adjustments and lessons that come from utilizing CAM’s and their associated wisdom practices as part of a holistic spiritual lifestyle—whether it be as a full-time Zen monk or committed Yoga teacher or student.

Lynette Hunter’s feminist critique of science methodically reveals how “the rhetoric of small groups attempting specific end-directed goals and working from agreed assumptions is common to the entire history of science” (131). In the current case, Yoga and Ayurveda’s emphasis on simplicity and natural medicine, and their growing popularity in all sectors of society, stands in direct opposition to the increased technologization of medicine through the pharmaceutical industry, biotechnology and genetically modified foodstuffs.

Yoga and its allies Ayurveda and herbal medicine are a threat to what Hunter calls “institutional science and technoscience” precisely because they work, the community is growing, and they are getting more aggressive about defending their practices. The Yoga community, through organizations, certifications and research, is today finding new ways to demonstrate how Yoga operates as a holistic lifestyle practice, and disseminate these results to the scientific and medical establishment. One can only hope that in time the medical establishment will begin to acknowledge the incredible strides  Yoga is making in people’s lives.

 

Notes

[1] One controversial article published in the New York Times Magazine was heavily criticized by the Yoga community. Entitled “How Yoga Can Wreck Your Body,” it emphasized Yoga’s “riskiness,” described a dangerous potential for Yoga to cause neck injuries or strokes, and claimed that “many teachers lack the deeper training necessary to recognize when students are headed toward injury” (2012).

[2] In 1937, Yale professor K.T. Behanan studied with Swami Kuvalayananda in India and wrote Yoga: A Scientific Evaluation., emphasizing the medical aspects of Yoga, cosmology, ideas of mental states, psychology, and the postures. Medical and scientific research on Yoga is more common in India as well.

[3] Quotation marks by De Michelis.

[4] From the book Planet Medicine: Origins, for which I assisted the author by conducting research at the UC Berkeley Foster Anthropology Library. I analyzed early European and American ethnographies to categorize indigenous and shamanic medical practices. Grossinger’s describes how multiple lineages of medical traditions from cultures worldwide can contribute to a modern understanding of CAMs. The world’s major medical systems were formed upon the basis of Stone Age medicine, which primitive peoples practiced in conjunction with spiritual practices that considered humans in the context of larger ontological and cosmological structures, than one which looks simply at the body itself.

[5] Blog is online at http://www.camlaw.blog.

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