Education, Faculty of
Educational and Counselling Psychology, and Special Education (ECPS), Department of
DSpace
UBCV
Beveridge, Samantha
Master of Arts - MA
University of British Columbia
Yoga is a mind-body practice that is widely practiced in North America and has demonstrated physical, mental, and emotional benefits, many of which overlap with the benefits of counselling and psychotherapy. Yoga postures, philosophy, breathing, and meditative practices have begun to be used within the counselling paradigm. However, little research has been done on the use and integration of yoga in counselling. This study explored the experience of clients who engaged in counselling that included yoga. Descriptive phenomenology was used to gain a rich understanding of the common essential features of the phenomenon from the participants’ descriptions of their lived experience. Participants included six clients of counselling that integrated yoga (i.e., the use and inclusion of mindful awareness, breath, and bodywork with verbal processing). In-depth interviews and two follow-up member checks were conducted with each participant. Essential themes that emerged include: (1) yoga components: breath, bodywork, body awareness, and mindfulness; (2) counselling component: curious, nonjudgmental verbal processing; (3) integration and transition between components; (4) yoga facilitates processing and regulation; (5) counsellor qualities matter; and (6) this therapy as a whole person, whole life approach. This study contributes to the understanding of this holistic psychotherapy from the client perspective, which gives clients, counsellors, and researchers greater insight and awareness into this emerging integrative practice. Implications for future research and practice in counselling psychology are discussed.
CLIENTS’ EXPERIENCE OF COUNSELLING THAT INTEGRATES YOGA: A PHENOMENOLOGICAL INQUIRY by Samantha Beveridge B.Sc., University of Alberta, 2010 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Counselling Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) August 2015 © Samantha Beveridge, 2015 ii Abstract Yoga is a mind-body practice that is widely practiced in North America and has demonstrated physical, mental, and emotional benefits, many of which overlap with the benefits of counselling and psychotherapy. Yoga postures, philosophy, breathing, and meditative practices have begun to be used within the counselling paradigm. However, little research has been done on the use and integration of yoga in counselling. This study explored the experience of clients who engaged in counselling that included yoga. Descriptive phenomenology was used to gain a rich understanding of the common essential features of the phenomenon from the participants’ descriptions of their lived experience. Participants included six clients of counselling that integrated yoga (i.e., the use and inclusion of mindful awareness, breath, and bodywork with verbal processing). In-depth interviews and two follow-up member checks were conducted with each participant. Essential themes that emerged include: (1) yoga components: breath, bodywork, body awareness, and mindfulness; (2) counselling component: curious, nonjudgmental verbal processing; (3) integration and transition between components; (4) yoga facilitates processing and regulation; (5) counsellor qualities matter; and (6) this therapy as a whole person, whole life approach. This study contributes to the understanding of this holistic psychotherapy from the client perspective, which gives clients, counsellors, and researchers greater insight and awareness into this emerging integrative practice. Implications for future research and practice in counselling psychology are discussed. iii Preface This thesis is the realization of an idea conceived by the author, Samantha Beveridge, who completed all work, including design, participant recruitment, data collection, transcription, analysis, and manuscript write-up. This research received ethics approval from the University of British Columbia’s Behavioural Research Ethics Board. The certificate number of the ethics certification obtained for this study was H14-01106, using the project title Yoga in Counselling. iv Table of Contents Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iii Table of Contents ......................................................................................................................... iv List of Tables ................................................................................................................................ vi List of Figures .............................................................................................................................. vii Acknowledgements .................................................................................................................... viii Chapter 1: Introduction ............................................................................................................... 1 Research Problem .....................................................................................................................1 Purpose of the Study .................................................................................................................3 Study Significance and Expected Impacts ...............................................................................4 Research Question ....................................................................................................................5 Chapter 2: Literature Review ...................................................................................................... 6 Holistic Health Trend ...............................................................................................................6 Inclusion of the Body ...............................................................................................................7 Mindfulness ..............................................................................................................................9 Self-Regulation .......................................................................................................................11 Inclusion of Spirituality ..........................................................................................................13 Current Integrative Therapies .................................................................................................16 Yoga: A Mind-Body Practice .................................................................................................18 Yoga and Mental Health .........................................................................................................20 Yoga in Mental Health Treatment ..........................................................................................21 Yoga in Counselling ...............................................................................................................23 Chapter 3: Research Methodology ............................................................................................ 26 Research Design .....................................................................................................................26 Participants .............................................................................................................................27 Situating the Researcher .........................................................................................................30 Data Collection .......................................................................................................................32 Data Management & Analysis ................................................................................................34 Trustworthiness & Rigor ........................................................................................................35 Ethical and Diversity Considerations .....................................................................................38 Chapter 4: Research Findings ................................................................................................... 40 Overall Theme Structure ........................................................................................................40 Theme 1: Yoga Components, The Inclusion of the Body in a Particular Way ......................41 Breath awareness and regulation. .................................................................................... 42 Bodywork. ....................................................................................................................... 44 Body awareness. .............................................................................................................. 46 Mindfulness. .................................................................................................................... 47 Theme 2: Counselling Components .......................................................................................49 Verbal exploration and processing. ................................................................................. 49 Counselling is curious and nonjudgmental. ..................................................................... 51 Counselling is person-centred and client-directed. .......................................................... 52 v Theme 3: Structure of the Integration of Yoga and Counselling ...........................................54 Theme 4: Inclusion of Yoga Facilitates Bottom-Up Processing and Regulation ...................56 Bottom-up processing. ..................................................................................................... 56 Body as access point to physical sensations, thoughts, emotions, memories. ............. 56 Psychophysiological insight and catharsis. .................................................................. 58 Affect regulation. ............................................................................................................. 62 Use of yoga to calm, relax, ground. ............................................................................. 62 Capacity to be with (uncomfortable) experience. ........................................................ 64 Theme 5: Whole Person, Whole Life Approach ....................................................................65 Whole person approach: Engaging the relationship between mind and body. ................ 65 Profound experience that becomes a way of life. ............................................................ 67 Theme 6: Counsellor Qualities Facilitated Trust in Relationship and Counselling ...............68 Counsellor embodies approach: curious, nonjudgmental, patient, supportive. ............... 68 Trust and comfort in relationship and counselling. ......................................................... 69 Non-essential, Important Patterns in the Data ........................................................................70 Healing through yoga can be a “double-edged” experience. ........................................... 70 Approach to self is accepting. .......................................................................................... 72 Developing an orientation toward: Yoga and community. .............................................. 73 Chapter 5: Discussion ................................................................................................................. 75 Situating the Findings Within Previous Research ..................................................................75 Yoga components, counselling components, and integration. ........................................ 75 Inclusion of the body. ...................................................................................................... 76 Mindfulness. .................................................................................................................... 77 Self-regulation. ................................................................................................................ 78 Counsellor qualities facilitate counselling. ...................................................................... 79 Whole person approach. .................................................................................................. 80 The missing spiritual, philosophical component. ............................................................ 81 Unique Findings of the Study .................................................................................................82 Safety considerations with embodied experiencing. ....................................................... 82 Affect regulation. ............................................................................................................. 85 Orientation toward: Yoga and the social nervous system. .............................................. 87 Relevance of the Findings to Counselling Psychology Practice and Training .......................88 Implications for Future Research ...........................................................................................90 Strengths and Limitations of the Methodology and Study .....................................................92 Conclusion ..............................................................................................................................93 References .....................................................................................................................................95 Appendices ..................................................................................................................................104 Appendix A: Recruitment Letter to Counsellors ................................................................ 105 Appendix B: Invitation to Study for Potential Participants ................................................ 106 Appendix C: Recruitment Poster ........................................................................................ 107 Appendix D: Initial Contact Participant Screening Form .................................................. 108 Appendix E: Consent Form ................................................................................................ 109 Appendix F: Community Resources Sheet ......................................................................... 112 Appendix G: Demographics Form ..................................................................................... 113 Appendix H: Interview Protocol ........................................................................................ 114 vi List of Tables Table 1: Theme structure of the experience of counselling that integrates the use of yoga ......... 41 vii List of Figures Figure 1: Tree of contemplative practices .................................................................................... 15 viii Acknowledgements I would like to acknowledge the six participants who provided their time and insights to the study. I am grateful for their thoughtfulness, willingness, and enthusiasm that made this project possible. My deepest thanks go to these women for making this project an incredibly rewarding and enriching experience. I am deeply grateful to my supervisor, Dr. Marla Buchanan, for tirelessly offering her commitment, expertise, and support. I would like to thank my previous thesis supervisor, Dr. Susan James, for her kindness and creativity that helped initiate this study. I would also like to express my gratitude to my committee members, Dr. Marvin Westwood and Dr. Alanaise Goodwill, for contributing their feedback and encouragement to the process. I would like to acknowledge Katrina Ariel, the yoga teacher who facilitated the transformative yoga experiences that led me to the questions posed in this research. A great teacher can change everything. Her authentic and inspired teaching and her openness to my questions changed my way of being in and relating to the world. Finally, to my friends and family for their endless love, laughter, and wisdom. To the yoga research group for being such a wealth of knowledge and source of support and consultation. To my parents and my dear friends, both near and far, who have been there throughout the process. This endeavour was only possible with your presence, care, and lightness in my life. 1 Chapter 1: Introduction Research Problem The practice of yoga is thriving in North America. A recent study found that 38% of Americans pursue complementary and alternative treatments, including yoga, when looking for ways to approach health concerns (Barnes, Bloom, & Nahin, 2008). Interest in yoga and other alternative practices has been attributed to a desire for holistic approaches to health (Forfylow, 2011). Motivation for practicing yoga includes a desire to improve health and achieve a greater sense of wellbeing (Saper, Eisenberg, Davis, Culpepper, & Phillips, 2004). The body of research investigating yoga is extensive. In the literature, there is great diversity among the types of yoga investigated, the components that make up the yoga, and the purposes and goals of the practice. Nevertheless, empirical support continues to demonstrate the effectiveness of yoga and has documented its therapeutic impact on physical and mental health. Yoga leads to increased flexibility, improved muscle tone, and reduced tension (Khalsa, Shorter, Cope, Wyshak, & Sklar, 2009). Yoga modifies the neurophysiology of the body, including reducing activation of the hypothalamic-pituitary-adrenal axis that is associated with the stress response and increasing activation of the parasympathetic nervous system that is associated with restoring a sense of relaxation and homeostasis in the body (Streeter, Gerbarg, Saper, Ciraulo, & Brown, 2012). Meta-analytic review articles have compiled studies documenting the effectiveness of using yoga practice for clinical concerns, including anxiety, depression, eating disorders, stress, and sleep disorders (e.g., Adams & Puig, 2008; Balasubramaniam, Telles, & Doraiswamy, 2013; Khalsa, 2004). In a study that used a healthy sample, yoga increased trait mindfulness and protected against future vulnerability to anxiety and depression (Shelov, Suchday, & Friedberg, 2 2009). Another study demonstrated that yoga significantly improved women’s energy levels and sense of wellbeing (Narayana & Gopal, 2008). Given the accumulating evidence, it is not surprising that yoga is emerging as a method of choice for those seeking mental health and optimal wellbeing (Forbes, Akhtar, & Douglass, 2011). This trend is also being echoed in the mental health field, with the introduction and incorporation of yoga in treatment. This is both consumer-driven and a result of mental health practitioners increasingly acknowledging the importance of the body in transformation (Forbes, Akhtar, & Douglass, 2011). Research has explored adjunct yoga programs that have been incorporated into the mental health treatment paradigm. Yoga classes and programs are being offered as an adjunctive treatment option on college campuses and in health facilities. These yoga programs have been shown to be beneficial (Milligan, 2006; Balasubramaniam, Telles, Doraiswamy, 2012). Mindfulness-based stress reduction (MBSR) is a well-known and well-supported treatment program that includes yoga that has been available as an approach to alleviate suffering from physical and psychiatric disorders for over two decades (Grossman, Niemann, Schmidt, & Walach, 2004; Kabat-Zinn, 2013). Recently, some mental health practitioners have begun to incorporate yoga in the counselling process (Forbes, Akhtar, & Douglass, 2011; Kocian, 2012). Though this emerging integrative practice is gaining popularity among some therapists and clients, there is little research exploring the use and integration of yoga in therapy sessions. One recent dissertation addressed this gap. In a qualitative study, yoga psychotherapists were interviewed to understand their motivations, how they define this practice, and what their experiences have been (Kocian, 2012). In her findings, the eight participants noted that although yoga psychotherapy needs to be more clearly defined, it is a holistic practice that works with the mind-body connection and 3 facilitates psychological healing. All participants described their yoga psychotherapy practice as including centering (i.e., meditation), breath work, yoga postures, and verbal processing. The psychotherapists found the greatest benefits of yoga psychotherapy included the ability to meet the unique needs of each client, the wholeness of the approach, and the ability to promote inner awareness and healing. Kocian’s (2012) dissertation has provided a deeper understanding of counselling that integrates the use of yoga; however, this area of research and practice is still in its infancy. Further research is needed to continue developing an understanding of this emerging integrative therapy and to ensure this service is provided in the most safe, effective, and ethical way possible. Yoga’s popularity makes it particularly important for counsellors to be aware of, regardless of whether or not they include it in their professional practice (Adams & Puig, 2008). It may be a tool many clients use in addition to other mental health practices, such as exercising, going to therapy, and meditating, and it would be helpful for clinicians to be informed in these popular self-care methods. Researchers encourage interested counsellors to utilize yoga’s demonstrated therapeutic ability through referring clients to yoga classes or using yogic philosophy within sessions; however, they note that future research is essential to better understand the benefits and risks of using yoga within the counselling paradigm (Adams & Puig, 2008; Forfylow, 2011). Incorporating yoga may have the potential to create counselling practices that are collaborative, individualized, and holistic; further research will inform and support this hope. Purpose of the Study More research is needed with a focus specifically on the phenomenon of counselling that incorporates yoga. Kocian’s (2012) dissertation was an important initial step toward fully understanding this integrative practice. Further research is required to unpack the various 4 aspects and perspectives relevant to this phenomenon. Some aspects of yoga counselling that are not yet addressed include the client experience, the minimum training level required for ethical practice, whether mental health concerns differentially benefit from yoga, and if all yoga styles have equal benefits. As yoga’s popularity and integration within counselling processes continue, it is important for the counselling field to match this growth and inform this practice through research (Behrman & Tebb, 2009; Forfylow, 2011). Fonnebo et al. (2007) note that the use of alternative treatments tends to become widespread before researchers are aware, which leads to efficacy and outcome studies pervading the literature. Though these studies are important, an initial inductive exploration into the process is an important first step before conducting deductive research and outcome studies. Yalom (2005) notes that the client experience is a rich and often untapped source of information. As the aim of counselling is to benefit the client, it is particularly important to understand the clients’ perspective. The current study focused on the client perspective in hopes of contributing to the research literature and benefitting clinicians, clients, and researchers alike. The purpose of the present study was to address this gap to understand this new and emerging phenomenon of counselling that integrates the use of yoga through the clients’ lived experience. Clients lent their perspective by describing their experiences of this integrative therapy and how they made meaning of it. It was hoped that this exploration would provide a clearer picture of the phenomenon and inform future research and clinical work. Study Significance and Expected Impacts The findings of this study drew out the essential features of this experience and provide awareness of how clients experience counselling that includes yoga and what they find 5 meaningful about this experience. Beyond this primary task of seeking to understand, it is hoped that this research will expand the dialogue and spark further research on this topic. It is important for any tool, technique, or therapy used with clients to be informed and empirically supported. The divide is dissolving between traditional psychotherapy and modalities typically viewed as alternative, such as yoga (Forbes, Akhtar, Douglass, 2011). This is an exciting time as assessment and treatment in mental health is experiencing a shift toward a more holistic, integrative approach. This evolution in practice requires us to keep pace as researchers. The findings of this study will be of interest to clients interested in these services as well as the growing body of mental health practitioners pursuing yoga training with the intention of integrating yoga into mental health services they provide. As this practice becomes more common, this study and future research will provide the understanding and justification that ensures this practice is viable, safe, and therapeutic. Research Question The research question is: What is the clients’ lived experience of counselling that integrates the use of yoga? It was important to look at this phenomenon through the clients’ perspective and understand their experience and how they made sense of it. This research question, with the aid of the questions in the interview protocol (see Appendix H), drew out the essential structure of this phenomenon in the form of common themes identified in each client’s description of her subjective experience. 6 Chapter 2: Literature Review Holistic Health Trend A trend has emerged with individuals seeking out more holistic approaches to their health. In a Canadian university sample, complementary and alternative medicine (CAM) was used by 70% of the students surveyed (Teper & Tsai, 2008). Individuals in Western cultures are found to be less satisfied with exclusive use of biomedicine and traditional Western therapies (Chan, Ho, & Chow, 2001). CAM includes practices that attend to body, mind, and spirit. These methods are described as holistic for the attention they pay to all facets of a person, which contrasts Westernized approaches that often work with one aspect of health and focus on the treatment of symptoms. Traditional Chinese medicine, ayurvedic medicine, acupuncture, massage therapy, and yoga are examples of interventions and modalities considered to be CAM (Teper & Tsai, 2008). More broadly, CAM has been defined by Health Canada as treatments that complement “mainstream medicine by contributing to a common whole, by satisfying a demand not met by conventional approaches, or by diversifying the conceptual framework of medicine” (Tataryn & Verhoef, 2001 as cited in Teper &Tsai, 2008, p. e5). People who engage in these alternative modalities state that they use it for the purposes of healing and improving health, but also to attain and maintain a sense of wellbeing (Barnes, Bloom, & Nahin, 2008). CAM also offers people a greater sense of agency in their health decision-making and it provides the ability to engage meaningfully with treatments that align with and honour personal beliefs (Behrman & Tebb, 2009). People often seek out these holistic methods for longstanding conditions, such as chronic pain, depression, anxiety, headaches, and cancer, particularly when conventional treatments have not sufficiently met all of their physical, emotional, social, or spiritual needs (White, 2000). 7 A concern commonly cited is that CAM is not supported by the literature in ways that biomedicine and traditional Western therapies are (Sointu, 2013). The benefits of CAM are often purported by those who use these services, rather than through outcome studies or randomized control trials (Sointu, 2013). However, conventional methods of researching health treatments may not be the most appropriate for modalities that fall into the realm of CAM. These unconventional interventions not only offer alternative ways of healing, they often view health and its treatment in a fundamentally different way from the Western medical model (Fonnebo et al., 2007). This difference challenges the validity of assessing CAM by evaluating its outcomes. The ability to understand the depth and complexity of healing is reduced when research focuses on outcome variables, as outcome research is less able to consider the context and subjectivity of experience. Despite lacking similar kinds of evidence attributed to biomedicine, the understanding, support, and popularity of CAM is growing. CAM will continue to be used in addition to conventional treatments because it addresses and satisfies elements of health that people feel are missed in conventional approaches (Behrman & Tebb, 2009). Inclusion of the Body CAM interventions have been found to be personalized and empowering methods that allow people to connect the physical and psychological facets of suffering (Cartwright & Torr, 2005). Integrating these aspects facilitates meaning making in a way that is not possible in other frameworks that focus on symptom resolution. In fact, until recently, approaches that aim to integrate mind and body have generally been viewed as “fringe” treatments. This, however, is no longer the dominant perception. Consumers, service providers, and researchers increasingly recognize the importance of including the body in health-related discourse and treatment. The 8 body is central to the meaning making and healing process (Sointu, 2013). Experience is always embodied and, therefore, the body is our way of being in the world; it is not only a container of suffering that is subjected to treatment (Sointu, 2013). Our experience and how we make sense of it relies on both embodiment and mental reflection. Sointu (2013) discusses this in the context of medicine, but it is also relevant to the field of psychology. Counselling and psychotherapy have been predominately language-based processes. Particularly, cognitive behavioral therapy (CBT) and psychodynamic psychotherapy include interventions that focus on verbal expression and languaged reflection of emotions, thoughts, and behaviours (Leijssen, 2006; van der Kolk, 2006). The use of the cognitive, intellectual system has been the major emphasis, and awareness of the body has been less present in these therapeutic contexts (Leijssen, 2006). The importance of including the body in therapy is poignant when considering trauma recovery, cases when the body is essential to healing. Research has demonstrated that reminders of the past can trigger extreme, irrational reactions in traumatized individuals because, in these situations, conscious control is bypassed and subcortical responses are stimulated directly (van der Kolk, 2006). Normally, the neocortex enables us to think logically, reflect on and attach meaning to external and internal sensations, and organize and execute our behavior. These are the cognitive processes that CBT and psychodynamic therapies often predominately rely on to gain understanding and insight. In trauma survivors, these processes are skipped. Instead, external and internal sensations directly initiate the original behavioural response to the traumatic event, which is no longer a relevant or helpful pattern of action. As a result, the trauma survivor’s body becomes a house for uncomfortable, scary feelings that are often avoided at all costs. However, healing from trauma requires sensitivity to and awareness of internal sensations 9 of the body, which is known as interoception. Attention to the body is essential to healing. Focusing on insight, though important, will not access the subcortical processes involved in psychological suffering, such as trauma. The body, like the mind, is a way of knowing oneself. Interoception helps trauma survivors recalibrate their sense-making process in order to attach accurate meaning to physical sensations that leads to behavior that is adaptive and appropriate (van der Kolk, 2006). For this reason, paying attention to the body is particularly important for sufferers of trauma who continue to interpret present sensations in the context of past events and, thus, seemingly “lose their way in the world” (van der Kolk, 2006, p. 280). Interoception and body awareness are important healing processes for anyone working through suffering. According to Mehling et al. (2011), body awareness is a mechanism of action through which mind-body approaches provide health benefits. Body awareness is the subjective, conscious aspect of interoception that can be modified by mental processes; it is also a key element in yoga, body-oriented psychotherapies, meditation, and mindfulness-based therapies (Mehling et al., 2011). Body awareness has been suggested as an avenue through which individuals are able to exercise control over emotions (Mehling et al., 2011; van der Kolk, 2006). Therefore, the body is not only another method for increasing self-awareness and understanding, but it can also facilitate change. Therapeutic gains can be experienced in healing modalities that include and attend to the body. Mindfulness Awareness of internal body sensations is necessary but not sufficient for facilitating health and healing; the quality of awareness also matters (Mehling et al., 2011). Awareness can be harmful if it has a negative valence, a judging quality, or is overly focused and ruminative. Overengagement involves being consumed by emotions or experiences, which is when worrying, 10 anxiety, and fears become maladaptive (Hayes & Feldman, 2004). However, the reverse, avoidance of awareness, is also unhelpful. Experiential avoidance can include denial, suppression, substance abuse, and dissociation. Although escape and avoidance strategies may regulate emotional experience in the moment, it is ineffective as a long-term strategy (Hayes & Feldman, 2004). Some even view experiential avoidance as a core etiological component of psychopathology (Hayes, Wilson, Gifford, Follete, & Stosahl, 1996). Instead, awareness can be therapeutic when it is characterized by a quality of mindfulness (Mehling et al., 2011). Mindfulness has been described by many researchers, however Bishop et al. (2004) attempted to come to a consensus with a definition of greater precision and specificity. The authors define mindfulness as non-elaborative attention to the present-moment experience in a way that is curious, open, and accepting. The practice of mindfulness encompasses focusing attention on all parts of the internal experience including body sensations, thoughts, and emotions (Hölzel, Lazar, Gard, Schuman-Olivier, Vago, & Ott, 2011). A mindfulness approach is hypothesized to create distance from one’s internal experience, which decreases emotional reactivity and helps to reestablish emotional homeostasis after stimulation (Hayes & Feldman, 2004). The benefits of mindfulness are “the conceptual opposites of the problems of avoidance and overengagement with emotions” (Hayes & Feldman, 2004, p. 256). Cultivating this open, non-elaborative approach to the present moment experience is a central component of many practices and therapies that help individuals get out of the thinking mind and into their embodied experience. The consistent, committed practice of mindfulness improves awareness of internal stimuli, cultivates a curious and accepting approach toward experience, and inevitably builds the capacity to experience and navigate stressful, anxiety-provoking events that happen in life (van der Kolk, 2006). Therefore, paying attention to our 11 internal world in a particular way offers profound opportunity for healing and resilience and, ultimately, enables people to act according to their goals and values instead of reacting to their emotions. Self-Regulation The body and mindfulness are components of many practices, including yoga, that are being or have been integrated into psychotherapeutic processes. As described above, these practices are beneficial in many ways, and these benefits overlap with the goals of counselling and psychotherapy, which could help explain the momentum integrative therapies are gaining. It is important to consider the mechanism of action and ask, namely, how do mindfulness-based practices work? The outcomes of these practices have been a focus within the literature. Some researchers have begun to look at the mechanism of action and begin to theoretically account for the changes that occur when these practices are used. Many researchers agree that attention plays a central role in meditative practices in general, including mindfulness, however several other facets of mindfulness have been suggested to mediate the beneficial effects (Hölzel et al., 2011). Many of the theoretical accounts have been descriptive in nature and have posited similar, overlapping components (Hölzel et al., 2011). For example, the components of nonattachment (Brown, Ryan, & Creswell, 2007), acceptance (Baer, 2003), and nonjudging and nonreactivity (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006) are similar and likely overlapping concepts that have been described and expounded by different theorists. Hölzel et al. (2011) endeavored to consolidate these findings and components from both a psychological and neuroscientific perspective. The authors propose self-regulation as the mechanism of action in mindfulness. Self-regulation, as the authors describe it, includes several closely interacting components: attention regulation, body awareness, emotion regulation, and change in perspective 12 on the self. Each of these mechanisms can be distinctly beneficial on their own, however it is when they work together, as the theory states, that they produce the powerful benefits experienced when practicing mindfulness. Attention is essential to mindfulness and any healing strategy as it focuses the individual on an object of interest. In mindfulness, attention is often open with no named object of focus, though it can be focused on internal experiences, such as the breath. The practice of regulating attention to one’s embodied experience has been shown to cultivate greater body and emotional awareness (Hölzel et al., 2011). The body responds to emotional experiences. Awareness of these physical sensations enables a person to notice the body’s response and facilitates greater awareness and understanding of one’s own emotional life. Awareness is a necessary prerequisite to regulating emotions and implementing goal-directed behavior. The emotion regulation strategies people use can be helpful or unhelpful, even if they function to ameliorate experience in the moment. Overengagement and avoidant strategies explained earlier are examples of unhelpful strategies that are reactive and do not facilitate processing or healing of emotional material. Mindfulness is an emotion regulation strategy that has received some debate. Some researchers view mindfulness as cognitive reappraisal in which people choose to approach emotions with a positive, accepting attitude (Garland, Gaylord, & Fredrickson, 2011). Others have instead proposed that cognitive control is absent and have termed mindfulness as a nonappraisal strategy (Gard, Hölzel, Sack, Hempel, Lazar, Vaitl, & Ott, 2012). In their review of the neuroscientific literature, Hölzel et al. (2011) note that further research is needed to understand the level of cognitive processing and control involved in mindfulness as an emotion regulation strategy. 13 Hölzel et al. (2011) summarized research discussing psychological disorders that have been associated with reduced capacity for emotion regulation, including borderline personality disorder, bipolar disorder, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), impulsive aggression, addiction, and generalized anxiety. Many researchers are honing in on emotion regulation as essential to mental health, and mindfulness-based practices demonstrate strong beneficial capacity in this field (Hayes & Feldman, 2004). This framework begins to provide a theoretical foundation for approaching counselling and psychotherapy in a holistic, integrated way that encompasses strategies that include the body, cultivate attention to put space between stimulus and response, foster emotion regulation, and enable people to act according to their values. Inclusion of Spirituality The definition Hölzel et al. (2011) provide for self-regulation uniquely includes a component that goes beyond cognitive, behavioral, emotional, and bodily processes. The last facet of self-regulation, change in perspective on the self, describes the deconstruction of and de-identification with the self. Mindfulness meditation can lead to meta-awareness when it enhances clarity of internal and external processes and exposes the transitory nature of experience. This is the essence of the Buddhist concept of impermanence, which negates the idea of a permanent, unchanging self (Epstein, 1988). Psychologist Engler (2004 as cited in Hölzel et al., 2011) noted that once this solid sense of “I” is deconstructed, concepts of attachment and separateness give way to connection and care for others. The concepts discussed within this last self-regulation facet describe the human capacity to move beyond a static, finite sense of “ego” and toward a felt understanding of being a part of a larger whole. These concepts are also reflected in themes of spirituality, including 14 interconnectedness, transcendence, love, and felt experience (Gockel, 2007). Spirituality has been defined in the 21st century as a “vivid, vital personal experience of the transcendent,” within or without a religious context (Gockel, 2007, p. 4). As Hölzel et al. (2011) postulate, this transcendent experience is likely a part of what happens during mindfulness meditation. Daniels and Fitzpatrick (2013) note that there is a clear relationship between transcendent, spiritual experiences and a sense of wellbeing in life. Many seminal characters in the field of psychology, including Carl Jung and Carl Rogers, have noted the importance of spirituality in psychotherapeutic endeavors. Abraham Maslow (1968) perhaps made this point most aptly when he noted that, “without the transcendent and the transpersonal, we get sick, violent, and nihilistic, or else hopeless and apathetic. We need something ‘bigger than we are’ to be awed by and to commit ourselves to” (p. iv). Despite this seemingly clear connection, spirituality and religion have only relatively recently experienced resurgence within counselling and psychotherapy. Since the Enlightenment, spirituality, like the body, has been pushed to the fringes in the field of conventional psychotherapy (Gockel, 2007). Intellect, reason, and science became predominant ways of understanding the human experience. However, as North America becomes a globalized community, exposure and interest in other spiritual and religious practices around the world, including Eastern philosophies, grows. This is enabling North Americans to find many ways to heal and connect their mind, body, and spirit. These holistic methods, including mindfulness meditation and yoga, are part of a greater framework of contemplative practices. Contemplative practices develop capacity to quiet the mind and concentrate deeply (Corsini & Wedding, 2008). This calm, centered state is the foundation for exploring meaning, purpose, and values. This description is similar to what some have theorized as the stabilizing and destabilizing aspects of 15 mindfulness in which calmness and tolerance are cultivated so exposure to unpleasant stimuli can function as a transformative process (Hayes & Feldman, 2004). As one becomes familiar with and more deeply understands contemplative practices, the easier it is to understand the overlap and merging of these practices with traditional Western psychotherapies (Corsini & Wedding, 2008). These practices address elements that can be missed by traditional talk therapies. Therefore, integrating these two disciplines enhances the capacity either has for healing from psychological distress and disorder, facilitating well-being, and promoting transpersonal growth and spirituality (Corsini & Wedding, 2008; Behrman & Tebb, 2009). For further understanding, a range of contemplative practices are illustrated in the tree of contemplative practices shown in Figure 1 (reprinted with permission of The Center for Contemplative Mind in Society). Figure 1: Tree of contemplative practices 16 Current Integrative Therapies It is clear that insight and understanding are not always sufficient for healing (van der Kolk, 2006). Mindfulness-based practices facilitate self-regulatory capacities that promote awareness, healing, connection, and growth (Hölzel et al., 2011). Mindfulness is a central component of many practices including Body Awareness Therapy (BAT), yoga, and other mind-body approaches (Mehling et al., 2011; Sointu, 2013; Braboszcz, Hahusseau, & Delorme, 2010). Mindfulness-based practices are one example of “holistic” approaches that are being integrated and used in mental health treatment. Clients and mental health professionals have recognized the potential for healing and growth through holistic, integrative therapies. Many current programs, interventions, and therapies have been designed to integrate Eastern philosophy and practice with conventional therapies. As noted earlier, meditation practices, including mindfulness, have become a popular, well-used component within the counselling paradigm (Charters, 2013). The term meditation encompasses an array of experiential practices that involve regulating emotion and attention through sustained focus on a chosen object (Gunaratana, 2002). Generally, meditative practices are grouped into two main categories: concentrative techniques and mindfulness practices (Braboszcz, Hahusseau, & Delorme, 2010). Concentrative, or focused attention, meditation requires a narrowing of awareness to a chosen object. Conversely, mindfulness meditation requires an opening of awareness in which there is no one focus; instead, awareness is expanded to include any and all of the sensations and stimuli present in one’s immediate experience. These practices can lead to insight into one’s mind and behavior, improved ability to self-regulate, and a sense of calmness and nonattachment (Braboszcz, Hahusseau, & Delorme, 2010). Practitioners can experience states of transformation, but it is through sustained practice that trait 17 mindfulness is cultivated and individuals become consistently freed from that habitual patterns of attachment and avoidance that cause suffering (Braboszcz, Hahusseau, & Delorme, 2010). These goals and results make meditative practices a potent addition to any psychotherapeutic process. Meditation and mindfulness have become an integrated component of counselling and psychotherapy in many ways. Many clinicians use mindfulness scripts and Eastern philosophy when it is relevant to individual client needs and as it fits within the theoretical framework they have already established. Mindfulness and related concepts have also served as the foundation of many third wave cognitive behavioral therapies, such as Dialectical Behavior Therapy (DBT), Mindfulness-based Cognitive Therapy (MBCT), and Acceptance and Commitment Therapy (ACT) (Kahl, Winter, & Schweiger, 2012). Nonwestern approaches are being increasingly valued and integrated into current practices; integrative therapies are valued and being pursued by clients and clinicians alike. Walsh and Shapiro (2006) note that although meditative and nonwestern traditions may lack the scientific precision and expertise found in many Western therapies, they offer “rich reservoirs of phenomenological data” (p. 232) that would otherwise be lost. Viewed in this way, Walsh and Shapiro (2006) argue that not only does the integration of meditative and Western systems fill in previous gaps to create a holistic approach, but these systems act synergistically and potentiate the effects of one another for a stronger system when combined than the additive result of either used alone. This argument is particularly powerful given that the goals of meditative practices and psychotherapy overlap. Some of these overlapping goals include personality change, reduction of trait anxiety, greater empathy, maturity, and ability to regulate one’s emotions (Walsh & Shapiro, 2006). 18 Yoga: A Mind-Body Practice Yoga is another Eastern approach that has much to offer and is being increasingly utilized by and integrated into Western psychotherapeutic systems (Forfylow, 2011). The use of yoga has become incredibly prevalent in North America. One study that surveyed a nationally representative sample of Americans demonstrated a lifetime prevalence rate of 7.5% of the sample engaging in yoga (Saper, Eisenberg, Davis, Culpepper, & Phillips, 2004). That percentage reflects almost 24 million Americans practicing yoga at some point in their lifetime. In a Canadian university sample, 42% practiced yoga (Teper & Tsai, 2008). Beyond survey statistics, the popularity of yoga is evident in the large quantity of thriving yoga studios in most metropolitan areas in Canada and the United States. Yoga is an ancient mind-body practice and philosophy developed for health and wellbeing (Desikachar, Bragdon, & Bossart, 2005). Translated from Sanskrit to English, yoga means ‘to yoke’, which connotes its union of body, mind, and spirit (Salmon, Lush, Jablonski, & Sephton, 2009). The Western use of yoga typically focuses on the asana practice, the physical postures of yoga (Desikachar, Bragdon, & Bossart, 2005). However, that is only one of the many components of yoga. Yoga includes physical postures, meditation, breathing control, ethics, philosophy, lifestyle, and committed study (Corsini & Wedding, 2008). Yogic philosophy and practice can best be understood through the seminal Yoga Sûtras of Patanjali, who was the first to formally write on the practices of yoga in a systematic way (Simpkins & Simpkins, 2011). These centuries-old sûtras, or general truths, describe concepts and principles for healing and living well (Simpkins & Simpkins, 2011). Patanjali’s system includes eight “limbs” of yoga that act as guidelines for living a meaningful, purposeful life (Simpkins & Simpkins, 2011). A comprehensive overview of the 19 eight limbs of yoga is not needed for the purposes of this discussion. The following is a brief description of the eight limbs of yoga. The first two limbs, the yamas and the niyamas, are ethical guidelines for everyday action. The third limb, asanas, refers to the physical postures practiced in yoga. The fourth limb, pranayama, focuses on breath work to control, direct, and distribute prana, or energy. The fifth limb, pratyahara, is about withdrawing from the sensory experiencing of the external world. The sixth limb, dharana, is concentration. All limbs interact with and layer on one another, and the sixth limb uses the disengagement with the outside world to focus attention on one object from within. The seventh limb, dhyana, is meditation or contemplation: the uninterrupted flow of concentration. The eighth limb, Samadhi, is the transformative and transcendent experience of unity, which is often described as a state of ecstasy. For further understanding, many books are available that provide an in-depth description and exploration of Patanjali’s system. Typical yoga practice in North America often overlooks the philosophical aspects and principles (Forfylow, 2011). The three core components that typically make up a yoga practice, regardless of the style, include asanas, breathing exercises, and meditation. As discussed, the Sanskrit word for breath work is pranayama, and the regulation of breath through various techniques can change one’s energy and foster a sense of control and concentration. Physical postures, or asanas, impact both the musculoskeletal system, by cultivating balance, flexibility, strength, and coordination, as well as impacting the psychoemotional state and ability of the yoga practitioner. Certain postures are argued to be invigorating and facilitate psychological response and emotional release (e.g., hip and chest openers), while others have a more calming effect on the nervous system (e.g., forward bends). Finally, meditation practice within yoga harnesses the ability to regulate and sustain attention and awareness without trying to change or judge it. All 20 three components are essential and work together as a holistic system that facilitates a sense of balance, regulation, and peace in yoga practitioners. Yoga and Mental Health Individuals have described an abundance of reasons for practicing yoga. Generally, reasons individuals give for practicing yoga fall into two categories: to treat current health concerns and to attain a sense of wellbeing (Saper et al., 2004). This highlights that the practice of yoga is not only used in a reparative, healing capacity that is similar to the biomedical model where freedom from disease constitutes health. In addition, yoga is sought as a practice that will help to develop a greater sense of balance and to create opportunities for growth and transformation. To a great extent, the literature has been able to demonstrate these effects in many ways. Yoga practice has been shown to have benefits for both physical and psychological wellbeing (Salmon, Lush, Jablonski, & Sephton, 2009). Khalsa (2004) discusses empirical support for the use of yoga to manage cardiovascular conditions, respiratory conditions, chronic pain, and neurological conditions. There have also been many outcome studies that have assessed the effectiveness of yoga with many psychological concerns. One meta-analysis that reviewed 35 clinical trials and randomized control trials (RCTs) found that 25 of the studies demonstrated significant improvement in stress and anxiety symptoms when a yoga program was implemented (Li & Goldsmith, 2012). In another meta-analysis, 12 RCTs evidenced a real therapeutic effect of yoga on individuals diagnosed with depressive disorders and individuals experiencing subclinical, yet elevated levels of depression (Cramer, Lauche, Langhorst, & Dobos, 2013). There is also emerging evidence for the use of yoga with sleep disorders and eating disorders, but the support is much less established than it is for stress, chronic pain, 21 anxiety, and depression (Balasubramaniam, Telles, & Doraiswamy, 2013; Douglass, 2009). There are other health concerns yoga is purported to be beneficial for, however some of these claims have not been substantiated through the literature and have, as a result, been left out of this discussion. Even in the literature that is building a strong empirical foundation for the use of yoga with various mental health concerns, many questions still remain. What styles of yoga are effective? For whom or what concerns does each style work best for? Are there circumstances in which the use of yoga would be contraindicated? What type and level of training should the yoga instructor have to be most effective? Should yoga be used as a stand-alone treatment or as a complement to or component of conventional treatments? What is the practitioner’s experience of yoga? Do people find yoga helpful? If so, in what ways? Are there elements of yoga missing in the current discourse potentially due to the current overemphasis on outcome studies in the literature? Yoga in Mental Health Treatment Given yoga’s effectiveness for use with mental health concerns, it is unsurprising that it is crossing over into the field of mental health treatment. The exemplar of this movement includes the mindfulness-based stress reduction (MBSR) program. MBSR, created by Jon Kabat-Zinn in 1979, is an 8-week program that includes Hatha yoga, meditation, and a body scan (Kabat-Zinn, 2013). MBSR was created within the framework of integrative medicine and was originally developed for use with chronic pain. Kabat-Zinn (2013) describes MBSR as a way for individuals to take a participatory role in their treatment. MBSR, like other mindfulness-based practices, is built on the understanding that our psychological health, the way we think, feel, and behave, is connected with and impacts our physical health. Since its inception, much research has been conducted looking into the use of MBSR for both psychological and physical concerns. 22 MBSR now has a strong empirical base for use with many clinical populations (Kabat-Zinn, 2013). The interest in this program and the volume of research it has inspired may help explain the greater interest in yoga as a psychotherapeutic tool in North America over the last few decades (Salmon, Lush, Jablonski, & Sephton, 2009). Studies have discussed and investigated the use of other yoga programs as an adjunctive treatment with many different populations. In their review article, Adams and Puig (2008) highlight yoga’s potential benefit for college students. The authors note that yoga is particularly popular with the postsecondary student population and many of the concerns that students face, including stress, anxiety, depression, and eating disorders, are concerns for which yoga has demonstrated its clinical effectiveness. Adams and Puig (2008) suggest that college counselling centres hire counsellors with yoga training or connect with yoga instructors in the community “in order to effectively integrate yoga-based practices into existing services” (p. 369). Milligan (2006) implemented a yoga program for stress management within her college counselling centre. Purportedly, the yoga program was “a favorite among students and faculty” (Milligan, 2006, p. 185). The author hoped that the program would promote growth of participants through self-awareness and self-acceptance, which are capacities typically cultivated through a consistent yoga practice. Milligan’s (2006) review of the yoga program did not include standard rigorous steps of a typical research study; nonetheless, it does demonstrate that yoga programs are being implemented within counselling facilities and have received positive, encouraging feedback from many of the participants. Visceglia and Lewis (2011) conducted a pilot RCT to assess the impact of an 8-week yoga program used as an adjunct treatment for psychiatric inpatients with a diagnosis of schizophrenia. Compared to waitlist controls, patients who participated in the yoga program 23 experienced a significant improvement in their symptomatology and their subjective sense of quality of life. These studies show how yoga can be beneficial component of treatment for people suffering from mental health concerns. Yoga in Counselling Some clinicians are going beyond the use of adjunctive yoga programs within mental health treatment settings and are beginning to further integrate yoga into the counselling process. There is an emerging trend for registered psychotherapists and counsellors to seek out training and registration as yoga teachers or yoga therapists (Forbes, Akhtar, & Douglass, 2011). The goal of many of these mental health professionals is to be able to directly use their developing knowledge-base and skill-set as registered yoga teachers (RYTs) or yoga therapists in their counselling and psychotherapy practice. Generally, clinicians who seek dual certification acknowledge the importance of the body in health and wellbeing (Forbes, Akhtar, & Douglass, 2011). Many clinicians and researchers affirm that integrating yoga with psychotherapy can create a holistic, individualized, collaborative approach that honours and addresses the whole person (Forfylow, 2011). Interest in integrating yoga with psychotherapy is growing, as is the discussion and practice of this integration. Nevertheless, there is a paucity of articles researching this phenomenon directly. Forfylow (2011) acknowledges the great potential for using yoga within counselling sessions, but she also highlights the need for research to inform this practice. A dissertation completed in 2012 did directly examine this integration. Kocian (2012) interviewed eight psychotherapists that integrate the use of yoga into their practice. She used the term yoga psychotherapy to define this practice. It is important to note that this term is not necessarily a consistent or agreed upon term for this integrative therapy. The author’s interviews with the yoga psychotherapists yielded six themes. In one particularly important theme, the 24 therapist-participants define yoga psychotherapy. The participants all described yoga psychotherapy as “a holistic practice integrating the principles of yoga with traditional psychotherapy, and is different than the more physically-based yoga therapy” (Kocian, 2012, p. 36). Although this was the definition that all eight participants independently agreed upon, they all also recognized that a formal definition is needed for the profession. The other particularly important theme from Kocian’s (2012) dissertation included the yoga psychotherapists’ descriptions of what this integrative therapy looked like in practice. The way in which each therapist integrated yoga into each session varied based on the client and their needs in each session and each moment. All eight yoga psychotherapists named four main components of yoga psychotherapy. Yoga psychotherapy, as defined by the eight participants, included (a) centering, (b) pranayama, (c) asana, and (d) verbal processing. The therapists mentioned that the timing and method in which these components are included can be adapted to many different client issues, and each therapist described the process uniquely. Nonetheless, these were the four core components all participants independently identified as being the essential aspects that define the yoga psychotherapy process. Generally, centering included some form of meditation practice to bring the clients into their bodies as well as the present-moment. The psychotherapists all noted that pranayama, or breathing exercises, used in therapy were more calming in nature than energizing. The asanas used in sessions varied and depended of the emotional needs and physical abilities of each client. On average, four asana postures were used each session, and the yoga psychotherapists stated they tended to use hip openers, chest openers, and forward folds most frequently. Kocian (2012) highlighted that hip openers, chest openers, and forward folds have been described as beneficial in previous research due to their ability to facilitate emotional release (Valente & Marotta, 2011). Verbal processing is not 25 an aspect of yoga. It is the psychotherapeutic process that gives clients the opportunity to reflect on and language their experience to facilitate understanding, meaning making, and integration. All eight yoga psychotherapists were unable to identify a consistent guideline for how a typical session may be structured. This is because each session needs to be flexible to meet the highly individualized needs of each client, and use of yoga in session should be driven by the moment-to-moment needs of the client. Though this makes yoga psychotherapy challenging to describe in a consistent way, the author notes that this is consistent with how traditional psychotherapy is conducted. Kocian’s (2012) research is an important starting point to understanding counselling and psychotherapy that integrates yoga. However, there is still much to learn. 26 Chapter 3: Research Methodology Research Design The purpose of this study was to explore and understand the essence of the phenomenon of counselling that integrates the use of yoga. In exploring this emerging integrative therapy, the client experience was an essential perspective to understand and, therefore, was the perspective of interest chosen for this examination of the phenomenon. The study focused the exploration through the following question: What is the clients’ lived experience of counselling that integrates the use of yoga? To best address the research purpose and question, the study used a descriptive phenomenological research design. This methodology enabled an in-depth exploration of this phenomenon, obtaining a rich understanding of what the common essential features are from the clients’ descriptions of their lived experience. Much of the literature looking at yoga’s therapeutic capacity uses a quantitative research approach. Outcome research is valuable; however, our ability to understand the phenomenon of interest is limited when the literature does not include in-depth descriptions. Qualitative inquiries can provide a rich, bottom-up method of understanding, which is especially important when exploring a new field of interest. This is a unique aspect not available in experimental designs that require the a priori choosing of variables. A phenomenological approach enabled this study to explore and highlight the themes deemed important by those who experienced the phenomenon of interest. In other words, themes identified are those that clients, rather than researchers or even therapists, highlight as important elements of this integrative therapy. This methodology also supports the exploratory nature of this study, as it examined a relatively unaddressed area of the literature (Kocian, 2012). 27 Descriptive phenomenology is a methodology developed through Husserl’s philosophical ideas as they apply to research in psychology (Giorgi, 2009). Husserl described the value in using “experience as perceived by human consciousness” as the object of study in research (Lopez & Willis, 2004, p. 727). According to Husserl, we live our lives according to what we perceive to be real, and the way experience is perceived and reality is constructed cannot be fully understood without direct exploration (Lopez & Willis, 2004). He argued that each lived experience has common features that transcend any individual’s experience. This phenomenological approach attempts to explore and understand the underlying, universal structure of a human experience. Descriptive phenomenology was chosen due to its fidelity “to the things themselves,” rather than taking a narrative approach that would give voice to each participant’s unique experience or an interpretive phenomenological approach that would pursue the meaning of this experience. Thus, the methodology chosen best fit the goal of this study, which sought to understand the experience of counselling that uses yoga, and aptly allowed the researchers to best understand the structure of this phenomenon. The steps and components of the descriptive phenomenological method in psychological research is explicated in greater depth in the subsequent sections that outline the data collection and analysis processes. Participants According to Wertz (2005), in phenomenological research, it is difficult to know beforehand the appropriate number of participants to study. When thinking about sample size in this methodological framework, it was important to consider the aim of the research question and continue recruiting participants until data saturation (i.e., when redundancies emerge in collected data in regard to the research goals and no additional information is being provided that would create novel categories) (Wertz, 2005). Langdridge (2007) also notes, from a more pragmatic 28 point of view, that sample sizes for descriptive phenomenological research tend to include approximately five or six participants “due to the time-consuming nature of the analytical process” (p. 87). To examine the phenomenon of counselling that integrates yoga, participants in the current study were clients who have lived this experience. Six participants were interviewed and included in this examination. Participants were recruited through purposive and snowball sampling methods. All participants had been clients in psychotherapy with counsellors who used yoga in their counselling practice. Recruitment included physical and online poster advertisement and contact with counsellors. Counsellors were sought out through google searches, word of mouth, and contact with organizations in British Columbia known to integrate some form of yoga and psychotherapy. Counsellors were given study and researcher contact information and were invited to share this information with their current and previous clients, who could then call or email if they were interested in participating in the study. In line with a snowball sampling method, I asked the counsellors to also give the study and contact information to any of their colleagues that also use yoga in counselling. Posters were distributed at campuses, yoga studios, psychology-related conferences, yoga-related retail stores, and community centres in the Lower Mainland of British Columbia to recruit clients or counsellors that self-identify as being a consumer or practitioner, respectively, of counselling that integrates the use of yoga. Posters were also distributed online using classifieds websites (e.g., craigslist) and social media websites (e.g., Facebook). Through these recruitment efforts, participants included in the study disclosed learning of the study through: word of mouth (two participants), poster advertisement in a yoga studio (one participant), and online poster advertisement on craigslist (three participants). 29 Recruitment was kept broad in order to be consistent with the maximum variation sampling method used in descriptive phenomenology (Langdridge, 2007). In descriptive phenomenology, the goal is to obtain a varied sample of individuals who have experienced the same phenomenon to enable the analytical process to identify robust, invariant features of the phenomenon of interest. Broad recruitment was used in hopes of obtaining a diverse sample in regard to sex, age, education, ethnic background, and geographic location (within feasible limits of the study). For the purposes of this study, an age requirement of individuals 19 years of age or older, or greater or equal to the age of consent in the participant’s geographic location, was used to ensure clients were voluntary, consensual participants of counselling. To be included in the study, participants’ counsellors needed to be currently registered with a regulatory body that allows them to ethically and legally practice psychotherapy (e.g., RPC, RCC, CCC, RPsych, RSW) and to have completed a yoga teacher or yoga therapy training program (e.g., 200-hour yoga teacher training). Forbes, Akhtar, & Douglass (2011) state therapists using yoga should have a minimum of the 500-hour training level. However, the likely small pool of potential participants to draw from unfortunately limited the study from having stricter inclusion criteria. Study inclusion also required clients to have had at least some counselling sessions that included yoga. This study utilized the definition of yoga in psychotherapy outlined by the yoga psychotherapists in Kocian’s (2012) study. According to their definition, the use of yoga in counselling includes centering, breath work, postures, and verbal processing. Participation in the study was permissible for both current and previous clients of the counselling experience examined in the study. Four of the study participants were previous clients, one participant was still currently engaged in counselling, and one participant was not currently actively seeking counselling, though maintained a relationship with her 30 therapist. For participants that were not in counselling at the time of the study, it was ensured that they felt the counselling was recent enough that they could recall and speak to their experience. All potential research participants were assessed for appropriateness during an initial phone screening. Exclusion criteria included anyone who was experiencing acute psychiatric disturbance, current suicidal ideation, or anything else that would have impeded ability to fully and safely participate in the study. The first six participants that met the above inclusion and exclusion criteria were included in this study. All six participants were female and identified as Caucasian. Participants ranged in age from 28 to 48 years old, with a mean of 37 years of age. The educational background of the participants included: technical school (one participant), some university (one participant), university degree (one participant), master’s student (one participant), and master’s degree (two participants). Four participants were born in Canada, one participant was born in the United Kingdom, and one participant did not disclose her place of birth on the demographics questionnaire. The experience of interest in this study, counselling that used yoga, took place in Canada for four participants, the United States for one participant, and Costa Rica for one participant. Situating the Researcher I, the researcher, am a graduate student in counselling psychology and have been practicing yoga for nine years. I have practiced yoga in classes, workshops, retreats, boot camps, and independently. As a counsellor in training, I believe the body is an essential element to understand and include when working with mental health. From my own practice, I hold deep value in the transformative nature of yoga. My personal experience and learning in this area shapes the lens through which I see the world, which has been important for me to consider as a 31 researcher. This lens includes, for example, seeing yoga as inherently beneficial, holistic, and healing. This corresponds with my interest in the mind-body connection and my belief in the therapeutic value of a holistic, integrative approach to mental health. Given my perspective as the researcher, it was important that I acknowledge its potential to influence how I conducted the research. For example, without consideration of my potential biases, the way I conducted the interviews and perceived the participants’ responses could have been affected. Bracketing provides the opportunity set personal experience aside to obtain the essential form of the participants’ lived experience (Lopez & Willis, 2004). In constructivist philosophies, there is an awareness that bracketing a part of oneself as the researcher is a challenging task (Lopez & Willis, 2004). Nevertheless, it does not relinquish researchers from the necessity of trying, just as the inability of quantitative researchers to account for all potential confounding variables does not prevent them from attempting to isolate the variable of interest. Pascale (2011) notes that to truly understand a participant’s perspective and way of making meaning of experience, the researcher’s own knowledge, experience, assumptions, and expectations should be suspended to the best of his or her abilities. Bracketing my stance provided the best chance of identifying the core universal components of the phenomenon (i.e., themes) the participants highlighted, with as little influence or interpretation as possible. Nevertheless, bracketing is a challenging, complex, and dynamic process, and it required consistent effort and reflection as I progressed through the study. My ability to be reflexive as a researcher was an important, ongoing element of the research process, particularly when interviews were conducted and transcripts were analyzed. 32 Data Collection Once participants were screened and agreed to participate in the study, a semi-structured interview was conducted with each participant individually. All interviews were attempted to be face-to-face to ensure the contextual and interactional richness of the in-person interview was not lost. However, all interviews but one were in-person; Skype video calling was used with one participant when an in-person meeting was not feasible due to geographical distance (the participant lived in another province). Skype has begun to be used and researched as a viable alternative to conducting in-person interviews in qualitative research (Hanna, 2012). Nevertheless, this was used only as a necessary measure due to extenuating circumstances. Ethical considerations relevant to conducting online interviews were reviewed and consent was obtained from the participant with whom Skype was used as the interview medium. Meetings took place in a conference room on the University of British Columbia (UBC) Vancouver campus or at appropriate, quiet alternative off-campus spaces for participants that were unable to or preferred not to commute to the UBC campus. Each meeting began with a review and signing of the consent form, a brief demographic questionnaire to fill out, and time to answer questions from the participant. The demographic questionnaire covered contextual elements relevant to understanding the experience being studied and the sample of participants (see Appendix G for Demographics Form). Context has a role in how people construct their perspective and was important to track in case it had been needed to make sense of the data at the analysis phase of the research process (Lopez & Willis, 2004). After consent was obtained and the participant was fully informed, an in-depth, semi-structured interview was conducted. Semi-structured interviews are the most common method of collecting data in phenomenological research as it enables the research to capture the description and meaning of a phenomenon as it 33 is lived by participants (Englander, 2012). Interview data is preferable to written descriptions, as verbal accounts tend to be more extensive and detailed (Giorgi, 2009). Each interview was tape-recorded for the subsequent transcription. I took notes as needed to capture observed nuances that could not be caught by the recording and to note any thoughts during the interview process. All interviews were an average of one hour in length, which is typical for phenomenological interviews (Giorgi, 2009). In line with phenomenological interview procedures, the interview included broad, open-ended questions. The questions started out broad and got more specific as the interview progressed. The interview process was designed to follow the participant as they described their experience. Therefore, each interview varied slightly, including prompts and questions that were specific to the responses of the individual participants. This provided space for the depth and complexity of each participants experience to be elicited and captured. It also provided flexibility to accommodate various perceptions of the interview questions. When the verbal description strayed from aspects of the experience of yoga in counselling, I guided the participant back to discussing the situation of interest. This qualitative approach enabled me to capture a holistic, descriptive picture of the lived experience for each participant. For more information on the general interview structure and questions used, see Appendix H: Interview Protocol. Each participant received a $25 gift card of their choice, which included to Starbucks, Chapters, a yoga studio, and a tanning salon. Given the effort and time the study required of participants, this was an important token to demonstrate gratitude and respect for participation in the study. Gift cards were distributed at or shortly after the time of the interview. 34 Data Management & Analysis After each interview, I transcribed the voice-recorded interview verbatim. The transcripts are stored in print copy and saved as a password-protected file on a USB drive. Transcripts, the USB drive, consent forms, and demographic questionnaires are kept safe and confidential in a fireproof lockbox inside the researcher’s home. The participant names were replaced with codes (i.e., P1, P2, P3, P4, P5, and P6) to further protect confidentiality. For this descriptive phenomenological study, the five-step method of data analysis, outlined by Giorgi (2009), was used. First, I took care to assume the phenomenological attitude through acknowledging my biases and bracketing them. By bracketing my biases, previous knowledge, and experience, I was more fully present and able to see what the participants’ responses revealed without bent or posit. As described earlier, this was an ongoing process; I was intentional and consistent with my endeavour to be reflexive and bracket any new biases as they came into my awareness throughout the interviewing and research process. Second, I read each transcript in its entirety to get a holistic sense of the experience (Giorgi, 2009). Third, I broke each transcript into meaning units. Demarcations were made each time the meaning shifted in the transcript, and the process created a series of manageable portions of the greater text. This process was dynamic, and the size of meaning units fluctuated as I became more familiar with the transcripts individually and as a group. Fourth, I transformed the meaning units by attaching statements that described their psychologically-relevant lived meanings (Giorgi, 2009). Transformation requires psychological formulation to describe the essence of the meaning unit without interpretation or positing. It is essential that each statement reflect the true meaning of the corresponding unit. This transformation is the first real analysis conducted on the data. I kept a researcher log, or journal, that described the reasoning behind transformations and 35 exemplars from the data that best showcased the choice of wording for the transformation. This documentation is essential to justify and remember intentions at each transformational stage in the analysis. The fifth and final step synthesizes the constituent components to draw out the universal structure of the lived experience of the phenomenon common to all participants. Synthesis was done through reviewing all text in search of convergent meanings, which become the constituent components of the experience that constitute the general theme structure described in the results section, the subsequent chapter. Trustworthiness & Rigor Husserl believed consciously perceived human experience is possible to study in a scientific way (Lopez & Willis, 2004). He founded phenomenology in a way that reflects the values of traditional scientific research, demonstrating his commitment to ensuring phenomenology is a rigorous form of science (Lopez & Willis, 2004). This is exemplified in the assumptions and processes involved in phenomenology. For example, descriptive phenomenology assumes “that essences can be abstracted from lived experiences without a consideration of context” (Lopez & Willis, 2004, p.728). This is ideologically similar to the assumptions made in quantitative scientific research. Also, bracketing is embedded in the process of conducting descriptive phenomenological research, which implies that a researcher can become a near objective observer of the phenomenon of interest. Giorgi’s (2009) modified Husserlian approach to phenomenological research is more expansive with its understanding of the subjective, contextual nature of people’s ways of being in the world. The validity of the findings is also founded through the researcher’s strict adherence to and consistency in using the chosen methodological approach. Particularly with descriptive phenomenology, commitment to the procedures demonstrates fidelity “to the things themselves,” to the essence of the 36 phenomenon of interest (Wertz, 2005). This is further demonstrated through inclusion of raw data throughout the study report as corroborative evidence of the findings being described. Beyond the strength that comes from the structure of the phenomenological approach and strict adherence to it, as stated previously, I kept an audit trail, or researcher log, throughout the analysis process. This log provides explicit evidence and justification for the process in which analysis transformed raw data to themes of the phenomenon of interest. To ensure validity of the findings, two member checks were conducted. The initial member check was conducted after the interviews were transcribed and the second was completed after analysis. For the process of the initial member check, each participant reviewed her own transcript and had the option to add, remove, or modify any part of the transcript so it would best represent the experience. This gave participants the opportunity to reflect on what they said and clarify what is included and, thus, what was interpreted to ensure accuracy and completeness. Three participants made minimal edits and additions (and no deletions) to their transcripts to clarify or support existing elements in their transcripts. All modification were included as data and analyzed. For the remaining participants, two participants responded with no changes to the transcripts and one participant did not respond. The second member check gave each participant the opportunity to review and provide feedback on the analyzed end product. The overall theme structure was sent to each participant in both the form of a list (see Table 1.) and description. The following three questions were included for participants to respond to regarding their review of the theme structure: (1) Do the findings resonate with your experience of counselling that used yoga? (2) Is this structure comprehensive? (3) Do the findings have clinical relevance? This member check was an important feedback opportunity to ensure that the structure of the experience that emerged through analysis accurately represented 37 what the participants felt they were describing in their interviews. Any theme that any participant would not have believed reflected a part of their experience would not have been included in the end gestalt of the phenomenon. Responses from the three participants that responded were: a unanimous “yes” to question (1), a unanimous “yes” to question (2), and a unanimous “yes” to question (3). Two participants provided additional comments to supplement their responses. In regard to question (2), one participant wrote “you have covered just about everything except maybe a reference to how the insight around certain emotions, responses also facilitate integration of experiences that have previously been denied, numbed out or separated from self”. This integrative element was accounted for and subsumed under sub-theme Psychophysiological Insight & Catharsis of Theme 4, which is why it was not present in the overall theme structure presented to the participants in the second member check. In regard to question (3), two participants provided feedback: “useful as there are so few studies validating this type of therapy” and “Definitely. Body work encourages holistic healing and integration through somatic experiencing. This is especially important when dealing with trauma that may have become rooted in the body. It is essential that this is done with the guidance of an instructor/therapist who embodies the key principles of yoga i.e. not just any therapist can do it.” Three of the six participants did not respond to the second member check email. The results have been evaluated by a peer reviewer who, with her knowledge and background as a yoga instructor and masters student in counselling psychology, attended to whether the findings reflect what she understands of, or what can be reasonably imagined to be true of, the yoga in counselling experience. Finally, the completed thesis is reviewed by and defended in front of a committee of academic researchers that have expertise in the study’s 38 methodology and/or content, which acts as another filter through which the findings are scrutinized to ensure trustworthiness and rigour of the study. Ethical and Diversity Considerations The study focused on the clients’ experience of the counselling process, rather than the content, which was anticipated to be a minimal risk for creating psychological distress in participants. Nevertheless, the study included many required and additional methods to ensure participant psychological health and safety. Administrative methods in which ethical considerations were cared for included obtaining study approval through the ethics board. Second, the consent form, which was reviewed with each participant prior to conducting the interview, outlined potential risks and benefits, voluntariness of participation, ability to decline at any time, and freedom to disclose only what the participant feels comfortable with. Unanticipated difficulties were pre-emptively prepared for incase discussing the counselling experience reminded a participant of sensitive topics discussed in counselling. With my training as a counselling psychology graduate student, I endeavoured to provide a safe environment to ground, process, and debrief with participants if it had been necessary. If, for any reason, a participant had needed or wished, the interview would have been stopped immediately and resources would have been provided to ensure the participant felt safe and supported. Contact information for the study’s Primary Investigator, the crisis line, and local sliding scale counselling resources were on hand, if needed. These steps were taken to be prepared for any potential risks participation might pose to the participants. That being said, these considerations were thought to be solely precautionary as the phenomenon of interest is not one of traumatic or psychologically risky nature. Nevertheless, monitoring the verbal and nonverbal cues of each 39 participant helped to ensure safety is kept as the utmost priority. None of these measures were needed or used in any interview in this study. Though the current study does not directly discuss culture, diversity considerations are important to acknowledge given that it was hoped that a heterogeneous sample would be obtained. A consideration prior to starting the research included that there was the potential for the sample to show a similar bias to the typical demographic profile observed in the population of yoga practitioners in North America, which is predominately a young adult, female, Caucasian population of upper middle class means. Though sampling methods used attempted to obtain a maximum variation sample to both account for diverse experiences and gain a robust perspective of counselling that uses yoga, the study’s sample was uniform in regard to gender and ethnic background (i.e., all participants identified as female and Caucasian). There was some variation in age and educational level (i.e., age ranged from 28 to 48 years old; educational level ranged from technical school to master’s degree). The pattern in the demographic profile of this sample will be considered later in the discussion chapter. 40 Chapter 4: Research Findings The results of this study are described below in the thematic structure of this phenomenon as described by the six study participants. Only themes that were endorsed by all participants were included to form the theme structure. The purpose of this study was to understand the essential structure of the lived experience of clients who have engaged in counselling where yoga was included as a part of the therapy. More specifically, the research question being addressed is: What is the clients’ lived experience of counselling that integrates the use of yoga? Within the descriptive phenomenological framework, Giorgi’s (2009) five-step method of data analysis was used to extract a rich, thick description of the ‘essence’ of this experience from the interview data collected from the six participants. Interviews with participants included questions, that progressed from open to more specific, to assist them in describing their experience of counselling that integrated the use of yoga (for more information on the interview protocol, see Appendix G). The following is a description of the themes that were elicited from the data. These six themes make up the essential structure of the phenomenon. For the description and discussion of the study’s findings, participants have been given pseudonyms to maintain confidentiality and to avoid the use of impersonal participant codes (e.g., P1, P2, etc) when referring to the participants’ personal experiences and reflections. Overall Theme Structure Through the analysis process, six super-ordinate themes emerged from participant data. These main themes include: yoga components; counselling components; integration of yoga and counselling; inclusion of yoga facilitates processing and regulation; whole person, whole life approach; and counsellor qualities facilitate counselling. All themes, excluding the third, include sub-themes. See Table 1 for the overall theme structure. 41 Table 1: Theme structure of the experience of counselling that integrates the use of yoga Theme 1: Yoga Components, Inclusion of the Body in a Particular Way Breath Bodywork Body Awareness Mindfulness Theme 2: Counselling Components Verbal Exploration and Processing Approach is Curious and Nonjudgmental Counselling is Person-Centred and Client-Directed Theme 3: Integration of Yoga and Counselling Theme 4: Inclusion of Yoga Facilitates Bottom-Up Processing a. Body As Access Point to Physical Sensations, Thoughts, Emotions, Memories b. Psychophysiological Insight & Catharsis Affect Regulation a. Use of Yoga to Calm, Relax, Ground b. Develop Capacity to Be With (Uncomfortable) Experience Theme 5: Whole Person, Whole Life Approach Whole Person Approach Profound Experience that Becomes a Way of Life Theme 6: Counsellor Qualities Facilitate Trust in Relationship & Counselling Counsellor Embodies Approach: Curious, Nonjudgmental, Patient, Supportive Trust and Comfort in Relationship & Counselling Theme 1: Yoga Components, The Inclusion of the Body in a Particular Way The inclusion criteria required participants to have engaged in counselling that included yoga as defined by the use of breath, meditation, and bodywork. These represent major aspects of the 8-limb yoga system (Simpkins & Simpkins, 2011) and were present for each participant. In describing their experiences, participants named many different aspects of yoga and related concepts (e.g., compassion, acceptance) that were used in sessions. The aspects that were a part of all six participants’ experiences are described here. Though these components are described separately, they were often used in conjunction with one another. Awareness was always present when the breath or the body were being engaged through yoga in counselling. In this way, these are inextricably related constituent parts of what may be considered the yoga component of this 42 experience. However, these components also represent distinct parts of this integrative therapy that are used independent of one another at times and merit description on their own. Breath awareness and regulation. Breath was a major component of all six participants’ experiences. When asked about the breath component, four of the six participants described counselling that uses yoga to include “a lot of” breath. When, how, and why breath was used varied within and between participants. It involved having clients close their eyes and bring their attention to their breathing. A very common use for breath, especially in the early stages of counselling, was to facilitate reconnecting with the body, or body awareness. Anna’s counsellor encouraged her to spend time connecting with the breath with the objective being to “just come back to the breath.” Anna found this comforting because it was “about finding an inner connection.” Dana’s counsellor facilitated “focused breathing time,” which Dana described as an opportunity to “internalize your awareness and become connected to how your breath was and where it was in your body.” Dana often felt more whole and contained within herself afterward, which was a comforting sensation for her. Rebecca also found breathwork in her group therapy to be a calming and comfortable experience. She reflected that taking time to focus on breathing allowed her the space to simply be with experience in the present-moment without needing to do anything. Brenda also described breathing in counselling as a time without expectations because it requires her to shift into the present-moment to pay attention to the embodied experience of breath. Paying attention to the breath was a naturally calming experience for all of the participants. The word ‘just’ was often used when describing the experience of breathing (e.g., “just breathe”) as there is little to do other than focus on breathing. This non-doing, passive awareness of breath, in which the focus is attending to the breath and not changing it, provided 43 time and mental space for participants to stop talking and thinking and simply be with their experience, explore their embodied experience, notice the space that’s created, and just “chill out”. In other words, breath is used to access and explore internal experience which, as described later, is an essential aspect that makes up this style of counselling. Counsellors also guided clients to attend to the breath and manipulate it in a particular way to make it “helpful”. Manipulations of the breath included making it slow and deep, taking long and equal inhalations and exhalations, and guiding the client to find their own way of making the breath feel helpful. In this way, breath was more active and explicitly intended to promote calm and relaxation. For Dana, Rebecca, and Stacey, their counsellors included breath when they noticed the client was feeling stuck, anxious, overwhelmed, or confused. Rebecca found taking deep breaths helpful and calming: “[taking a deep breath] helped a lot because it kind of calms you down a little bit and it’s also kind of a comfortable place as well. You’re not doing anything really strenuous but it helps when you take a deep breath in just to calm things down”. Participants felt a simultaneous sense of calm and clarity in thinking, which facilitated the talk therapy aspect, or verbal processing, that would typically begin again after taking time to focus on the breath. Megan had a unique breath experience in which a style of breath called Holotropic Breathwork was used to activate and facilitate self-exploration. Megan’s counsellor guided her through accelerated breathing in the supine position. It typically lasted for 20 minutes and, during this time, old emotions, memories, and thoughts would arise. After the breathwork, Megan felt more open and able to talk about what came up in the breathing process. 44 Bodywork. Bodywork is related to body awareness; however, it is a constituent part that warrants its own description in this theme. Bodywork is the term chosen to describe the actual engagement of the body through movement. Although yoga postures were used in four of the six participants’ counselling sessions, body movement was the predominant and unanimous method for engaging the body. Movement was not technical, specific, or strenuous; the aim and focus was the sensation that arose, rather than the movement itself. Movement included stretching, incremental shifts, nonspecific poses, walking, and any body motion that created sensation. Counsellors emphasized that the movement should be comfortable and that the client should not push themselves or their bodies. Bodywork could be done in a chair, though it usually occurred while sitting, standing, or lying down. Commonly, participants were in the supine position with their eyes open or closed listening to their counsellor guide them through the movement while they verbally described anything that was coming up internally. Counsellors facilitated this exploration through asking open questions, such as “What is happening now?” Counsellors guided participants to pay attention to body sensation in a curious, nonjudgmental way. While movement kept participants connected with the body, a significant aspect of what participants described to their counsellors included the arising psychological content, including thoughts, memories, emotions, and old beliefs, that was connected with the physical sensations. Rebecca described bodywork as providing an opportunity to “let go” through movement. In their descriptions of the use of movement in session, Dana and Anna highlighted the abstract quality of the movement and the purpose of the movement being to connect with and explore sensations that arose. Dana noted that “the movement is really abstract so I can’t even totally remember 45 what it is, it’s just a sensation.” Anna differentiates what was done in therapy from what’s typically described as yoga postures in the following statement: . . . you wouldn’t call them postures because they weren’t technical postures, but just going through different motions and being aware of what came up when I was doing that you know, what sensations I was aware of and actually just beginning to listen to my body again, just the somatic experience of that. For two of the six participants bodywork included touch; the combination of bodywork and touch was called yoga therapy. For Dana, touch was supportive and contributed to a sense that the counsellor was engaged in the process. For Stacey, touch extended into adding gentle pressure to deepen the stretches. Stacey had a few experiences where yoga therapy facilitated an intense physical sensation, particularly when her counsellor used touch to deepen a stretch. Typically after these deepened physical stretches, Stacey’s counsellor would allow her to fully experience the discomfort and shake it out before guiding her into a regulating breathing exercise. For five of the six participants’ experiences, the use of yoga-like poses and postures were part of the counselling experience, or recommended for use at home. Four of these participants engaged in postures in session. The fifth participant actually engaged in a yoga practice (moving through physical postures in a group) as a part of her intensive group therapy program. The postures used in session were typically simple poses that functioned to facilitate body awareness, reduce anxiety or tension, and help to regulate the client. Poses used included child’s pose, supported squat, mountain pose, and forward bend. These postures helped clients to come back to the present moment and feel the body in it’s current state. Counsellors guided clients through these poses when clients were overwhelmed by their experience and felt as if they were back in a past upsetting memory, which helped clients to come back into their present bodies and become calm and grounded. Megan had an asana practice as a part of her counselling program and 46 described the yoga as a “moving prayer” that had a different, deeper quality than regular yoga classes. Body awareness. A major aspect of this counselling for all participants was that the use of yoga included bringing attention to the body. This was described in many ways, including being “aware of what was going on in my body,” “inner connection,” “experience your body,” “focus on your own body,” “listening to the cues,” and “integrative body awareness.” Two of the six participants stated they had been disconnected from or avoiding their bodies. Through yoga, participants learned to connect, or reconnect, with their own internal experience. Including the body in this way broadened the participants’ awareness of what was happening within them and how that changed from moment to moment. Body awareness is noticing body sensations, which included but was not limited to tightness and tension. Through internalizing her awareness, Rebecca realized aspects of her experience that she was not connected to before, which helped her tend to what the body needed. Connecting with the body and intentionally attending to sensations enabled participants to notice their embodied experience, which provided them with information on their own current physical, emotional, and mental state. In addition, body awareness brought participants into the present moment because, as many participants learned from their counselling experiences, the body is always in the present. Brenda describes how counselling helped her get out of her head and access her mental experience through her body. She stated: as soon as I shift into the breath or the body I have to be in right now, and therefore I am in my own feelings, thoughts, emotions, whatever and not in the expectations that I think I put on myself or that I perceive others put on me . . . the moment I pay attention to my breath I’m back in right now. 47 Four of the six participants were guided to close their eyes when paying attention to the body, which removed distracting external stimuli and potentiated their awareness of what was happening within. For Dana, this counselling was made unique by its use of connecting with and exploring the body. She noted, “that you can really experience your body is what makes [this therapy style] unique . . . So, there’s truly an invitation to play around with your body and have it be supported.” Participants found this therapy more profound and engaging than just talking because it included being connected to the body and feeling something physically. Participants developed body awareness through repeatedly “connecting within” during counselling, which was facilitated by counsellors’ open questions reminding participants to scan and verbalize their embodied experience. Stacey reflected on developing the ability to know what is happening in her body and how that empowered her to know what she needed in therapy: “I’m aware enough of my body now and you know kind of understand a little bit of what’s going on, so I just can go my own pace.” Mindfulness. As discussed in the previous section, counsellors guided participants to pay attention to their bodies. For all participants, body awareness had the quality of being in the present moment, on purpose, without judgment, which is Jon Kabat-Zinn’s (2013) definition of mindfulness. Mindfulness was explicitly named as part of the experience for two of the six participants. Based on the participants’ descriptions of the way they learned to pay attention to stimuli in the present moment (i.e., focused nonjudgmental awareness), mindfulness was a part of all participants’ experience. Although body awareness used in counselling was always described as mindful by participants, mindfulness is described here as an independent component 48 because participants learned to be mindful of other objects of attention in addition to the body. Other objects that were mindfully attended to included thoughts, feelings, emotions, and memories when the client and counsellor were exploring and processing psychological concerns. When the client was overwhelmed, gentle awareness focused on the stimuli in the room to regulate, calm, and ground the client (body awareness can be triggering when the physical state is in a stress response). Participants also described being mindful of breath and engaging in a more open form of mindfulness meditation in which attention was not on any particular object, but open to all stimuli in the flow of experience. The use of mindfulness, also described in the literature as mindful awareness, to explore present-moment experience started with using yoga components (e.g., bodywork) to bring awareness to the body. Through this, participants noted their counsellors taught them how to ‘notice.’ This awareness was slow, gentle, nonjudgmental, curious, and removed of any expectations or desire to change the experience. Participants described learning how to pay attention mindfully through two means. First, they learned explicitly through counsellors’ verbal guidance. When discussing her counsellor, Brenda stated “she trained me to be a lot more curious about what I'm noticing.” Anna's counsellor taught her mindfulness meditation, which started as attending to the breath and later broadened to include being mindful of passing thoughts, inner dialogue, and sensations. Through this process, Anna described “developing a practice of noticing where I was attempting to attach to [thoughts], where I was attempting to push away from them or distract myself from them, where I was judging, you know, the different thought processes and emotions.” This mindfulness skill was learned through her counsellors’ guidance. Counsellors’ questions also facilitated the development of this skill by being very open and curious. Seemingly simple questions, such as Rebecca’s counsellor asking “how do 49 you feel now?” after guiding her through a breathing exercise, helped participants access and reflect on their authentic, present-moment experience without judgment or expectation. Participants also learned to be mindful implicitly through modelling. Counsellors’ way of being was mindful and participants described internalizing this mindful approach. Brenda described her counsellor as “really there without judgment but with curiosity . . . spirit of wondering.” For Megan, mindfulness meditation taught her to not judge her internal experiences and it provided “space” and a method for observing rather than reacting: “It gives me that space to become aware of what’s in my mind, and then step back from it and see that these are thoughts and they will come and go.” Attending mindfully to the internal experience was easy and often enjoyable for participants when the sensations being attended to were neutral or pleasant. Mindful awareness enabled the participants to explore their experience and notice what arose. It also facilitated a sense of inner connection, which felt cohesive and comforting. The practice became challenging when sensation was unpleasant. Then, participants describe the counselling work as focusing on noticing if the participant can stay present with that uncomfortable feeling. Mindfulness of unpleasant sensation has been described as intense, overwhelming, and unnerving. However, this ability to stay present and connected to unpleasant sensations relates to building capacity or resilience, which was also part of this experience for participants and is described later. Theme 2: Counselling Components Verbal exploration and processing. All participants described dialogical exploration and processing as part of their experience. This is the aspect of the experience participants viewed as the “talk therapy” component. Counsellors facilitated two aspects in counselling: (1) exploration of present- 50 moment experience and (2) processing of psychological content that arose in counselling. This occurred during and independent of yogic work. Through questions and probing, counsellors had participants verbally describe and explore their present-moment experience, including naming what they are aware of and how they feel and what their automatic reactions or urges are in response to their experience (e.g., desire to pull away). Reflection occurred during an experience or shortly after, such as after a breathing exercise. Reflection was an important aspect of being able to be aware of, process, and gain understanding and information through embodied experiences happening in the session. Checking in during and after the yoga components helped slow participants down and enabled them to maintain connection to their bodies during the experiences. When mindful body awareness brought up memories or thoughts, the focus transitioned from naming and reflecting on the experience to deeper exploration of the psychological content. Through open questions and prompts to elaborate, counsellors dove deeply into and unpacked participants’ memories, old negative beliefs, and previous meaning made of past experiences. By “working through” these emotions, memories, thoughts, and underlying beliefs, participants’ awareness grew and they were able to understand their experiences in new, more helpful ways (i.e., make new meaning from a place of awareness and understanding). Anna and Megan described what the process of developing awareness looked like in their counselling experiences. Anna stated that she developed “awareness around what the narrative is around that emotion and why it needs to be, why I’ve been shutting it down, and what could be a different.” Megan mentioned: basically taking a current emotion or current upset, staying with the feeling, tracing it back to an earlier time where you had that same feeling and through that you could see these were the different messages I gave myself. 51 Awareness, developed through verbal processing, helped open participants to new possibilities in regard to the way they perceived, what they thought, and how they behaved. Brenda described this aspect of the counselling as changing her interpretation through widening her frame. She learned that her habitual ways of being and reacting have “less to do with what’s actually happened than with my interpretation.” For Rebecca, the opportunity to reflect on and process the embodied experiences occurring in counselling brought a sense of closure. Megan felt that she was able to take back ownership of her past through her counsellor following and exploring her experience and deepening her awareness of the meaning she made and how that meaning impacted her way of perceiving the world in her present life. Paying attention to and being curious about the way she understood the past enabled Megan to undo those meanings and understand past events in ways that were more realistic or more helpful. Counselling is curious and nonjudgmental. Participants described the counselling approach as nonjudgmental and curious. Counsellors were described as kind, compassionate, and nonjudgmental. They facilitated a counselling process that was patient, gentle, and slow. For Dana, the nonjudgmental aspect of the counselling comes, in part, from the therapy including attention to the body as well as the mental and emotional aspects of the client. She stated: It feels, to me it feels nonjudgmental even more . . . you can relax your physical being and have that also not be judged, it’s being attended to as well. I think that’s a huge advantage of being able to go to someone who can work with your body and talk about your stuff. Brenda described what she found when she came to counselling that included yoga: “This nonjudgmental, kind, accepting attitude mixed with a sense of curiosity is what I found.” Exploration felt more full, spacious, with more options. A nonjudgmental approach facilitated by inclusion of the body helped clients be more open, trusting, and feel safe to be themselves in 52 sessions. Brenda describes how the counsellor's accepting, curious approach transformed counselling into a place of being: “a place that’s a lot more curious and a lot more gentle and a lot less judgmental.” Dana provided a general definition of talk therapy within the context of this therapy experience: talk therapy meaning . . . able to get support from [the counsellor] and . . . she’s going to listen and be empathic and nonjudgmental and potentially offer me ways of looking at things differently, different perspective, feedback what I’ve said, help me explore, and essentially hopefully help me feel like I have found some solutions or feel that I’ve had some catharsis or been able to be vulnerable or whatever the heck it is. Counselling is person-centred and client-directed. Counselling that includes yoga is described by one participant as “like the counsellors who use yoga aren’t trying to figure out what is happening, they are following the experience – using the body as a map.” Brenda states that counselling that uses yoga: involves a sort of person-centred perspective, that every individual has the answers to their own life quest, however you want to put it, that learning to be your own teacher and your own pupil is part of it and learning that trust in yourself. Above, two participants describe their experience of this approach being person-centred. This is a theme that emerged from the participants' descriptions, with all six describing this counselling as person-centred, collaborative, client-directed, Rogerian, following rather than guiding, or experiential rather than theoretical. This counselling approach, which is curious, nonjudgmental, and includes the body, sees the client as the expert in their own lives and counselling as the place to expand their awareness and capacity to help themselves. Participants described their experience of one of feeling truly listened to, attended to, and supported. The counsellors were engaged, present, and involved in the counselling, which created a sense of co-participation or collaboration. 53 All participants described this approach as client-directed. The counsellor was a guide who offered and initiated ways of working and exploring in session, but ultimately the decision of whether to engage or not came from the client. Counsellors offered suggestions tentatively. All participants felt able to say no to an offer, though many of them noted that they did not because safety, trust, and comfort had been built. Clients also felt able to choose to be with an experience or not and to share what is going on internally or not. Nevertheless, again, most participants noted that they felt safe to explore, try, and share when prompted with their counsellors, though it was important to them to know they had the option. Counsellors, including those of Dana, Rebecca, and Stacey, also invited clients to design the activities done in session to suit their preferences and needs. For example, Stacey’s counsellor initiated yoga therapy and would have Stacey guide her own body in what felt good. At times, Stacey talked for the entire session because she “couldn’t help” herself. Her counsellor would respect her choice to talk on that day and allowed Stacey to initiate the yoga therapy when she felt ready and willing to transition from the need to “just talk.” It was clear that the counsellors trusted in their clients’ abilities to help themselves, which strengthened a sense of empowerment in each client. Brenda described it as facilitating change that felt nourishing instead of imposed. Rebecca’s counsellor helped her develop small, achievable goals that were realistic and enabled her to work at a pace that honoured her. The participants reflected that being able to decide what is best for them was an important part of this counselling approach, and it was facilitated by the counsellors’ person-centred approach. Clients did not feel that the counselling focused on an agenda, was coming out of a manual, or was based on interpretation. Counsellors appeared to approach the clients from a place of curiosity and “not knowing.” Participants described this counselling as non-interpretive and non- 54 pathologizing; in their experience, the client understands and makes meaning for themselves rather than the counsellor imposing a universal meaning onto their experience from an outside source. For example, Dana’s therapist did not provide interpretation and would encourage Dana to expand on her response, which created a collaborative, empowering, and client-directed experience. Theme 3: Structure of the Integration of Yoga and Counselling Each counsellor had their own unique way of conducting counselling and including yoga. However, there were combinations of components and ways of transitioning and integrating the components that were common to all. All participants’ counselling experiences included periods of talk therapy without yoga, talk therapy with yoga, and yoga without talk therapy, in which the client stayed with their embodied experience without verbally exploring or processing it. Transitions to the use of yogic elements, including breath, body, and mindfulness or meditation, were initiated by the counsellor based on what was happening in the session. In other words, the inclusion of yoga was based on the counsellor’s evaluation of the client’s moment-to-moment experience and needs in session. For example, when a client felt acutely anxious, the counsellor often encouraged the client to transition to breath awareness, meditation, or a grounding posture to bring relief. Another example includes when Brenda told her counsellor about feeling tight in a particular pose, her counsellor encouraged her to transition into doing micro-movements while paying attention to her body and what memories, thoughts, and emotions arose while tracking physical sensations. In this example, transitioning to the yoga helped Brenda come out of being stuck in regard to the tightness and she developed an awareness of old memories and ways of being that were associated with movement in that area of her body and, as a result of this process, Brenda was able to access a little more freedom of movement in that body area. 55 Transitions happened in a spontaneous, natural way that the client had ultimate direction of. Rebecca noted the use of yoga components was offered as optional and some aspects were client-chosen (e.g., she chose the mantra to focus on while meditating). Dana describes what this process was like for her: “organic and spontaneous the way that the addition of the physical work was done. Ya. And it was . . . directed by me in the sense of deciding when that would happen or not.” Three, or half, of the participants had group components to their experiences, while the experience of the other half included individual counselling only. For all of the participants, periods in therapy that focused on verbal processing without yoga occurred in chairs and typically one-to-one. The groups tended to focus more on using and integrating yoga and verbal processing. Though the individual sessions also included integrated yoga and verbal processing, the one-to-one counselling did include more time sitting in chairs and talking than the groups did. So, structurally, the individual sessions included more transitions between what would be considered traditional talk therapy and the use of yoga in counselling. Once the yoga was being used in session, whether group or individual, the process was described similarly. Three of the six participants explicitly noted that the yoga and counselling components are not experienced as separate and distinct. The components overlapped in different ways at different times. Dana named this integrative counselling style “the new mix,” meaning that the integration of talk therapy and yoga therapy combines the physical being with emotional and intellectual ways of processing in a way that is different from the sum of the parts. Participants noted that they could not truly tease apart the components. The yoga and counselling aspects are constituent parts of this therapy style in that they can be described independently, but rarely occurred in true isolation. Counselling was described as having both yoga and psychotherapy 56 tools readily available to the client and counsellor in session, and clients would engage in them (e.g., body awareness or breathing) when reminded or prompted by the counsellor. The interwoven nature of the yoga and psychotherapy elements was strengthened as clients became more practiced at paying attention to their body and breath and would include body awareness or breath as they continued to verbally explore their thoughts, feelings, and memories. Dana reflected on the ambiguity and benefit of this mix in the following statement: “this is nice because it just feels quite expansive. Again, it being the marriage between talk therapy and yoga therapy coming together as some new amorphous thing.” Theme 4: Inclusion of Yoga Facilitates Bottom-Up Processing and Regulation Participants described a body-based counselling process in which the inclusion of yoga facilitated access to psychological content through body awareness and regulation of self through connecting with the body, breath, and present moment. Below is the description of these two processes, the opening and containment of the self in session. Bottom-up processing. Paying attention to the sensation in the body in a curious, nonjudgmental way brought awareness to arising thoughts, emotions, and memories. When verbally explored and processed with the counsellor, this process facilitated a physical release or catharsis experience and new insight into and understanding of past experiences and present struggles. The two sub-themes that comprise this aspect of the experience are described below. Body as access point to physical sensations, thoughts, emotions, memories. The curious, nonjudgmental exploration of the body, described above, was the main modality used in this counselling style to access and work with psychological content. For all participants, connecting with the body was a way of making contact with thoughts, emotions, 57 and memories. Paying attention to physical sensation and following the embodied experience enabled participants to notice mental and emotional experiences as they arose. Participants then shared these experiences with their counsellor and explored the content while staying with their present-moment experience. Participants noted that although part of the function of including the yoga components was to connect with and feel the body, the primary purpose of exploring body sensation was to focus attention on and access thoughts, emotions, and memories that arose through attending to physical sensation. Dana noted that the movement her counsellor facilitated kept her connected to sensations in the body while she maintained focus on the cognitive and emotional aspects of self: “It's that you're having this sensation of being connected to on a physical and emotional and psychological level . . . you’re still very focused on what you’re thinking and feeling.” In the statement below, Anna describes her experience of connecting with emotion through paying attention to the body and the breath, even when it felt unrelated or inconsequential: Within the counselling sessions we did some work where, when I was aware of a sensation when we were doing the body work, [my counsellor] would encourage me to breathe into that area and then just explore what’s coming up even if it seems totally not related to anything. And often actually breathing into that area and bringing awareness to that, something would come up that would seem inconsequential in that moment, but actually it was something, an emotion or something happening behind that. Brenda described the inclusion of the body in counselling as a “back door” to the mind: “goes from what’s happening in my head to what’s happening in my body, and then I can explore things more fully, in a way that kind of bypasses that inner argument.” She described this experience as becoming “unstuck” when she brought her awareness away from the internal conflict happening in her mind and focused her attention what was happening in the body. Responses that came from the body awareness and were shared with the counsellors related to physical sensations, memories, fight-or-flight reactions, emotions, and thoughts. For 58 two of the six participants, accessing and connecting to their embodied experience felt intimate and vulnerable. Including those two, three of the six participants described “connecting within” as comforting, cohesive, or caring. Participants also described experiences in counselling where “following the body” brought them in contact with unpleasant sensory experiences. In these descriptions, participants made contact with unpleasant or intense emotional, embodied experiences and memories that felt uncomfortable to be with. Five of the participants had both pleasant and unnerving experiences when they connected with emotions and memories through the body in session. Anna described how somatic experiencing could be both pleasant and unpleasant: It can be unnerving. Sometimes, in a way it's really comforting because it's about finding an inner connection . . . But sometimes when something does come up, and there's a pain . . . it brought back a memory of a traumatic incident that had happened in the past and in that moment I'm there . . . So ya, that can be disconcerting. For Anna and other participants, connecting with unpleasant sensation in the body triggered memories and emotions that they have previously avoided or pushed away. Body awareness accessed this content and the participants’ work became noticing whether they could stay with the uncomfortable feeling, which is described further in the sub-theme Capacity to Be With (Uncomfortable) Experience. Psychophysiological insight and catharsis. Once participants accessed psychological content through the body, counsellors facilitated exploration and processing of the material. They discussed thoughts, emotions, memories, beliefs, and meaning made of past events. Through bringing these various aspects into awareness, participants were able to: (1) develop insight, (2) experience a release or catharsis, and (3) integrate the parts of self being processed and worked through. The body was a powerful tool for facilitating integration of disparate parts of self. Participants described the 59 process of moving toward integration as starting with body awareness, through tracking physical sensation. Then, the process moved through noticing what comes up, exploring what arises in a curious, nonjudgmental way, processing past experiences, understanding old meaning made, and integrating the previously avoided, separate parts. Participants described understanding past events in new ways, which created more freedom and coherence in their present lives. Megan had a formalized experience of this process. One of her counsellors had previously created a structured approach to facilitate insight through body awareness. Megan’s experience started out similarly to the other participants with the development of insight into how she had made meaning of past experiences, which was facilitated through tracking discomfort in the body and the associated memories, thoughts, and feelings. Her counsellor guided her to connect with the earliest memory associated with the sensation, emotion, or thought coming up through the body. With the guidance and support of her counsellor, Megan became aware of how she had understood that experience at that time. Then, she could see how these old messages, embedded in past experience, were still operating under the surface in her life today. Through this awareness, Megan was able to change the way she understood the past and use that information to change the way she perceives, thinks, and acts in her life now. In this way, she felt she was able to integrate this new awareness and translate it into her life. Megan described this style of counselling as working on a deeper level than other mental health treatments that she had experienced. Insight, or awareness, was part of each participants’ experience. The counselling process, described above, facilitates insight through pairing verbal processing and mindful body awareness. This process, which Anna described as “unpack[ing] the narrative,” explored the beliefs and meaning underlying past experiences and current ways of perceiving. Participants 60 described awareness as coming to them in a rush of insight. Phrases and terms participants used when referring to this experience include “magic” and “oh my gosh.” Clarity and freedom was the sense described after participants developed new cognitive understanding. Participants also described experiencing physical catharsis, or release, through this process. At times, this was facilitated by insight. Brenda described an example of this when she reacted to her counsellor’s insight: “[the counsellor] would name her guess about what that body pattern meant. And often I would just burst into tears”. Physical release, or catharsis, was a part of all six participants’ experiences. The release experience was typically described as a physical sensation joined by a cognitive insight. The release could feel peaceful as well as intense. Through the bodywork and verbal exploration, participants noticed tension or a sense of holding in the body, made contact with previously stuck material, worked through it, and experienced a physical cathartic release. Rebecca experienced this through the mindful movement facilitated in her yoga group therapy. Moving the body in certain ways helped Rebecca to release emotions: “[moving the body] can release emotion so it’s not necessarily something that would reduce anxiety but it can release things and something may come up but then you may get rid of some energy that’s held there.” Rebecca defined this entire counselling experience as a “peaceful release.” For Dana and Stacey, catharsis was facilitated by the simultaneous engagement of the body and mind in an open, supportive environment. Dana felt that the opportunity to talk, be abstract, think, feel, and have contact with her physical sensations provided a more profound sense of catharsis than would be possible without the inclusion of the body in therapy. Stacey also felt that opening up about personal things while in physical postures facilitated intense release. Stacey and Anna believed that bodywork connects with and opens the body which 61 encourages the processing and releasing of emotional suffering. Through this, participants described experiencing a sense of connection with self, comfort, and cohesiveness. The combination of opening up about personal things and opening up the body had powerful cathartic potential and facilitated profound release experiences for participants. Four of the six participants experienced some catharses in session that they described as “intense,” “disconcerting,” “unnerving,” or “overwhelming.” For Stacey, intense physical release often occurred when facilitative touch was used, and she had the sense that “powerful electricity was coming out” of her body. These catharses felt overwhelming to Stacey; she felt “too much up in [her] head” and not grounded enough to handle the intense energy emerging through her. Not all of Stacey’s experiences felt overwhelming. She noted that despite moments of feeling overwhelmed in session, the overall counselling process helped her become grounded overtime. Stacey, Anna, and Megan described timeframes associated with the intense experiences. The immediate experience in session included feeling overwhelmed and a desire to pull away from the experience. Later in the day, after staying with the experience, regulating, and noticing the intensity subside, participants described feeling disoriented and fatigued, needing time to rest and self-soothe (be comforted). Days after the session, participants described further release and feeling lighter, clear-minded, and free. Insight and release facilitated integration by making a connection between disparate parts that was not present before. Participants developed awareness of the ways they had made meaning of the past, which helped them change their perception. They also experienced a sense of clarity and freedom through breathing into and releasing old holding patterns in the body. Working through blocks or places where the participants felt stuck, physically and emotionally, brought new awareness and the opportunity to integrate aspects of the participants’ self that they 62 did not have access to previously. This inner connection was powerful and had the ability to be both comforting and overwhelming. Anna summarizes this style’s ability to access and process psychological content through the body and the utility of that: I think counselling, it’s really about integration and helping, facilitating people find that integration of all the different parts of their selves that they’re trying to perhaps mould or shape or disown or detach from or let go of or banish or however you want to, and revering some parts of themselves over other parts, and it’s trying to, yoga for me is about finding that cohesiveness between all those different parts, acknowledging all the different roles that they play, even the things that you don’t, that you would prefer not to embody, you know, acknowledging that there’s value to everything that’s within your experience and just I think the yoga part of that is really to do with, yoga is the mechanism through which you can do that work, yoga is the mindfulness meditation but because it engages the body so much, it puts your body in that position of kind of co-facilitating the growth and the movement within those mental and emotional patterns. Affect regulation. In addition to emotional processing, the yoga components were used in session to establish and develop the capacity for affect regulation. The regulatory capabilities of yoga were described in two ways: (1) to help clients calm in moments when they were overwhelmed by their emotional experience and (2) through working with curious, gentle body awareness in session, clients developed resilience, or a capacity to be with discomfort both in session and in life. Use of yoga to calm, relax, ground. There were times in counselling when the participants felt stuck or overwhelmed by their experience, such as when exploring trauma memories or feeling tense or anxious. Once the counsellors became aware of the clients’ state, the counsellors used yoga to help the client ground, calm, and relax. Counsellors used breath, grounding, mindfulness, body awareness, and yogic postures (such as child’s pose, forward bends, mountain pose, and other strong, rooting postures) to help clients calm and regulate. Grounding exercises included noticing the sensations 63 of one’s feet on the ground or attending to the sensory input in the room, which connected the participant to the present-moment and brought them out of “reliving” the past. Breath awareness was another means of helping clients calm and regulate in session. For example, Dana’s counsellor initiated time for her to focus on her breathing when she noticed Dana felt stuck, overwhelmed, or confused. The counsellor guided Dana to close her eyes, put her feet flat on the floor, internalize her awareness, and connect to her breath. For Dana, connecting within was comforting and intimate. Brenda found that body awareness brought a sense of relief and prevented her from getting stuck in her thoughts. Anna found that breath work and grounding were vital to bringing her back to the room and the present moment when she began to feel emotionally overwhelmed and split off: In instances where we have done some work that’s pretty intense and has brought up a lot of emotion or you know I felt fragmented or split off or something, then the breath really helps again to ground and just come back to the body, and [the counsellor] uses that you know in terms of just coming back into your body and calm down and taking breaths. All of these techniques functioned to bring clients back into the present moment and feel their body. Returning to their current experience took them out of worries of the future or memories of the past. The use of mindful awareness, breath, and grounding postures facilitated a calm, relaxed sensation that countered the anxious, overwhelmed, reactive state they were in. Through practice, clients learned to use these tools themselves and were able to implement them when they felt triggered outside of counselling as well. In addition to using yoga for affect regulation when clients were feeling overwhelmed or stuck in session, it was also used at specific times, such as at the beginning or end of a session or group. Rebecca stated that beginning sessions with meditation functioned to “help you ground and calm down and relax and then . . . move on to talking.” Breath and meditation facilitated calmness and clarity which translated into clear, calm thinking and talking in therapy. As clients 64 became less anxious and reactive, they also became more able to focus on and articulate their thoughts and feelings to their counsellors. In this way, affect regulation not only helped to calm clients, but it also facilitated talk therapy. Brenda describes an example of when her counsellor recommended postures that helped her ground. Doing these rooting postures in session helped Brenda to reconnect with the present moment and come to a clearer mental space that facilitated verbal exploration and processing: “when the energy was low in the body, I wasn’t in that anxious breathing place then I could look at it a lot more objectively.” Capacity to be with (uncomfortable) experience. In addition to regulating their experience, clients also found that yoga helped them develop a capacity to be with difficult experiences in session. This was described as “resilience,” “capacity,” “staying with,” “be with,” and “developing a practice of noticing.” This capacity to be with experience enabled clients to maintain contact with unpleasant sensations, thoughts, memories, and emotions. Capacity to be with experience was developed through the client learning in counselling to pay attention without judgment to the present moment. In other words, mindful awareness was the mechanism through which clients developed resilience. Mindfulness is different from relaxation. Techniques that promote relaxation, grounding, and calming have a purpose, they are doing something. However, mindfulness is non-doing and it enables clients to be with what is. Brenda describes this as a “capacity to meet whatever happens in the moment,” which enables clients to feel self-sufficient and resilient. Anna built tolerance by focusing on “can I stay there?” when she came into a place of discomfort. Through this ability to be with experience, clients were able to explore what lay underneath these experiences and process them through talk therapy. The ability to be in discomfort in the body and approach that experience with curiosity and acceptance facilitates the “capacity to work on things.” 65 Brenda felt able to “meet adversity with quality of curiosity, non-judgment” because “yoga and counselling together have helped me realize that I have capacity to meet whatever happens in the moment.” Sustained exposure to uncomfortable experiences builds tolerance and allows clients to explore at a deeper level and notice reactions and behavioural urges that arise instead of living in them. Mindfulness and yoga helped participants build a container to notice, be with, and explore experience with curiosity and breath. Megan noticed a difference when she was to able accept discomfort. For her, there was more space, less attachment, and opportunity to process the deeper aspects of the experiences that led to healing and growth. Anna and Brenda, respectively, describe how this counselling style led to a life practice of being with: My life can be a continual exploration of what is there for me in each moment and it’s not about a polarity of illness and health or wellness and ya. It’s just about learning to be with what’s there, especially as big emotions come up. Using yoga in counselling helps to build personal capacity and resilience. When I don't know what to do and I feel out of control in my life, I can come back to my breath and body and connect in. I can pay attention to or even change aspects of my experience (even when nothing external will shift or change). This has greatly increased my capacity to sit with difficult experiences, emotions, and thoughts; to wait to act until I am sure that the action is best for me - rather than acting for the sake of acting to release the tension caused by difficulty. Theme 5: Whole Person, Whole Life Approach Whole person approach: Engaging the relationship between mind and body. The inclusion of yoga in counselling facilitated insight, release, and integration through simultaneously engaging the mind and the body. Underpinning the use of the physical sensation to reach and activate mental and emotional content is the relationship between the mind and the body. Participants learned the body and mind are interrelated. Brenda, Stacey, and Anna pointed out that the kind of thoughts and beliefs that they paid attention to, and strengthened into patterns, had an effect on their bodies (e.g., their posture was concave when negative thoughts 66 were pervading). This style of counselling accessed the body first, not the thoughts, beliefs, or memories. Participants learned to observe the relationship by noticing what happens to emotions and thoughts when there are changes in the body. Examples from Brenda and Anna, respectively, include: [The counsellor] uses a lot of exercises to help us begin to study what’s happening in your head and what’s happening in your body and how they relate . . . sometimes I’m not really aware of the thoughts and there’s just something going on in the body and I start exploring the body and then I notice the thoughts and then I, I don’t know it’s like it’s moving back and forth. My experience of it is just that it’s really about allowing the body to speak back to the mind and teach the mind rather than the other way around . . . then you know, what is going on in relationship to that memory and in my body? Anna felt that breath connected the mind and body: This relationship between breathing in to find the relationship between the mind and the body and figure out ok, what can the body show the mind rather than the other way around … I think the breath is just the thing that links and holds it all together. The breath is the canal way through all these processes. Participants often described experiencing the mind and body together and recognizing the relationship between these parts of themselves as expanding their awareness and a sense of realizing that they are more than just their thoughts or their beliefs. Being attended to, supported, and self-aware physically, emotionally, and intellectually is a powerful experience. Dana described this as heightening a sense of vulnerability and creating an approach that is holistic, valuable, and intense. Participants described this process that marries the physical being with emotional and intellectual ways of processing as a whole person approach that “says yes to” and supports all parts of the client. Brenda describes this as an integrative, whole person approach: “I feel like it’s just more integrative I think. Like it’s the whole person, not just some disembodied brain.” Rebecca and Stacey also described the comprehensiveness that this combination of psychotherapy and yoga allows for by being able to attend to mental, physical, 67 and emotional issues. Stacey and Megan emphasized that the deeper root of their issues was accessed and addressed through this work, in contrast to other therapies they had experienced which focused on symptom relief and behaviour change. Participants felt less stuck in and less reactive to their thoughts in part because they learned their thoughts are just one aspect of the self. Brenda summarizes the wholeness of this counselling approach through her thoughts on the experience: “when you put yoga in there you realize that you’re more than you ever believed you would be, and you’re certainly more than your thoughts … It’s just the whole package.” Profound experience that becomes a way of life. When reflecting on the impact of this counselling experience, all participants described this counselling as valuable, profound, and life-changing. It was a positive experience and all participants displayed excitement and reflected on the therapeutic potential they feel this counselling has to help people heal and grow. Five of the six participants felt grateful to be able to practice and process in this way. Four of six participants stated that this counselling process changed their life. They developed skills in counselling that they could use in their own lives, including mindful exploration of mind and body, capacity to be with discomfort, and using breath to self-regulate. Rebecca noted that yoga is not just a tool for therapy, but a skill for life and learning to cope in a healthier way. Clients learned these tools through direct teaching by the counsellor as well as observing and adopting the counsellor’s way of working. The five participants that described learning these tools for life also noted that it was important to integrate these tools into a life practice. In this way, these tools became the “underlying curiosity” participants learned to use when engaging in their lives. Brenda noted that this process helped her “to have the tools to meet anything, with a quality of curiosity and 68 nonjudgment, and space.” The processes that happened in counselling became integrated into a way of life for participants. This development of a mindful lifestyle seems essential when considering participants’ reflections that healing is a dynamic, life-long process. Developing the tools to be able to cope and engage in life in a new, vital way helped all participants feel empowered, self-sufficient, and able to be their own healers. Anna described feeling more capable, inquisitive, curious, and compassionate toward herself. Trusting in their own ability to cope and heal was important to the participants and, as Anna concluded, this counselling is about “giving a tool for [clients] to help themselves.” Theme 6: Counsellor Qualities Facilitated Trust in Relationship and Counselling Counsellor embodies approach: curious, nonjudgmental, patient, supportive. It is important to acknowledge that all participants brought up their counsellors qualities when asked to describe their experiences of counselling that included yoga. All six participants provided spontaneous descriptions of the qualities of their counsellors, including their approaches and ways of being in session. Participants described their counsellors as kind, open, nonjudgmental, accepting, compassionate, patient, and lovely. Four of the six participants described their counsellors as embodying the yogic approach they used in counselling. For example, Rebecca, Anna, and Megan felt their counsellors upheld the yoga principles in the way they were in session and in their presence with the participant; it felt to those participants that their counsellors truly lived the teachings that they offered. Dana and Anna felt that their counsellors were truly present in sessions, connected and engaged in the counselling process, and were truly mindful. Mindfulness was not just a technique used in counselling, it was a way of being that many of the counsellors embodied. Anna described her counsellor’s presence as an essential feature of the counselling. Through knowing that her counsellor was processing and 69 reflecting with her, she trusted that her counsellor was working from a place of awareness, integrity, and honesty. The following quotes from Anna and Dana describe the importance of their counsellors presence to their experience: “she brings of all of those principles, in terms of how she conducts herself and so, just her essence of just being present with me in that place conveys those things;” “the therapist, [my counsellor] in this case, is 100% with you.” Trust and comfort in relationship and counselling. The qualities of participants’ counsellors created a sense of comfort and fit within the therapeutic relationship. Dana immediately felt that her counsellor was a good fit: “right away she was a really good fit for me, somebody that I felt really comfortable with.” All participants mentioned a feeling of fit, comfort, trust, and safety as a part of their experience and an important aspect to proceeding with counselling. It was often contrasted with other experiences with more traditional counselling in which participants felt judged or were not able to build a sense of trust and safety. Three participants felt that counsellor training contributed to the ability to feel safe in counselling. It was important that their counsellors had the required training necessary for both talk therapy and yoga therapy to be competent and safe working with the body and exploring psychological content. Dana also mentioned that with both trainings, she felt able to just talk if she wanted, which was not available to her in pure yoga therapy. With the training background and qualities that the counsellor embodied, this therapy set up a safe, supportive place to fully explore and be vulnerable. Other aspects that participants felt supported a sense of safety, trust, and comfort in counselling included a nonjudgmental approach, first building a strong therapeutic relationship with the counsellor before yoga is introduced, the counsellor's presence, and knowing that the counsellor had also experienced suffering and healed through practicing the teachings. Brenda 70 described that the counsellor’s presence created a strong relationship and ability to explore in counselling: I feel like that the relationship is more there. Like the counsellor who uses yoga really I feel like they’re really there, and they’re really there without judgment but with curiosity and together we can go into these places that I wouldn’t let myself go on my own. Anna expressed that trust was important and it was a part of the ongoing therapeutic alliance: I can trust that she’s working from a place of integrity and honesty and that that facilitates the trust within the relationship. And that’s a process in itself, that’s kind of part of the ongoing alliance. Ya, I think that’s been really important for me … I think one of the main things that has allowed trust to be built within that relationship is the feeling that I get, an honest reflection of what is going on. Not that she, she doesn’t share that with me verbally, but it’s, I can, ya, just to know that she’s there, she’s present. Non-essential, Important Patterns in the Data The following section has been included to highlight aspects of the experience that many, but not all participants discussed. Though these patterns in the data were not unanimously acknowledged by all six participants, and therefore not included in the general theme structure of the phenomenon, they do warrant attention as each pattern described below was a major element of the experience for a majority of the participants (i.e., four or five participants described the pattern). Healing through yoga can be a “double-edged” experience. It is important to expand on the theme Body As Access Point, which noted that some participants described this experience as overwhelming and intense. Four of the six participants described this aspect of the experience, with three of the participants noting that at times they felt overwhelmed, including when re-experiencing traumatic memories in session. Stacey described the overall counselling process as worthwhile and grounding, with experiences of integration and experiences of intensity. She noted that: 71 Yoga is the hard way of healing but it does actually work . . . it’s sort of a double-edged sword because all that stuff is sort of there and I can feel it inside of me and the yoga does open it up and release it and it you know does actually really heal on a deeper level. Anna and Megan described situations when embodied exploration and processing of traumatic memories would bring them back into that moment and they would no longer be in their present selves. For example, Anna noted: It brought back a memory of a traumatic incident that had happened in the past and I that moment I'm there . . . I had never allowed myself to sit with before and that was pretty scary stuff because it felt like I was no longer my adult self. The way in which counsellors worked with these experiences differed from their usual approach. Counsellors focused on grounding the client and exploring what the client needed (and had not received) at the time of the traumatic event. Megan describes how one experience she had was overwhelming, but by staying with the experience and with her counsellor guiding her, she was able to move through the process and explore more deeply: That part of the process would be so overwhelming and hard and I would want to rip myself apart in the actual process of it and then by continuing to do it, it would drop you into a deeper level where you would actually go through it and move through it. The three participants who described experiencing overwhelming embodied experiences when processing traumatic memories noted that it took time to recover from this process. Anna described the process after an intense session. She noted: In the hours after that, I would feel tired and depleted, I would go home and sleep. I would often feel the need to be kind of fetal, in a sort of comforting, ya, comfort myself kind of pose. And often the day after that, like within 24 hours of that, I suppose it would feel like something, a pressure valve had been released in some way, and that I was in some way just a bit lighter. Despite the yoga being a “double-edged sword,” Stacey reflected on why yoga therapy is difficult but important to her to do: With yoga therapy it’s like, for me anyway, it’s like you’re not always going to feel good after (laughs) because there’s something that you have ignored and buried inside of you 72 and not fully felt and that’s going to come up and it’s going to say ‘hey! remember me?’ (laughs), and you’ve got to let it, give it a voice, and that voice isn’t always going to be a pretty voice and so ya, but you’ve got to clear that shit away if you want to make room for good stuff. Approach to self is accepting. Five of the six clients described developing a more curious, accepting approach to self through this counselling style. The way the counsellor and the counselling worked was through a mindful approach, which the clients, through practice, inevitably internalized. When starting counselling, clients described holding negative views and beliefs about themselves and often blaming and judging themselves for their circumstances. Over the course of the counselling process, they learned to develop a way of noticing, wondering, and being curious toward the automatic thoughts and feelings that would arise. Five of the six clients described their counsellor’s approach as gentle. Through practice and consistent reinforcement from their counsellors, clients began to become supportive, compassionate, and less judgmental toward themselves. Anna described it as an “easing up on myself” that she developed through learning to pay attention to negative beliefs, expectations, and judgments as they arose without attaching to them, judging them, or wanting them to change. This allowed her to learn about the deeper aspects underlying her reactions and urges. Anna eventually developed a curious, compassionate relationship to her thoughts and beliefs and felt able to reframe expectations. Brenda and Megan both learned a healthier approach to self through practicing self-acceptance in therapy. In this regard, Rebecca noted that: “in the moment I’m just doing the best that I can, there is no judgment of right and wrong, it just is what’s happening is what’s happening.” This new approach to self relates to the clients’ developing resilience. With acceptance to self and the moment, Brenda notes that she has the “capacity to meet whatever happens in the moment.” Yoga and counselling together taught many of the clients that if they can accept what is, 73 including of themselves, then they can work with that. Megan described the importance of this way of relating to one’s self when she noted that: “This is where I’m learning to be gentle with myself and learning to just accept myself as exactly as I am in this moment, whatever that is.” Developing an orientation toward: Yoga and community. Four of the six participants felt this therapy style facilitated an orientation toward community. Rebecca and Anna found being engaged in a community that shared an intention to practice yoga and mindfulness potentiated the sense of empowerment and wellness they experienced. They both acknowledged that social comparison was present or something they feared, but that fear diminished as they developed trust in the group and experienced the benefit of being in a community of like-minded others. For Megan, “service to others” was a major aspect of the immersive therapy program she engaged in, and developing an attitude of service was used as one of the markers for healing. She noted that part of what designated someone as ready to go home from the immersive therapy program included a transition from a “what can I get attitude to what can I give.” Brenda’s experience differed slightly. The less judgmental, more equanimous approach she was developing toward herself in therapy began to translate into how she interacted with others. This counselling process has changed the way Brenda interacts with self, others, and the world. She noted: “this yoga and counselling style is really important because it helps me to be able to meet people in my community in a completely different way.” She noticed there were less conflicts in her relationships and she felt she was able to be more understanding and accepting of others. From these experiences, Brenda reflected on the potential that this therapeutic work may have in a broader social context: “I think that if we can learn, if more of us can learn to do that, it would build stronger communities and bigger acceptance of each other.” 74 This reflection suggests that learning skills, such as mindfulness, may shift people’s way of relating to another in a way that is more understanding and accepting and less reactive. 75 Chapter 5: Discussion The purpose of the study was to describe and understand the client experience of counselling that integrates the use of yoga. In this chapter, the study’s findings are situated within the previous literature and the unique contributions that this study offers are presented. This chapter also includes a discussion of the strengths and limitations of the study, possible directions for future research, and implications for counselling psychology practice and training. Situating the Findings Within Previous Research Yoga components, counselling components, and integration. The first three themes discussed in the findings pertain to the component and organizational structure of this counselling style. Specifically, the yoga components (i.e., breath, bodywork, body awareness, and mindfulness) and the counselling components (i.e., verbal exploration and processing that is curious, nonjudgmental, and person-centred) are described as integrated and transitioned between in counselling. These findings confirm the component parts of yoga psychotherapy described by Kocian (2012), namely that all clients’ experiences included bodywork, breath, some form of meditation or mindfulness, and verbal processing. It is important to note the possibility that this finding may be an artifact of the study’s inclusion criteria, as these were requirements for participation to ensure the study captured the experience of counselling that included yoga and not solely mindfulness or meditation, which are also practices commonly used on their own in counselling. Nevertheless, the components of the phenomenon described by the client-participants in this study are congruent with the components described by the counsellor-participants in Kocian’s (2012) study. Given the paucity of research on the integration of yoga and psychotherapy, the consistency in findings between the present 76 study and Kocian’s work offers promising insight into the likelihood of this new integrative therapy having common elements and organization. Inclusion of the body. Bodywork and breath awareness used in this experience were primarily described as ways to facilitate connection to physical sensation. Awareness of the embodied experience helped participants access associated thoughts, feelings, and memories that arose when they focused on sensation in the body. van der Kolk’s (2006) review of the neuroscience research outlines how body awareness facilitates healing through accessing and making sense of experience. Participants’ descriptions from the current study are consistent with this outlined process. Participants noted experiencing a sense of freedom, understanding, and integration through combining body awareness and verbal processing to make meaning of the psychological content that came up through the body awareness. The body has been argued as another way of knowing oneself and a necessary aspect to include in trauma therapy, where insight and understanding are not sufficient to change the automatic physical responses to triggers (Rothschild, 2000; van der Kolk, 2006). Clients in the current study connected with aspects of self and suffering through body awareness, and being able to verbally process the material that arose is what enabled clients to understand and make meaning of past events and current experiences that seemed disparate but were, in fact, related. In the literature, body awareness has been named as an essential feature through which affect regulation, healing, and integration occur (Mehling et al., 2011). The inclusion of the body is a powerful way of facilitating psychotherapeutic benefits, and it was described as a significant part of the counselling experience for participants in this study. 77 Mindfulness. Mehling et al. (2011) highlighted that body awareness is necessary but not sufficient for facilitating healing. To be therapeutic, body awareness needs to be attentive to present-moment stimuli in a way that is non-elaborative and nonjudgmental; in other words, body awareness needs to be mindful. This study found that body awareness and mindfulness were inextricably related components of the essential structure of the experience for clients. Although only two of the six participants explicitly named the quality of awareness as mindful, all participants described the awareness in therapy as mindful: the awareness was nonjudgmental, in the present-moment, and intentional. Mehling et al. (2011) describe an essential skill clients learn in therapies that include body awareness is “the ability to notice sensations, thoughts and feelings as they occur in their actual immediacy” (p. 6). The current study found that participants cultivated this nonjudgmental, curious approach to their present-moment experience, and that skill generalized to their life outside of counselling. Five of the six participants acknowledged that through repeated practice overtime, this mindful approach to body sensation became a mindful approach to self. Participants described a shift in their way of relating to self from being judgmental and negative to being gentle and compassionate. This development of a gentle, accepting approach to self is reflective of the growing body of research on mindfulness. fMRI research on participants of an MBSR program showed a thickening of brain regions associated with the sense of self, emotion regulation, and perspective taking (Hölzel et al., 2011). Mindfulness has also been shown to be highly correlated with self-compassion (Hollis-Walker & Colosimo, 2011). Kristin Neff (2003), who brought the Buddhist construct of self-compassion to the scientific research community, conceptualized mindfulness as a component of self-compassion. Dan 78 Siegel (2010) highlights the difference between acceptance and complacency. He notes that mindfulness allows one to take a step back from being over-identified with the content of the mind (e.g., thoughts, feelings, beliefs), accept that these are the elements of experience in this moment, and approach the elements with curiosity and non-judgment. This is a skill, a way of looking at self, others, and the world, that participants from this study describe using and developing that has fundamentally changed the way they relate to themselves, others, and their life. Self-regulation. As described in the literature review, theoretical frameworks are being developed for understanding how mindfulness and yoga work to facilitate healing and wellbeing. Researchers have proposed self-regulation as a possible mechanism of action for yoga and mindfulness meditation (Gard, Noggle, Park, Vago, & Wilson, 2014; Hölzel et al., 2011). Hölzel et al. (2011) integrated a neuroscience perspective with previous conceptual, psychological literature and posited that the self-regulation components that enable mindfulness to be a beneficial practice include attention regulation, body awareness, affect regulation, and change in perspective on the self. All participants in the current study described attention regulation (i.e., bringing awareness to an object, such as physical sensations, thoughts, and emotions), body awareness, and affect regulation as being part of their experience. Hölzel et al. (2011) describe change in perspective on the self as developing an awareness of impermanence (i.e., the transient nature of all of existence) and a “[dis]identification with the contents of consciousness” (p. 547). Through mindfulness, some participants in the current study described realizing the transitoriness of their thoughts and feelings. Although disidentification did not emerge as a theme in the current study, it was explicitly acknowledged as part of the experience by two participants. Brenda and Megan 79 experienced an expansion in their awareness where they became observers of their mental contents and had space between themselves and their thoughts and feelings. This occurred through meditation, breath, and mindful body awareness, and it enabled the participants to feel less reactive. Engaging in these yoga components, Brenda & Megan's perception of themselves and the world shifted when they realized that their thoughts, emotions, and beliefs are just one aspect of their whole selves. Jon Kabat-Zinn (2013) describes this process as being the mechanism through which transformation occurs, namely that taking a wider perspective enables us “to realize that we are bigger than who we think we are” (p. xxvii). All participants described developing a capacity to be with uncomfortable experience without trying to change the experience. “Staying with” experience, particularly when it is challenging, was described as keeping awareness on the experience that is uncomfortable with curiosity and acceptance, or nonjudgment. This self-regulatory skill was also described as part of the experience in the phenomenological study conducted by Mehling et al. (2011) on patients’ (and practitioners’) experience of body awareness in mind-body therapies. Patients described learning to accept, not judge, and not appraise their present-moment experience (Mehling et al., 2011). The current study also found that participants developed the ability to regulate themselves through mindful body awareness. This study’s findings are consistent with extant literature and support body awareness and mindfulness as important components of yoga that facilitate both the processing and regulation of emotions in therapy. Counsellor qualities facilitate counselling. In this study, when participants were asked about their experience of counselling they inevitably included a reflection on their counsellor and how the qualities of their counsellor facilitated the relationship, counselling, and healing process. The interview protocol did not 80 include questions regarding the counsellor or the counselling relationship, and this was an unexpected aspect that participants spoke to in their descriptions. In light of previous research naming these aspects as essential to effective psychotherapy (Siegel, 2010; Wampold, 2015), it makes sense for them to arise in participants’ descriptions of their counselling experiences. The spontaneous emergence of this theme confirms that it is not only the approach that matters, but that the counsellor and therapeutic relationship also matter. This corroborates literature that demonstrates that the therapeutic relationship is an essential common factor in effective psychotherapy (Wampold, 2015). In the current study’s findings, counsellor qualities and style were important in facilitating a sense of trust, comfort, and safety in counselling. Participants stated their counsellors were compassionate, accepting, curious, kind, open, and caring. This finding is in line with the elements Dan Siegel (2010) describes as necessary for fostering trust: curiosity, openness, acceptance, and love. Whole person approach. Participants described this experience as a whole person approach that attended to and worked with the physical, mental, and emotional aspects of the self. Words participants used to describe their overall experience included profound, intimate, powerful, and life-changing. The Whole Person, Whole Life Approach theme found in this study fits with the extant literature that notes that alternative therapies, such as counselling that uses yoga, offer a holistic approach that addresses aspects of the whole self. People have reported seeking out alternative therapies because they feel conventional approaches lack this holistic perspective (Berhman & Tebb, 2009). Jon Kabat-Zinn (2013) describes mindfulness meditation as a practice of non-doing that “is a door into direct experiences of wholeness” (p.188-189). In contrast to even relaxation 81 techniques that require doing or achieving something (i.e., a calm, relaxed state), mindfulness helps widen awareness and free the mind from constant mental striving. Though a sense of calm and relaxation often results from practicing mindfulness, it is not the ultimate goal (Kabat-Zinn, 2013). For participants in the current study, simultaneous mindful body awareness and emotional and cognitive processing facilitated a sense of wholeness. This finding fits with the results of Mehling et al.’s (2011) examination of therapies that use body awareness. The process of these therapies was defined as a progression toward wholeness, the union of mind and body. The missing spiritual, philosophical component. Gard et al. (2014) established a new model for understanding how yoga facilitates self-regulation. The four yoga tools described in the model include three of the yoga components found in this study (i.e., postures, breath, meditation) with the addition of one other: ethics, or yoga philosophy. These are the four aspects of yoga practice that work to unite the mind, body, and spirit. In North America, both the spiritual aspect of human life and the philosophical component of yoga are less acknowledged and emphasized (Forfylow, 2011). In the current study, spirituality and yoga philosophy did not emerge as a common theme among participants. Nevertheless, one participant noted spirituality was an overt part of her counselling process, another participant noted that her counselling program used a spiritual text, and two other participants named yoga philosophy constructs that were a part of their counselling experiences (i.e., oneness, selfless service, gratitude, setting intention, do no harm, impermanence, and non-attachment). These seemingly idiosyncratic elements represent a component that warrants further consideration. Though spirituality and yoga philosophy was absent as a theme in the current study and in Kocian’s (2012) examination of this integrative therapy, it was acknowledged as an aspect of the experience for some participants in both studies. Researchers 82 have reflected on the relative exclusion of spirituality in therapy and philosophy in yoga within the North American context (Forfylow, 2011; Kocian, 2012). Still, four of the six participants in the current study acknowledged the presence of a spiritual, philosophical component to their counselling, and it is an important aspect covered in prevalent yoga texts (Simpkins & Simpkins, 2011). This is an important aspect to pay attention to. This may be particularly true in present discussion as the ultimate purpose of yoga is not described to be mental health, but transcendence: its function to “unite the personal spirit with the Universal spirit” (Forfylow, 2011, p. 134) that facilitates the realization of “connectedness, non-separation, integration . . . wholeness through disciplined practice” (Kabat-Zinn, 2013, p. 107). Gockel (2007) names interconnectedness, transcendence, love, and felt experience as themes of spirituality. In different words (e.g., “support,” “acceptance,” and “present with” rather than “love”), these elements of spirituality were present in the participants’ descriptions of their experiences of this counselling style. How we think about spirituality and the language we use to describe it likely impacts our perception of the degree to which mind-body therapies, such as yoga psychotherapy, include a spiritual, philosophical component. It will be important consider how spirituality may be presently experienced and described in a predominately Western, secular culture, such as Canada, where the present study took place. Unique Findings of the Study Safety considerations with embodied experiencing. Within the fourth theme of the findings, Body as Access Point to Physical Sensations, Thoughts, Emotions, Memories, described how the use of yoga in therapy enabled the body to be a “back door” to the internal experience of clients. Participants’ descriptions of embodied experiencing were two-fold, ranging from comforting to overwhelming, which related to whether 83 the somatic sensation was pleasant or unpleasant, respectively. Participants described accessing the present-moment emotional experience through the body as helpful and impactful and also as powerful and potent. Stacey described this as the “double-edged” quality of the use of yoga, because it can facilitate integration and also be an intense, difficult experience. The experience of making contact with the felt sense was described by participants as overwhelming during times when this experience was new and unknown, when they did not feel grounded enough, or when unpleasant physical sensation triggered a trauma memory. The potential to access and expose clients to their trauma histories through the body speaks to the importance of ensuring the maintenance of safety in this counselling process, and any body-oriented psychotherapy process that accesses and processes psychological pain through the body. Further, given the prevalence of exposure to traumatic events in the general population, which has been cited as high as 76% in a nationally representative sample of Canadians (Van Ameringen, Mancini, Patterson, & Boyle, 2008), this discussion proposes that any psychotherapy that includes the body should operate within a trauma-informed framework. Participants in the current study with trauma histories described accessing trauma memories through exposure to present-moment feeling states that were analogous to those associated with the memories. Participants who experienced this felt as if they were back “there,” experiencing that memory again as if it were their present experience. van der Kolk’s (2006) review of the neuroscience literature provides an understanding of the inextricable link between the body and memory in trauma. Human action emerges through direct stimulation of “emotional and arousal systems” that is then modulated by the prefrontal cortex, which applies rational thought to behavioural impulses (van der Kolk, 2006). However, highly stressful events that elicit intense emotions downregulate neocortical activity, and therefore rational modulation, 84 and an automatic stress response occurs that can continue as an automatic action pattern even after the original stress stimulus or threat is gone (van der Kolk, 2006). Somatic marker hypothesis describes the relationship between emotions and physical sensations, which are stored as memories to be later triggered by analogous stimuli (Damasio, 1994). In her book The Body Remembers, Babette Rothschild (2000) uses a case example of a boy being bitten by a dog as a child who later freezes in fear when a dog rests his head and creates physical sensation on the same area of the body where the boy was previously bitten. Though the dog was not threatening, the stimulus triggered the automatic action pattern that resulted from a previous threatening event. This evocation of an emotional response through physical sensation in the body was described as happening in the counselling experience for participants in the current study. Counselling was gentle and provided grounding and containment when the participants felt out of control of their experience. However, one participant described rare experiences of not feeling grounded enough for the intensity of the embodied sensation felt in session and that facilitative touch increased the sensation (i.e., through deepening a pose) and deepened the intensity of the experience. Though it felt like “too much” to cope with in the moment, the participant noted that the intense release and the calming breath her counsellor facilitated after the experience helped her feel more grounded and integrated overtime. Hayes and Feldman (2004) highlighted over a decade ago the importance of clinicians taking care when applying mindfulness to psychotherapy “to assess clients’ abilities to tolerate the negative material that they will face without their current coping strategies” (p. 257). Accessing threatening body sensation and emotion and maintaining contact with it, when the participants felt able to, enabled the participants to make sense of and uncouple past events from 85 present sensation, which released the hold or pattern that had been created. This speaks to the healing potential of this practice. It is also important to acknowledge the necessity of the counsellors’ ability keep the client within the window of tolerance and use containment and grounding when the client feels overwhelmed or out of control of their experience in session (Ogden, Minton, & Pain, 2006). Yoga has the potential to expose clients to experiences that may be challenging and may, at times, overwhelm their capacity to cope. Safety is developed and maintained through the client learning to regulate and tolerate discomfort, and it is essential to processing and integrating difficult experiences in therapy. Clients described the body as a “back door” that “bypasses” the rational mind, which engages in the process of analysis to find solutions and defend against pain. Bypassing the rational mind exposes clients to embodied experiences that will not always be pleasant. A trauma lens, suggested in this discussion, would ensure safe use of yoga in counselling. It is interesting to note that Rebecca sought out counselling for depression and described this counselling style as activating, which helped with her depression symptomatology, including amotivation and anhedonia. In contrast to the participants with trauma histories who highlighted the vulnerability and intensity they accessed in this counselling, Rebecca highlighted the experience of being reconnected to joy and being reactivated in helpful ways. Future research could explore this difference and whether it relates to the arousal state of the nervous system experienced in different mental illnesses (e.g., hypoarousal in depression and hyperarousal in PTSD). Affect regulation. Participants described two parts to self-regulation experienced and developed through this counselling style. First, physical postures, breathing, and present-moment awareness were 86 components used in session to facilitate a sense of calmness. When participants felt overwhelmed, confused, or anxious, the counsellors utilized yoga strategies to promote grounding and relaxation. Research has shown that yoga produces these effects through reducing the stress response and increasing stimulation of the parasympathetic nervous system that functions to relax and restore the body (Streeter et al., 2012). In the present study, yoga practices enabled the clients and counsellors to reduce arousal and reorient to therapy with increased clarity and focus. Participants noted that yoga helped them return to talk therapy with a clear, calm mind. This finding is consistent with research showing that the neural structures needed for higher level thinking (i.e., structures that are engaged during talk therapy) return to optimal functioning when the nervous system comes out of the stress response and returns to homeostasis (Siegel, 2010). The second aspect of self-regulation that was experienced and developed in this counselling style includes building capacity to be with experience through mindfulness. Jon Kabat-Zinn (2013) describes mindfulness as non-doing rather than a strategy focused on facilitating relaxation, though mindfulness does naturally calm the nervous system. This second component is about being with experience that is uncomfortable. This “being with” builds a tolerance through practicing non-elaborative awareness of the sensation. Through this practice, participants built a “capacity” to be “self-sufficient” and “resilient” when faced with difficult experiences in life. Dan Siegel (2010) speaks to the importance of a capacity for resilience, stating that “[w]ithout ways to strengthen the mind- to build the resilience that comes with being present, with being mindful- we are at risk of becoming overwhelmed in the moment, and of burning out in the long run” (p. 2). Mindfulness develops resilience through building an 87 approach-orientation, rather than avoiding or withdrawing from difficulty (Craig, 2009; Siegel, 2010). These two parts represent overlapping yet distinct short-term and longterm strategies facilitating affect regulation and, more broadly, self-regulation through the use of yoga in counselling. In summary, yoga provided tools that could be used in the moment to regulate a client (e.g., breath regulation, specific yoga postures) as well as the opportunity to develop self-regulation skills that endure over time and translate to life outside the therapy room. The self-regulatory capacity described by participants fits with the self-regulation model of yoga emerging in the current research (Gard et al., 2014). In addition to regulation being an important outcome of counselling, it also helps clients to stay within the window of tolerance to be able to process and integrate psychologically relevant material. Therefore, the inclusion of yoga facilitated emotional regulation and optimal circumstances for emotional processing, which are essential to healing and wellbeing, the goals of therapy. Orientation toward: Yoga and the social nervous system. Four of six participants in the study noted that this style of counselling changed the way they oriented to community. One participant noted that she was more curious, compassionate, and nonjudgmental toward others, including loved ones and strangers. Researchers and clinicians note that mindfulness cultivates compassion toward others (Kabat-Zinn, 2013) and yoga facilitates changes in the nervous system (i.e., increased parasympathetic activity) that correspond with reduced arousal, increased prosocial behaviour, and an approach-orientation (Craig, 2009). In contrast with avoidance and withdrawal, an approach-orientation allows people to better engage with themselves, others, and the world. According to Steven Porges (2011), the stress response and nervous system has a third function in addition to being equipped to respond 88 to threat with arousal and removal of threat with relaxation. Porges’ polyvagal theory describes the social engagement system, which is a component of the parasympathetic nervous system constituted by the myelinated vagus, that regulates behaviours related to social communication. Therefore, in addition to building resilience and reducing reactivity of the stress response, yoga tones the parasympathetic response that includes stimulating a part of the vagal nerve that mediates social engagement (Porges, 2011). Further inquiry will help elucidate if the change in orientation toward community that four participants in the current study experienced was facilitated by a generalization of the learned curious, nonjudgmental way of attending to objects in awareness, activation of the social nervous system, another mechanism, or some combination thereof. Regardless of the mechanism, including yoga and mindfulness in counselling helped participants in the study gain perspective, build resilience, and engage in their life and the world in a more curious, nonjudgmental way. Relevance of the Findings to Counselling Psychology Practice and Training The implications of the study’s findings relate to the therapeutic potential of this integrative counselling style, how to utilize this counselling safely, and training needs and considerations. The use of yoga in counselling was a life-changing experience for clients in the study that enabled them to process psychological material and develop self-regulation. Though there are many theoretical articles and books expounding the integration of yoga and psychotherapy, there is little research examining this therapy in practice. For clinicians using or thinking of using yoga in therapy, the reflections of the participants in this study highlight some considerations that may enhance the safety and effectiveness of therapy. Some participants disclosed an appreciation for or, if absent, a desire for being informed about what they can 89 expect from the therapy. For example, Brenda described appreciating the counsellor preparing her for what questions, probes, and processing opportunities were to come in the counselling session that day, which prevented her from being caught off-guard by a facilitated strong emotional experience. Stacey described a desire to have been previously apprised of the intensity of emotional and embodied experience that was possible in this type of therapy, so she would know it was a part of the process that all clients experience rather than feeling surprised when overtaken by her emotions, memories, and sensations in moments of intensity. Brief psychoeducation on what to expect in therapy can help clients feel prepared and comfortable and has been shown to reduce premature termination in psychotherapy (Reis & Brown, 2006). This may be particularly important in any therapy that connects clients with body sensation, especially if clients have little experience with body awareness prior to counselling. In this regard, another important aspect for a counsellor to consider when wanting to implement yoga safely and comfortably in therapy, is a client’s current level of awareness and connection to his or her body. Awareness of the client’s experience of interoception enables the counsellor to balance the use of body awareness and safety building, according to the client’s needs. Yoga-integrated counselling is a relatively new therapy style. Future research will ensure this therapy is practiced in way that is safe, ethical, and effective. Three participants reflected on the issue of training needs for clinicians. They expressed the importance of having training in both yoga and psychotherapy. Dana had experienced pure yoga therapy, pure talk therapy, as well as counselling that integrated yoga therapy. In pure yoga therapy, she felt unable to express her emotional and cognitive experiences that occurred during the yoga therapy without the safety and ability provided by clinical counselling training: “I’ve been to just straight up Yoga Therapists and it doesn’t feel as safe to discuss things or there isn’t room to just talk if you want 90 to just talk.” Talk therapy training enables psychological processing to occur; however, yoga or yoga therapy training is also important to understand and safely implement yoga techniques in counselling. Forbes, Akhtar, and Douglass (2011) highlighted the importance of dual trainings for clinicians who are motivated to include yoga in their counselling and psychotherapy practice. An example was provided in the article of teaching a breathing intervention to psychotherapists. Though the clinicians were eager to use the breathing intervention with their clients, they lacked understanding of how the breath works, possible ways it could intensify symptoms, and how to help the client if this occurs. Yoga training would provide clinicians with this understanding. The need for training in both counselling and yoga was also highlighted by the emotional intensity clients in the current study experienced when yoga accessed memories and emotions that were previously avoided or out of consciousness. Training would provide clinicians with the skills needed to work with what comes up in the therapy sessions. Further, as considered in the previous section, Safety Considerations with Embodied Experiencing, trauma training would provide safety through knowledge of how to titrate processing so it is safe and therapeutic and how to work with clients when their experience in session becomes overwhelming and containment is necessary. Implications for Future Research The integration of yoga and counselling is a new area of practice and research with many avenues to explore. The use and credibility of yoga and yoga therapy in mental health treatment continues to grow. There are many aspects of the integration of yoga and counselling that can be explored. From this study’s findings, the implications for future research include further inquiry into how yoga in counselling facilitates self-regulation, processing, healing, and integration. Theoretical models of the self-regulatory mechanism of yoga and mindfulness are in the early 91 stages of being described, examined, and understood (Gard et al., 2014; Hölzel et al., 2011). Further exploration of how this works on its own as well as within a psychotherapeutic context will be valuable. Neuroscience research on how yoga psychotherapy affects the tone of the nervous system and stress response would also be helpful to the understanding of the neurophysiological changes underlying the healing, regulation, and integration that occurs in this counselling style. The demographic characteristics of the participants, described in the results chapter, represented an intelligent, self-reflective group of adult women who are earnest in their approach to their healing and yoga practice. It is important to acknowledge that this sample of participants was homogeneous in their gender and ability to reflect on and speak about their experience. Future research should review the use of this integrative therapy with a range of client populations. Although some aspects of participants’ experiences did not emerge from analysis as essential themes of the core structure of the phenomenon, in that they were not endorsed by all participants in the study, there were a few of these non-essential aspects mentioned by participants that warrant further exploration. First, three participants explicitly mentioned their thoughts on training needs for this therapy, highlighting the importance of having training to safely and effectively engage in both the yoga and counselling work. Forbes, Akhtar, and Douglass (2011) discuss the "trend toward the integration of yoga and psychology" (p. 7) and what this shift means for ethical practice and training requirements. Future research should include an examination of training needs for this therapy. Second, four participants mentioned their way of relating to community changed through this therapy. With the advances seen in neuroscience research and understanding, including polyvagal theory, further research on the 92 clinical practice of yoga psychotherapy would develop awareness of how this practice may facilitate prosocial behaviour. Finally, a potential difference was noticed among the participant experiences relating to the mental health concern being worked with in therapy. Specifically, the participant who described experiencing depression symptomatology found the therapy to be activating and participants with trauma histories found the therapy to be over-activating at times, particularly when processing memories and sensations related to the trauma. When analyzing the data, a query that arose included whether this difference could be accounted for by arousal states typically associated with different mental health concerns. Future research in this area would have clinical implications with regard to how to balance the use of yoga to regulate and to access emotionally salient material when windows of tolerance may differ according to the mental health concern being experienced by the client. Strengths and Limitations of the Methodology and Study Descriptive phenomenology was a useful methodology to learn the essence of this new integrative therapy. The use of yoga in counselling sessions is a relatively new phenomenon; therefore, the methodology used in this study enabled the experience of this counselling, as it is described by the clients, to be the focus of our way of understanding the phenomenon. A description of the structure and function of the therapy emerged from analysis of the transcripts. The first three themes described the components and organization of the structure of yoga psychotherapy. The last three themes described what functions the inclusion of yoga facilitated, the importance of the counsellor to the therapy process, and this therapy as a whole person approach that engages the mind-body relationship and integrates into the client's life. Bracketing is an important part of the descriptive phenomenological process, as it enables the researcher to be open and receptive to insights emerging from the data without the overlay of 93 previous knowledge or ways of understanding (Giorgi, 2009). A reflexive journal was kept when challenges emerged in maintaining the epoché. In the process of being reflexive and bracketing prior knowledge, I reflected on the question of how much my inherent lens of perceiving, shaped through my previous knowledge and experiences, unconsciously identifies and fixates on particular aspects from the transcripts over others. The transcendental phenomenological attitude is a foundational aspect of descriptive phenomenology with the intention of withholding evaluation of data based on prior knowledge and looking at all data, that is pertinent to the phenomenon, as equally relevant, initially (Giorgi, 2009). To ensure the study’s findings stayed true to the phenomenon as experienced by the participants, a peer reviewed the results and participants member checked the general theme structure that came from the analysis process. Conclusion This study was conducted to understand the essential structure of the experience of yoga-integrated counselling from the client perspective. The aim was to elucidate this new integrative practice that is just entering the eye of research, despite the prevalence of research on its constituent parts (i.e., yoga and counselling) and increasing popularity, discussion, and use of this therapy. Valuable insights into how this counselling happens and how clients experience it were obtained through the in-depth interviews. The use of Giorgi’s (2009) descriptive phenomenological method of analysis allowed themes present in all clients’ experiences to be drawn out and described. Findings included expected themes, including the component and organizational structure of the experience: spontaneous transitions between and integration of yoga components (breath, bodywork, body awareness, mindfulness) and counselling components (verbal exploration and processing that is curious and nonjudgmental). Analysis highlighted the 94 dual role of yoga as the gateway (i.e., accesses emotional and mental experience through body awareness) and gatekeeper (i.e., calms, contains, and build capacity to tolerate difficult experience through particular movement, breath, and awareness techniques) to the psychological experiences of the client. An unexpected theme emphasized the importance of the curious, nonjudgmental, patient, and supportive counsellor to the counselling process and development of trust and safety in the therapeutic relationship. Finally, this study’s findings support counselling that includes yoga as a whole person approach with a profound impact that can be integrated into a way of life for clients. The findings of this study support previous research and offer unique findings not yet identified in the literature. The hope is that this exploratory study adds to the understanding of counselling that includes yoga and demonstrates the value of this new practice through the reflections of the clients who have engaged in it. The counselling psychology and yoga therapy fields will benefit from more research into this promising integrative practice. 95 References Adams, C. M., & Puig, A. (2008). Incorporating yoga into college counseling. Journal of Creativity in Mental Health, 3(4), 357-372. Baer, R. A. 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New York, NY: Basic Books. 104 Appendices 105 Appendix A: Recruitment Letter to Counsellors 106 Appendix B: Invitation to Study for Potential Participants 107 Appendix C: Recruitment Poster 108 Appendix D: Initial Contact Participant Screening Form Participant Screening Questions If a potential participant contacts me and is interested in the study, I will begin by thanking them for taking the time to contact me and I will answer any initial queries they may have. I will then start by explaining that in order to participate in the study, it is important that I ask them a few questions to determine their eligibility. I will remind each potential participant that the information they provide during this call and throughout the research process will remain confidential. The screening questions will include the following: 1. How did you hear about the study? 2. How old are you? 3. When did you start and finish counselling that used yoga? 4. What did the yoga aspect of counselling include? 5. Would you feel comfortable sharing your experiences of counselling that included yoga? 6. Are you able to meet for a 1 to 2 hour in-person interview? 7. I will also be contacting each participant once I have transcribed and analyzed the interview for a brief follow-up discussion. Is this ok with you? 8. Are you currently experiencing any stress that may make it difficult to talk about your experiences at this time? 9. Are you currently seeing the counsellor that used yoga in sessions? 10. Are you currently receiving any other counselling or psychotherapy? 11. What interests you about participating in this study? 12. Do you have any questions for me? Information for Interview After the screening questions are answered, I will further describe and clarify with the eligible research participants the study and what participation will entail, including the following note: Through the interview, I would like to gain a thorough understanding of your experiences in counselling that included yoga. In preparation for your interview, I invite you to think about and reflect on your experiences. I want to clarify that this research is interested in your experience of the process counselling that integrated yoga and not the content, or what you discussed with your counsellor. 109 Appendix E: Consent Form 110 111 112 Appendix F: Community Resources Sheet Community Resources Crisis Centre Distress Lines Greater Vancouver 604-872-3311 BC-wide 1-800-SUICIDE (1-800-784-2433) Online Distress Services www.crisiscentrechat.ca 211 - Call this 3-digit number for information and referral to a range of community, social, and government services Dragonstone Counselling 604-738-7557 In Kitsilano neighborhood in Vancouver, BC Sliding scale counselling offered with supervised interns Family Services of Greater Vancouver, Counselling Program 604-874-2938 Fees based on household income Can have a waitlist Oak Counselling 604-266-5611 Reduced fee counselling provided by supervised volunteers with Master’s degrees On Oak St. in Vancouver, BC UBC Scarfe Counselling Centre 604-822-4639 Free counselling provided by counselling psychology graduate students Terra Counselling 604-442-4769 Sliding scale, long-term counselling (if appropriate) 113 Appendix G: Demographics Form Participant Demographics Form Please answer the following questions by filling in the blanks sections and circling answers where appropriate. If you need any help, please feel free to ask the researcher. If there are any questions that you feel uncomfortable answering, please remember you have the right to leave them blank. All information provided will be kept strictly confidential. Thank you so much for participating! Age: Gender: □Male □Female □Other Marital Status: □Single □Long-term Partner □Married □Separated or Divorced □Widowed □Other Occupation: Highest Education Level: , in (program name) City of Residence: Ethnic Background: , City of Birth: Do you or have you practiced yoga? □Yes □No If yes, what type(s) of yoga have you practiced? How many years have you practiced for? Are you currently practicing yoga? □Yes □No How often do you practice? What, if any, practices do you engage in that are similar to yoga? How did you hear about this study? What do you hope to get from this study? Any comments or other information you feel would be important to know: Thank you! 114 Appendix H: Interview Protocol Clients’ Experience of Counselling that Integrates Yoga: A Phenomenological Inquiry Interview Protocol Orienting Interview Question I’m interested in hearing about your experience of counselling that integrated the use of yoga. I would like to hear and fully understand your perspective. I may ask you specific questions if I need clarification or if I want to know more about something you mention. I really want to follow you and go where you are interested in taking me. This is about your experience. I want to clarify I am interested in your experience of the process of counselling that integrated yoga and not necessarily the content, or what you discussed with your counsellor, although this may come up or be a part of how you describe your experience. If there is anything that you feel uncomfortable sharing, remember that you can always choose to not include something, to not respond to a question, or to stop the interview at any time. This is your choice about what you want to share. Also, please feel free to take as much time as you need to respond to a question or think about what you would like to say. Before we begin, do you have any questions for me? Let’s begin the interview now. Main Interview Question Tell me about your experience with counselling that integrated yoga. Possible Facilitating Questions I intend on starting with the main interview question in order to explore each participant’s experience in a very open fashion, to follow where they go, and probe aspects of the experience they raise and deem important. I have included the following prompting questions in case a participant finds it challenging to continue to access their experience without facilitation. These may or may not be used in interviews. 1. What does a typical session look like? What does it include? 2. Describe for me a time when you experienced yoga in counselling. What was your experience? 3. What has been a challenging experience for you regarding the use of yoga in counselling? 4. Describe a profound experience you have had in session. 5. Tell me about what happens in counselling after the yoga experiences? 6. How do your experiences with counselling that uses yoga relate to your life? 7. What haven’t we touched on that is important to know? 8. What has been important to you in reflecting on your experience of yoga in counselling?
Thesis/Dissertation
eng
Counselling Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivs 2.5 Canada
Graduate
Clients' experience of counselling that integrates yoga : a phenomenological inquiry
Text