yoga research essay

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Journal of Yoga Studies, Volume 5 (2024) with an illustration of a Hindu ascetic seated under a tree, near Calcutta, West Bengal. Coloured etching by François Balthazar Solvyns, 1799. Wellcome Collection.

Volume 5 (2024) of the Journal of Yoga Studies.

ISSN: 2664-1739 DOI: https://doi.org/10.34000/JoYS.2024.V5

The Journal of Yoga Studies (JoYS) is a peer-reviewed, open access e-journal committed to publishing the highest quality academic research and critical discussions on all topics related to the study of all forms of yoga, from ancient to contemporary, across multiple humanities and social sciences disciplines. Note that JoYS does not accept submissions of natural sciences, medical or experimental psychology articles, but would welcome review or analytical articles written by specialists in these fields with the specific aim of reporting relevant findings to non-specialist academic readers. Authors will retain copyright of their articles.

JoYS aims to serve the needs of this emerging field of study by offering a forum for reporting on research findings, discoveries, theoretical discussions and critical debates in the field, and for disseminating critical editions, translations, book reviews and other key reference materials.

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To start with, papers will be published on a rolling-basis throughout the year in electronic form only (downloadable PDF). A yearly collection of papers will form a single volume of JoYS . On occasion, a number of papers may be gathered together under a specific thematic heading (article sets).

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Yoga research review

Affiliation.

1 Touch Research Institute, University of Miami, Miller School of Medicine, United States; Fielding Graduate University, United States. Electronic address: [email protected].
PMID: 27502816
DOI: 10.1016/j.ctcp.2016.06.005

This paper is a review of empirical studies, review and meta-analysis publications on yoga from the last few years. The review includes demographics/prevalence of yoga as a practice, bibliometric analyses of the yoga publications and the use of yoga for physical fitness and cognitive function. Most of the studies reviewed here involve yoga effects on psychiatric and medical conditions. These include pregnancy, prenatal and postpartum depression; stress, PTSD, anxiety, and obesity; cardiovascular conditions including hypertension; pain syndromes including arthritis, headaches and low back pain; autoimmune conditions including asthma, type II diabetes and multiple sclerosis; immune conditions including HIV and breast cancer; and aging problems including balance, osteoporosis and Parkinson's. The methods and results of those studies are briefly summarized along with their limitations and suggestions for future research. Basically yoga has been more effective than control and waitlist control conditions, although not always more effective than treatment comparison groups such as other forms of exercise. More randomized controlled studies are needed in which yoga is compared to active exercise groups. Having established the physical and mental health benefits of yoga makes it ethically questionable to assign participants to inactive control groups. Shorter sessions should be investigated for cost-effectiveness and for daily practice. Multiple physical and physiological measures need to be added to the self-report research protocols and potential underlying mechanisms need to be further explored. In the interim, the studies reviewed here highlight the therapeutic effects of yoga, a practice that could come to be called yoga therapy.

Keywords: Yoga research review.

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Open access
Published: 24 June 2024

Yoga as an adjunct treatment for eating disorders: a qualitative enquiry of client perspectives

Jennifer O’Brien ORCID: orcid.org/0000-0001-8227-6788 1 ,
Shane McIver ORCID: orcid.org/0000-0003-1837-8661 2 ,
Subhadra Evans ORCID: orcid.org/0000-0002-1898-0030 1 ,
Eleanor Trethewey ORCID: orcid.org/0000-0002-3973-7195 1 &
Melissa O’Shea ORCID: orcid.org/0000-0003-0230-3729 1

BMC Complementary Medicine and Therapies volume 24 , Article number: 245 ( 2024 ) Cite this article

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This qualitative enquiry explores the experiences and perspectives of individuals with an eating disorder (ED) regarding their perceptions of yoga as an adjunct intervention to psychotherapy. It also explores the feasibility, acceptability, and safety of yoga from their perspectives.

This study used a practice-based evidence framework and employed semi-structured interviews with 16 females with an ED. Participants were asked about their perspectives on the use of yoga as an adjunct intervention in ED recovery, perceived risks and what factors supported or hindered engagement. Thematic template analysis was used.

Three topic areas were elaborated. The first included participants’ perceptions of how yoga enhanced their ED recovery. The second included how and when participants came to find yoga in their ED recovery. The final topic explored factors that supported participants with ED to engage in yoga. These resulted in the development of guiding principles to consider when designing a yoga intervention for EDs.

Conclusions

This study adds further to the emerging evidence that yoga can bring complementary benefits to ED recovery and provides a biopsychosocial-spiritual framework for understanding these. Findings provide an understanding of how yoga programs can be adapted to improve safety and engagement for people with an ED. Yoga programs for people with EDs should be co-designed to ensure that the physical, social, and cultural environment is accessible and acceptable.

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Plain english summary

Recent research has explored the benefits of yoga for individuals with eating disorders (EDs). However, only a few studies have interviewed individuals about their perspectives on using yoga within their ED recovery. This study interviewed 16 individuals with an ED to obtain their perspectives about using yoga as a therapeutic treatment in their recovery. Participants perceived multiple benefits of how yoga enhanced their recovery. They reported their views on how to incorporate yoga in ED treatment approaches to decrease potential risks. This study offers unique insights into how yoga may be safely applied to the care of people with an ED to enhance their treatment and recovery.

Eating Disorders (EDs) are a set of psychiatric diagnoses characterised by an unhealthy preoccupation with eating, exercise, and body weight or shape [ 1 ]. They are associated with a broad range of negative outcomes, including medical complications, major disruptions in cognitive, emotional, and social functioning [ 2 ], and significant impacts on quality of life [ 3 , 4 ]. Presently, EDs represent a major public health concern, with an estimated 4% of the Australian population affected [ 5 ], with research showing a rise in presentations since Covid-19 [ 6 , 7 ]. Current treatment for EDs includes a multi-axial approach, including medical, psychiatric, and psychological interventions [ 5 ] with transdiagnostic approaches such as family-based therapy (FBT) (primarily for younger people) [ 8 ] and enhanced cognitive behavioural therapy (CBT-E) (for adults) demonstrating positive results [ 5 , 9 , 10 , 11 ]. Nonetheless, treatment research outcomes indicate high rates of dropout, modest rates of recovery, and high rates of relapse [ 5 ]. As such, some ED services have incorporated complementary interventions, such as yoga [ 12 ], that aim to facilitate a mind–body connection in the hope that this may support recovery [ 13 ].

Yoga typically involves a combination of breathing practices, gentle physical poses, and meditation [ 14 ]. Research examining yoga suggests it has a promising effect on ED symptomatology [ 12 , 13 , 15 ]; such as improving psychological factors including body responsiveness and awareness [ 16 ], interoception and embodiment [ 17 , 18 , 19 ], mindfulness, self-compassion, self-efficacy [ 20 ] body satisfaction, body appreciation, and body image [ 21 , 22 , 23 , 24 ]. Despite this, given the lack of research, currently, yoga is not recommended as a stand-alone treatment but as an adjunct intervention for the treatment of EDs [ 12 , 15 ].

Research indicates that people with lived experience of EDs perceive yoga as helpful for recovery [ 25 ]. However, only a small number of qualitative studies published to date examine these perceived benefits. One qualitative study employed in-depth interviews ( n = 16) to understand the experiences of using yoga to support ED recovery for women with Anorexia Nervosa (AN); finding that yoga enhanced embodiment, leading to increased feelings of empowerment, enhancing ED recovery [ 26 ]. In their subsequent publication, Pizanello [ 27 ] analysed their results further, explaining that the enhanced embodiment improved participants’ interoceptive awareness and improved mindfulness and emotion regulation. In another study, [ 28 ] interviewed a single individual with AN finding yoga enhanced a new sense of body acceptance, awareness, and safety, allowing them to process traumatic memories safely. Both studies focussed on AN only, and questions relating to yoga's perceived risk or safety were not explored. Two further studies used qualitative methods as part of a mixed methods evaluation of novel yoga programs for people with EDs [ 29 , 30 , 31 ]. Diers et al., [ 29 ] piloted a yoga program for 67 people diagnosed with an ED using mixed methods with quantitative data showing decreased body image concerns. The qualitative data suggested that the yoga program improved participants’ self-acceptance, self-awareness, confidence, and emotional and physical strength, and that group discussion enhanced the experience of embodiment through verbal processing and peer-based support. However, along with these perceived benefits, participants reported that at times they had negative experiences with yoga due to self-judgement, vulnerability, and confrontation of uncomfortable feelings McIver et al., [ 30 , 31 *] piloted a yoga program for 25 people with Binge Eating Disorder (BED) which resulted in a decrease in BED symptomatology with qualitative data indicating that participants felt more positively connected to their bodies, and food, resulting in feelings of self-empowerment [ 30 , 31 ]. Qualitative data in this study was limited to self-report diary entries, and participants were not asked about the feasibility or safety of the yoga program. Adding to this picture are two qualitative studies examining yoga's impact on body image in the general population [ 24 , 32 ]. These studies found yoga led participants to feel empowered, which improved body image and acceptance but were coupled with findings that at times yoga had a negative impact on individuals as it could encourage comparative, negative and perfectionist thinking [ 24 , 32 ].

Given that current literature indicates that people with an ED report both positive and negative experiences when engaging with yoga, an examination of yoga's acceptability, feasibility, and safety is a critical next step. This is particularly important as yoga is commonly used in contemporary ED services [ 12 ] As such, this study employs a Practice-Based Evidence (PBE) framework [ 33 , 34 ] where in the perspectives of people with an ED as to the acceptability, feasibility and safe of yoga as an adjunct intervention to ED treatment is sought using semi-structured interviews. The study is the second of a two-part qualitative enquiry, with the other focusing on mental health clinicians' perceptions [ 35 ].

The research questions for this study are as follows:

From the perspectives of people with an ED,

What are the perceived benefits of yoga as an adjunct intervention for ED treatment?

What are the perceived risks or safety issues of yoga as an adjunct intervention for ED treatment?

What are the factors that support or hinder engagement with yoga as an adjunct intervention for ED treatment?

Methodology

Study design.

A constructivist realist approach was taken, which argues that research is not independent of the clinical researcher’s perspective but that meaning is observed, described, and even co-created [ 36 ]. Specifically, a PBE framework was adopted to integrate clinical expertise with systematic research evidence [ 33 ]. Qualitative enquiry was used to draw out stories and understand experiences [ 37 ], with semi-structured interviews being used to capture these rich stories [ 38 ].

Recruitment

The study was advertised on Eating Disorders Victoria’s (a not-for-profit peak body) website and social media pages and at a regional ED service in Victoria, Australia. This advertisement explained that the study was recruiting a broad range of participants with a lived ED experience to understand their perspectives on yoga, noting that experience with yoga was not a requirement of participation. Interested participants completed an online consent form and were provided with a plain language statement. Once consent was obtained participants were contacted via email by the researchers and offered an interview via Zoom or telephone. The study was approved by Barwon Health Research Ethics, Governance and Integrity Unit [RHEA-75618] in September 2021.

Purposive sampling procedures were used and participants were deliberately invited due to their unique insights related to their experience with an ED [ 39 ]. Inclusion criteria included that the participant self-identified as having a diagnosed ED and had received treatment for this. The only exclusion criteria was prospective participants aged under 12 years. Recruitment was not limited to individuals who had experienced yoga but was open to anyone with an ED diagnosis and interested in participating.

Participants

Interviews were completed with 16 female participants who had been diagnosed with an ED and had received psychological treatment for it. Participant diagnoses ranged from AN ( n = 9), Atypical AN ( n = 1), AN (restrictive subtype orthorexia behaviours) ( n = 1), BED ( n = 2) & BN & AN ( n = 2) and one participant reported that they were not given a formal diagnosis ( n = 1). We asked participants to describe their ED journey, which indicated there was a broad range of experience. Some reported they were recently diagnosed and in active treatment, others reported that they were recovered, and some reported that despite symptom resolution, the ED would always be with them. Participants were or had been engaged in various ED services (public, private, community and inpatient) within Australia. All but one participant volunteered for the study as they had used yoga alongside their ED treatment and felt that it had enhanced their recovery. However, all had experience and understanding of what yoga was.

Interviews occurred over an extended timeframe due to initial recruitment difficulties (September 2021 to August 2022). Semi-structured interview schedules were used to provide consistency across all interviews while allowing participants to elaborate and tell their unique stories [ 38 ]. All interviews were completed on Zoom, given a unique identifier code, audio recorded, and transcribed. Any reference to names or places was omitted to ensure confidentiality. Participants were free to withdraw from the study at any time without consequences and were given a $30 gift voucher to reimburse them for their time.

Data collection and analysis

The interview guide had two streams of questions to capture a diversity of experiences with yoga [ 40 ]. One stream catered to individuals who had had some experience with yoga and the other to those who were new to yoga. For those that had used yoga alongside ED treatment approaches, questions such as: 1) What brought you to yoga in the first place? 2) Did you find that yoga brought any benefits to your health? 2) Are there any complementary benefits that yoga brings to your current psychological treatment? 3) Do you have any concerns about engaging in yoga? For those with little experience with yoga, questions such as: 1) Do you think yoga could bring physical and mental health benefits? 2) Would you have any concerns about engaging in yoga?

Data were analysed using template analysis as it provided a guiding set of procedures [ 41 ] that can be used in a top-down qualitative analysis. Template analysis is a practical approach that emphasises the use of hierarchical coding. It balances a relatively high degree of structure in the process of analysing textual data with the flexibility to adapt it to a particular study [ 41 , 42 ]. Template analysis has been successfully used with PBE research, particularly when the study aims to understand an intervention’s acceptability, feasibility and safety in clinical populations [ 43 , 44 , 45 ]. Central to the approach is developing a coding template, which enables a priori themes to be selected to structure the analysis [ 42 ].

After completing the interviews, the researchers reviewed the data to familiarise themselves with it. An initial subset of data ( n = 5) was taken by researchers (JO’B & SMcI) who commenced preliminary coding. This process included coding data in relation to the research questions and priori themes and grouping data where it was the richest [ 42 ]. Mind mapping was used to link codes of similar concepts that had a relationship with each other, followed by an iterative process that identified distinct themes and relevant sub-themes. Quotes were noted where the data was the richest, highlighting the themes identified. At all stages of coding and theme development, to ensure research rigour, documentation was kept, ensuring that the evolution of themes was clear and traceable [ 36 ]. The resulting thematic structure defined the initial template codes, which was further developed through the coding of another sub-set of interviews ( n = 5). All interviews were then reviewed by another researcher (MO’S) to ensure the template codes reflected the data. Researchers reviewed each other's codes and discussed the similarities and differences throughout the process before identifying and agreeing on themes and sub-themes [ 42 ]. This resulted in the final template codes and themes that were grouped into topic areas, which was then used with the remaining datasets, confirming that these were a comprehensive and rich representation of the data.

We identified three topic areas: (a) yoga’s capacity for healing and transformation in ED recovery; (b) when and how participants came to find yoga within their recovery and (c) what factors supported them to engage in yoga.

Yoga’s capacity for healing and transformation

Participants saw multiple benefits of yoga for their ED recovery, spanning physical, psychological, social, and spiritual domains (See Fig. 1 ). These were frequently described as overlapping, whereby one benefit was viewed as leading to another. For some participants, yoga was identified as the key to their recovery, describing transformative experiences with the practice .

"It’s helped the attitude I have towards my body, it’s made me more aware of a different way of seeing my body, instead of seeing it from the outside, how it looks from the experience of the inside, and so whenever I feel self-conscious about my body in public, I try to notice how it feels instead." (Participant 10 (AN)).

How yoga helps me

Some participants reflected that they previously experienced gaps in their current ED treatment, noting that it was heavily focused on nutrition and talking, neglecting how to relate positively to the body. Comparatively, they described yoga as being different in important ways, emphasising body connection and acceptance. “ I really loathed my body, but the yoga taught me to love my body and how strong it is and what it's able to do.” (Participant 6 (AN)).

Several participants remarked that yoga was an approach that worked for their bodies and minds. In acknowledging “ the body and the mind is ONE thing, they’re not separate things” (Participant 11 (AN)) ; they recognised that this unity was vital to recovery “in your psychology treatment for your ED, you have to have something that teaches you how to be okay with how your body feels, 'cause most of the time you spend time trying to get out of it.” (Participant 11 (AN)). Many participants described how yoga provided something different and complementary to psychotherapy. The yoga was described as providing an experiential and somatic method to explore their ED symptoms safely, which they felt psychotherapy could not do alone. For some, yoga was seen to be more beneficial for their recovery than psychotherapies such as CBT.

"Like if I was able to do those CBT skills, as I'm sitting here doing like absolutely nothing, I wouldn't be having these issues, but for me, the yoga was a way for me to physically force myself into it." (Participant 8 (AN subtype orthorexia behaviours)).

Physical benefits

Participants reported that yoga improved their body’s physical capabilities and helped them to gain physical strength; "a pose that was really hard a month ago now seems a little bit easier, you can hold things a little bit longer and you kind of notice your strength improving which is satisfying” (Participant 13 (BED)). Many participants talked about experiencing a difficult relationship with their bodies and that re-engaging with movement was a safe way to reconnect with their bodies, leading to a unique opportunity to explore the discomfort associated with their bodies. One participant reported:

"You'll be in a stretch and you'll feel that discomfort, but then on top of that, you might feel like your stomach or your ribs on your leg and stuff like that, getting used to that uncomfortableness but it was temporary. I could choose to come out of that stretch and that was really good for me." (Participant 8 (AN subtype orthorexia behaviours)).

Several participants also reported that yoga helped them to manage their relationship with eating, weight and cravings “I went to yoga to relax and occupy my mind so that I am not thinking about what I’m going to eat. The mindfulness aspect helped because a lot of my eating is because of boredom or pain.” (Participant 5 (BED)).

Psychological benefits

Participants talked about how yoga allowed them to develop mindfulness and relaxation skills. When participants engaged with their bodies via yoga, this connection allowed them to experience a psychological break from distressing ED cognitions that were normally present. ”it just takes me out of that and it gives me a different mindset, which is nice not to hear the ED all the time” (Participant 9 (AN)). Viewing distressing ED cognitions from a distance gave participants space to appraise and challenge these. Participants talked about how this led to feeling empowered, improved their self-esteem, increased positive self-talk, improved body acceptance, and helped them to learn to accept and trust themselves. One participant described how this then allowed them to explore a new sense of self separate from the ED.

"It just kinda makes me calm and it makes me... I'm not so focused on how I look, what I eat, that sort of thing, and it just... It reminds me of what I actually want out of life. Like I wanna be happy and calm and mindful and not worried about weight and what I’m eating." (Participant 4 (BN & AN)).

Social Benefits

Participants talked about yoga’s social benefits, such as a sense of community, and that they were not experiencing the ED alone. Participants talked about how these social connections promoted the feeling of being accepted and belonging. “I feel a connection to other people with EDs without having to talk about it" (Participant 2 (Atypical AN)).

Participants gained a sense of satisfaction from these social connections as described.

"I think the diversity of people you find in there helps, the yoga studio has some old person, some guy that's recovering from a knee injury...and there is just anyone and everyone, it kinda feels like a nice space where you don't have to be self-conscious." (Participant 11 (AN)).

Some participants described yoga as a meaningful hobby connecting them with people and a community. Two participants reported that they went on to become qualified yoga teachers.

Spiritual benefits

A few participants reported that yoga provided them with spiritual benefits, which was important in their recovery. For example, yoga gave one participant a feeling of gratitude and another an opportunity to seek something beyond the mundane. One participant explained that previously the only way to experience positive emotional states was through starvation whereas yoga now provided another avenue.

"You're reaching a higher state and not only is it not destroying you, it’s building you up, you're tapping into different frequencies you did before, it's centrally like a cosmic experience……… Essentially, we are spiritual beings, …..it kind of makes sense that you're trying to seek something beyond mundane living." (Participant 7 (AN)).

The participants that described spiritual benefits saw these as very important as yoga helped them connect deeper with a sense of themselves. “I found it to be really relaxing and help with mindfulness with the body, like your positive spirit, you're going into another trance with yoga.” (Participant 5 (BED)). This further provided distance from ED pathology, allowing this participant to connect with their sense of identity which they saw as integral to their recovery.

My yoga journey: how I found yoga, the timing counts

Participants found yoga at different times in their ED recovery, impacting their experience and attitude towards engaging with it. Several participants engaged in yoga whilst as an inpatient. These participants talked about how yoga was a safe way to start moving again after being physically compromised. These participants tended to start with gentle yoga. They built up their practice over time. Yoga was seen as a complementary intervention to psychotherapy and benefits were observed early in their recovery.

“We had to do it as one of our groups, and I just learnt that as it’s a good way of trying to practice movement without unhealthy movement, it’s movement where you are taking care of your body.” (Participant 12 (BN & AN)).

Other participants talked about how treating health professionals discouraged movement practices until medical stability was established. These participants tended to find their own yoga class in the community with less guidance or support which made it more challenging for participants to select an appropriate class that worked for them. Some participants in this group acknowledged that initially, they tried faster more intense yoga, hoping that the yoga would result in calorie expenditure.

"One of my health professionals was really supportive of it, but then she found out exactly what it was, and she was sort of a bit like, Okay, maybe we need to back up on this and figure out a more appropriate way to do it." (Participant 8 (AN restrictive subtype orthorexia behaviours)).

These participants reported that over time, as they experienced the benefits of yoga, they could reduce the intensity and move to more mindful practices.

A few participants with chronic ED symptoms that found yoga much later in their recovery, looking to yoga as an alternative treatment option. In contrast to those participants who found yoga earlier in recovery, these participants felt that earlier ED treatment interventions had failed to address key issues related to their illness. They saw yoga as an intervention that addressed the ED differently. It was a method to experience and understand their body ‘from inside, out’ allowing them to develop somatic ways to address their ED. “I feel that in recovery, we need to be looking deeper… And that's what yoga does. It really starts to sort of nurture, basically that inner child that's been completely wounded.” (Participant 14 (AN)).

Overall, offering yoga earlier and providing multiple opportunities to engage, was seen to improve the likelihood of finding yoga to be of benefit in recovery. Participants talked about how important it was to have multiple opportunities to engage with yoga as not all took it up when it was first introduced.

Factors that support engagement with yoga

Participants identified factors that supported a safe engagement with yoga and factors that felt unsafe or aversive (See Table 1 ). Most expressed a view that if yoga is not designed for people with EDs, it could be harmful and exacerbate ED symptoms, such as negative and critical thinking, body dissatisfaction, and excessive exercise. Participants talked about the importance of the physical and social environment, the type of yoga and who facilitates it as critical factors in enhancing engagement.

Physical environment

Consistent among participants was the view that a warm and inviting physical environment was critical. Multiple participants noted that a yoga environment was ideally quiet, with low lighting and no mirrors. Access to classes was important; those attending in the community talked about the difficulty in finding classes that were appropriate and close to home. Some participants noted that online options meant they could access yoga at home and that this mode also helped them manage self-judgement arising from comparing themselves to others. “I prefer to do it alone at home, just because of my own anxiety, and feeling out of place and worried about people like judgement and stuff. Which is a lot of my own anxiety” (Participant 4 (BN&AN)).

Social environment

The social environment was important, with participants reporting feeling self-conscious about their clothing and physical abilities and wanting to fit in. This negative self-evaluation was less likely to occur in small-group yoga with people of similar age and gender. Participants emphasised the need to wear loose and comfortable clothing, with many holding negative feelings about the yoga tight clothing fashion expectation. When the social environment was experienced as negative, this increased an individual’s comparative thinking and self-judgement. “I've seen other people in the waiting room before and it's made me think if you're really bad, I shouldn't be there 'cause they are actually underweight.” (Participant 2 (Atypcial AN)).

Type of yoga

The type of yoga was very important to participants, with many suggesting the need for the facilitation to be slow and gentle, even more so early on. As discussed earlier, there was a discrepancy among participants in that some participants drawn to faster movement found it difficult to engage in slow yoga early in recovery. One participant that did not use yoga as part of their ED recovery (all other participants did), described how the gentleness of the yoga put them off “It's just too peaceful. [laughter] I'm not a very peaceful person. It's very quiet, I'm not a very quiet person.” (Participant 1 (AN)). Other participants noted that it took time to understand the somewhat paradoxical benefits of yoga – in that a gentle movement practice previously viewed as a relaxation activity, could promote strength: "I feel like quite energized afterwards, and it's like the whole nature of it is being gentle on your body and listening to it while also feeling strong, noticing, building strength each time you do it and getting better at it. It's nice.” (Participant 10 (AN)).

Some participants described the importance of offering options for poses, ensuring that poses could be modified for those in larger or differently abled bodies and inviting participants to move in a way that felt comfortable for them. One participant described how her body was not able to engage with certain poses, but the teacher did not offer any suggested modifications leaving her to feel disheartened. “You get the sense that they almost do not know what to do with a bigger body.” (Participant 13 (BED)). Similarly, one participant described how important bolsters, blocks and other props were for her to be able to engage without pain. Most participants believed that specific ED yoga classes would help them feel more comfortable attending, noting that knowing other participants had similar experiences would help. Some suggested that using themes each week could allow participants to process and think about different aspects of ED recovery.

Role of the yoga teacher

Participants emphasised the role of the yoga teacher in supporting or detracting from their experience and was instrumental in building a warm and inviting group experience. Many suggested that having both a yoga teacher and mental health professional present would increase comfort and safety. Education about the complementary benefits of yoga for ED recovery and encouragement from a health professional was seen as key to supporting safe engagement. Many thought it important that the teacher understood EDs well as thoughtful instruction could reduce the striving and comparative thinking that was present for many. The language used was important to participants, who suggested teachers minimise the use of ‘triggering’ words (such as when referring to body parts or ways bodies were ‘meant’ to move or feel) as this can reinforce the idea that there is a right or wrong body or a way to do yoga.

"The voice in my head was incredibly loud, being incredibly critical, and it was very difficult, but with the right teacher and the right yoga script, it's very healing in the sense that what I experienced was being able to surrender to the now and practice acceptance." (Participant 16 (Diagnosis unknown)).

Participants also talked about the importance of the teacher acknowledging that everyone’s body is different to increase body positivity and acceptance.

This qualitative enquiry explored the experiences and perspectives of individuals with an eating disorder (ED) regarding their perceptions of yoga as an adjunct intervention to psychotherapy. It also explored the feasibility, acceptability, and safety of yoga from their perspectives. Results explored three topic area’s; yoga’s capacity for healing and transformation, when and how yoga was found, and what factors supported engagement with yoga.

Participants identified a range of physical, psychological, social, and spiritual benefits of yoga in their recovery. Accordingly, the reported benefits are consistent with previous yoga research, which found that yoga can provide biopsychosocial-spiritual benefits. Physical and psychological benefits such as managing weight gain and cravings [ 46 ], improving physical strength and capacity [ 47 ], body satisfaction, body appreciation and body image [ 21 , 22 , 24 , 29 , 48 ], mindfulness, self-compassion [ 20 ], self-efficacy [ 49 ], self-regulation [ 50 ], empowerment [ 30 , 31 ], motivation [ 49 ], connection [ 51 ], psychological flexibility [ 50 ], positive affect [ 52 ] where all reported by participants. Furthermore, participants reported that yoga provided an opportunity for developing social connections and a sense of belonging [ 13 ] and an opportunity for deeper spiritual reflection [ 32 ].

Overall, participants reported that yoga was a helpful adjunct to their psychological therapy, providing somatic and experiential ways to enhance recovery. The limited available literature suggests that there are benefits in using yoga as an adjunct therapy for a range of mental health diagnoses [ 53 ] and may enhance engagement in psychotherapy processes [ 52 , 54 ]. Yoga’s multiple techniques can provide an experiential platform [ 55 ] promoting introspection, cognitive, emotional, and behavioural changes [ 56 ], making it functional and transdiagnostic in its approach [ 57 ].

Importantly, participants endorsed the mind–body approach of yoga as key to recovery, explaining how benefits were interrelated and linked. Participants identified that the physical movement of yoga represented an essential process for safely reconnecting with their bodies and enhancing embodiment. Participants described how safely connecting with their bodies improved mindfulness and relaxation, allowing distance from their ED thoughts and an opportunity to appraise and challenge these.

Previous qualitative research has found that yoga has enhanced embodiment [ 58 ] and supported ED recovery in various ways [ 59 ]. For example, Pizanello [ 26 ] found that embodiment led to a new sense of empowerment (whereas power and control had only been previously experienced through maladaptive starvation behaviours), which allowed a deeper connection to the authentic self, supporting self-identity development necessary for ED recovery. Pizanello [ 27 ] then re-analysed this data through the lens of psychodynamic theory (D.W Winnicott's Object Relations Theory), attributing embodiment with improved interoceptive awareness and emotion regulation skills, as the mechanism that enhanced ED recovery. Osterman et al., [ 28 ] attributed embodiment with improved body acceptance, awareness and safety allowing one to process traumatic memories and ultimately recover.

In this study, participant responses reinforced previous findings that embodiment was the catalyst that facilitated further recovery processes (psychological, social, and spiritual) necessary for ED recovery. This study adds to existing evidence as additional pathways were identified for how yoga’s capacity to enhance embodiment can improve well-being [ 19 , 58 , 59 ] for various ED presentations. For example, participants with AN described how yoga helped them to slow down, improve mindfulness and distance themselves from critical thoughts. In contrast, participants with BED described how yoga supported healthier habit development, such as developing regular exercise patterns and healthier eating choices. In these examples, mindfulness practice was integral in enhancing motivation, which in turn can support the implementation of positive behaviour change interventions [ 60 ].

This study also adds to the existing literature on the social and spiritual benefits of yoga. These recovery domains are well-noted as important in ED recovery [ 61 , 62 , 63 ] but are not routinely addressed in psychotherapy. Participants described social benefits such as increased social connections, a sense of belonging, giving them new roles, and hobbies [ 64 ]. Participants described spiritual benefits such as an enhanced connection to identity, purpose, and overall sense of spirituality. These findings contribute further to our understanding of the prominent yoga model of health [ 65 ]. This also supports the rationale that in adjunct with psychotherapies such as CBT-E [ 57 ] yoga may be of additional value [ 66 ], as it addresses all biopsychosocial-spiritual elements [ 67 , 68 ] of recovery in a way that psychotherapies cannot alone.

This research provided insights into the benefits and challenges of engaging with yoga throughout the stages of recovery. Findings suggest that those offered yoga earlier were more likely to engage. When yoga was provided by a health service, education about yoga’s benefits and risks was provided, and the yoga focussed on ED recovery, participants felt that they were more likely to use yoga helpfully. A barrier to including yoga in ED services includes a lack of research into safe guidelines for the use of yoga and clinical staff concerns that yoga may exacerbate ED symptoms [ 69 ]. These findings suggest that ED services engage clients in discussions about the potential benefits and risks of using yoga early in treatment, as adequate education enhances outcomes and decreases risks. Our study findings indicated that when guidance from health professionals was lacking, participants sought out yoga classes themselves, which often perpetuated maladaptive ED cognitions. For example, participants with AN described initially seeking out faster yoga to burn calories. Previous qualitative research has identified potential risks associated with yoga as it can trigger comparative thinking and body checking [ 24 , 26 ]. When yoga teachers did not provide appropriate adaptations, participants with BED in a larger body described not being able to engage in certain poses as their bodies were unable to or experienced physical pain. The results of this study identified how these potential risks were seen to be mitigated or overcome when the yoga teacher has knowledge and training in EDs and provides thoughtful facilitation.

Study findings also indicated that participants who found yoga later in their recovery felt strongly that they missed opportunities for ED recovery, as these participants perceived psychotherapy alone as inadequate. Taken together with research indicating that early intervention can enhance ED recovery [ 70 , 71 , 72 , 73 ], and that yoga is an effective ED prevention intervention [ 48 , 74 ] and can reduce anxiety when used in early intervention with a range of mental health disorders [ 75 , 76 ], it is recommended that ED services offer it early in recovery [ 77 ]. There is a body of evidence that suggests that over time, EDs can become more entrenched through functional deterioration, neuroadaptation, and the development of chronic behaviour patterns [ 73 , 78 , 79 ] further reinforcing the importance of offering a range of transdiagnostic treatment options early in recovery.

This research identified a range of factors that participants viewed as supporting the establishment of a safe and inviting yoga environment. Many of these factors, such as using trauma-informed language, focusing sessions on themes related to ED recovery, and creating a safe and inviting environment, reflect elements included in yoga protocols for EDs that have been recently trialled [ 29 , 80 ]. Participants reported that if the yoga was designed for ED recovery and offered in collaboration with the ED service, having both a yoga teacher and mental health professional present would provide further confidence that the yoga would be used to promote recovery. The yoga teacher was seen as essential in building a supportive environment, acknowledging different bodies in the room, offering multiple poses and options for different bodies and being aware that critical or comparative thinking can occur. Given the diverse range of bodies and subsequent need for a range of adaptations and accommodations to support yoga participation within contemporary ED services [ 81 ] participatory research methodologies are recommended to adapt and design complementary yoga programs for ED treatment to ensure end-user participation, engagement, and safety [ 82 , 83 ]. This research points to the benefits of offering in-house adjunctive yoga for ED recovery, to provide education and an opportunity to experience how yoga can enhance embodiment, provide biopsychosocial-spiritual benefits and support ED recovery along with decreasing any potential risks. Taken together, these findings provide potential guidance for practitioners and services seeking to integrate yoga programs within current treatment programs. Drawing on PBE, qualitative research can be translated into intervention design objectives and subsequent guiding principles [ 84 ]. Table 2 describes guiding principles for designing an adjunct yoga intervention for ED recovery and may be a useful starting point for clinicians and researchers interested in future implementation of yoga-based ED recovery programs.

Limitations

A limitation of this study was the lack of demographic data collected from participants; subsequently, factors such as ethnicity, race, and age could not be considered. Furthermore, most participants volunteered for the study as they found yoga helpful to their recovery. Future enquiry may benefit from separately recruiting participants with positive and negative perspectives, including the perspectives of participants with little to no yoga experience. Additionally, more than half of the participants were diagnosed with AN. Future research would do well to have more participants for each ED diagnostic criteria to further contrast similarities, differences, and clinical implications.

This PBE research offers a biopsychosocial-spiritual framework for understanding yoga’s benefits to ED recovery. Findings from this study highlight further understanding of how yoga can enhance embodiment and ED recovery processes for a range of diagnoses. Participants from this study found that yoga enhanced embodiment which was the catalyst to engage with psychological strategies, such as mindfulness, cognitive appraisal and challenging, supporting ED recovery. Other findings indicate that offering yoga early is helpful and more likely to be safe when supported by health professionals. Yoga programs should be co-designed to ensure the physical, social, and cultural environment is accessible and acceptable. This study adds further weight to the emerging evidence that yoga can bring complementary benefits to ED recovery.

Availability of data and materials

A supplementary file attached contains raw data of all qualitative interviews along with analysis and final template documents.

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O’Brien, J., McIver, S., Evans, S. et al. Yoga as an adjunct treatment for eating disorders: a qualitative enquiry of client perspectives. BMC Complement Med Ther 24 , 245 (2024). https://doi.org/10.1186/s12906-024-04514-1

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Methodological issues in conducting yoga- and meditation-based research: A narrative review and research implications

Snehil gupta.

a Department of Psychiatry, All India Institute of Medical Sciences, Bhopal, 462020, India

Anju Dhawan

b National Drug Dependence Treatment Centre (NDDTC) & Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, 110029, India

Associated Data

Yoga and meditation-based interventions have been extensively utilized in the field of contemporary complementary and alternative medicine for various physical and mental health conditions. Ongoing COVID-19 pandemic has rekindled the interest of researchers in yoga and meditation for its preventive and therapeutic utilities. However, the available literature in this area has several methodological concerns, limiting formers’ clinical utility. A comprehensive literature on this topic would stimulate researchers and guide them to conduct research on this topic with robust methodologies. The current review highlights the methodological issues with the yoga and meditation-based Research (henceforth, MBR), discusses some of the contentious issues, and provides future directions. The PubMed, Medline, and google scholar databases were searched to screen records dealing with the methodological issues on MBR. The search yielded 299 records, upon screening, only 24 articles were found suitable for the current study. Common methodological issues with MBR: lack of the consensus definitions of the yoga and meditations, interventions lacking theoretical framework of meditation; inadequate description of the study design; difficulty with participants recruitment, setting up the control groups, and blinding; difficulty in assessing the baseline characteristics of the participants, and validity issues with the outcome measures. A few research, however, have also highlighted the potential measures to overcome these methodological challenges. Yoga and meditation-based interventions are promising for several health conditions. However, literature suffers from considerable methodological issues, thus, limiting its utility in modern clinical practice. The study findings can stimulate and guide future research on this topic.

1. Introduction

Meditation and yoga (defined as a combination of meditation and its context) [ 1 ], have gained popularity in contemporary scientific research and have been used for several mental health (stress, anxiety, depressive disorders, etc.) [ 2 , 3 ] and physical conditions (pain, etc.) [ 4 , 5 ]. Worldwide, yoga and meditation are explored as an alternative and complementary approach to the treatment for both psychological and physical disorders, and to attain a better quality of life [ [6] , [7] , [8] , [9] ]. Apart from the clinical population, it has also gained popularity among the non-clinical population as a means to attain a state of general wellbeing. It is seen as a relatively safe, inexpensive, and sustainable measure that can be used as a standalone or as an adjunct to the standard treatment, in achieving good health or for a specific health condition [ 10 , 11 ]. Ongoing COVID-19 pandemic has rekindled the interest of researchers on yoga and meditation for its preventive and therapeutic utilities. Both yoga and meditation (meditation, henceforth) have been utilized for various mental health problems and to boost immunity to fight against the physical impact of the SARS-CoV-2 (COVID-19) infection [ 12 , 13 ].

However, the available research on the yoga and meditation-based interventions suffered from several methodological limitations: non-incorporation of the theoretical framework of the yoga/meditation practices while developing the interventions, lack of validated instruments to measure the practitioners’ experience, issue related to participant recruitment, and setting up effective control arm, concern over monitoring of meditation-based clinical trials, difficulty in assessing the role of various overt and covert factors on the outcome, etc. [ [14] , [15] , [16] , [17] , [18] ]. This has also been reflected in the ongoing research on the efficacy of yoga and meditation-based intervention for mental and physical consequences of COVID19 pandemic [ 19 ].

Despite literature highlighting several methodological issues with yoga and meditation-based Research (henceforth, MBR), available literature is largely restricted to mindfulness meditation, while literature concerning other common forms of yoga and meditation practices is elusive, which have distinct methodological concerns. Furthermore, a comprehensive account on the ontological aspects of the yoga and meditation practices and their adaptation in the modern contemplative neurosciences, and associated challenges, particularly those centering around the meditation-based intervention, is still lacking. An inclusive literature on this topic can stimulate researchers and guide them to conduct research on this area with robust methodologies, which this paper intends to provide.

Hence, the current review is aimed to highlight various methodological issues in conducting research based on meditation-based interventions, discuss some of the contentious issues, and provides future directions.

2.1. PubMed, Medline, and Google Scholar databases were searched with the search terms

‘Yoga’ OR “meditation” (for yoga and meditation), ‘research’ and ‘methodologic issues’ or ‘research implications’ (for methodological concerns) were used to identify the relevant records ( Supplementary file 1 ). The inclusion criteria for the studies to be considered for the current review were articles primarily dealing with the methodological issues on MBR or research implications of these limitations (e.g., issues with the definition, study design, participants recruitment, intervention delivery, outcome assessment, statistical analysis, etc.), irrespective of the type of yoga and meditation practices, from the inception till 14th May 2020. However, articles not directly dealing with the methodological issues, those papers whose full text was not available (despite making efforts to contact the authors), and those not in the English language were excluded. Additional relevant records were obtained through the bibliographic search.

A total of 299 records were obtained. Upon title and abstract screening, only 24 records were found suitable for the current review. Among the 24 articles selected for the review, most were related to methodological issues in researching MM followed by those with transcendental meditation and yoga-based therapies (described in Table 1 ).

Table 1

Summary of the relevant research/papers on the methodological issues with the yoga and meditation.

Author (year)	Title of the study	Methodology
Vieten et al. (2018) [ ]	Future directions in meditation research: Recommendations for expanding the field of contemplative science.	cross-sectional to investigate the prevalence of a wide range of experiences. n = 1120 meditators current or past meditation practice MEQ30, Extraordinary experiences
Munaz et al. (2017) [ ]	The importance of research literacy for yoga therapists.	perspective
Van Dam NT (2018) [ ]	Mind The Hype: A Critical Evaluation and Prescriptive Agenda for Research on Mindfulness and Meditation	review mindfulness meditation to highlight difficulties of mindfulness, delineates scope of research into mindfulness practices, & illuminates crucial methodological issues for interpreting results from research of mindfulness
Davidson & Dahl (2017) [ ]	Outstanding Challenges in Scientific Research on Mindfulness and Meditation	commentary
Davidson & Kaszniak (2015) [ ]	Conceptual & Methodological Issues in Research on Mindfulness & Meditation.	review
Van Dam NT (2018) [ ]	Reiterated Concerns and Further Challenges for Mindfulness and Meditation Research: A Reply to Davidson and Dahl	commentary
Patwardhan AR (2017) [ ]	Aligning Yoga With Its Evolving Role in Health Care: Comments on Yoga Practice, Policy, Research	commentary
Field T. (2016) [ ]	Yoga Research Review	review (Of empirical research, systematic reviews and metanalyses)
Uebelacker et al. (2012) [ ]	Yoga for Depression and Anxiety: A Review of Published Research and Implications for Healthcare Providers	review
Jeter et al. (2015) [ ]	Yoga as a Therapeutic Intervention: A Bibliometric Analysis of Published Research Studies from 1967 to 2013.	bibliometric analysis of clinical trials based on yoga
Cook-cottone et al. (2013) [ ]	Dosage as a critical variable in yoga therapy research.	perspective
Josipovic Z (2010) [ ]	Duality and nonduality in meditation research	commentary
Park et al. (2015) [ ]	Comparison groups in yoga research: a systematic review and critical evaluation of the literature	systematic review
Goyal et al. (2014) [ ]	Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis	systematic review & Meta-analysis
Sedlmeier et al. (2012) [ ]	The psychological effects of meditation: a meta-analysis	Design: systematic review & Meta-analysis
Awasthi B. (2013) [ ]	Issues and Perspectives in Meditation Research: In Search for a Definition	commentary
Davidson RJ (2010) [ ]	Empirical explorations of mindfulness: Conceptual and methodological conundrums	commentary
Larkey L. (2021) [ ]	Meditative Movement as a Category of Exercise: Implications for Research	review (on Meditative Movement e.g., Tai-chi, Qigong, etc.)
Lustyk et al. (2009) [ ]	Mindfulness meditation research: issues of participant screening, safety procedures, and researcher training	review
Grossman P. (2008) [ ]	On measuring mindfulness in psychosomatic and psychological research	commentary
Travis et al. (2010) [ ]	Focused attention, open monitoring and automatic self-transcending: Categories to organize meditations from Vedic, Buddhist and Chinese traditions

AT: autonomic transcendence, a/w: associated with, CVDs: cardiovascular disease, d/t: due to, EEG: electroencephalogram, FA: focused attention, HCPs: Healthcare providers, MBR: mindfulness-based research, med.: medium, MEQ30: Revised Mystical Experience Questionnaire, MM: mindfulness meditation, MBI: mindfulness-based interventions, OM: open monitoring, PTSD: post-traumatic stress disorders, RCTs: randomized controlled trials, S/E: side-effects, TM: transcendental Meditation Tt: treatment.

4. Major methodological issues with the available MBR

Literature suggests the common methodological issues with MBR to be lack of the consensus definitions of the meditations, meditation-based interventions lacking theoretical framework of meditation; inadequate description of the study design; difficulty with participants recruitment, setting up the control groups, and blinding; difficulty in assessing the baseline characteristics of the participants, and validity issues with the outcome measures.

4.1. Defining meditation

One of the major methodological issues with MBR is the operational definition of the meditation practice under consideration and to explicitly describe its core component(s). There have been substantial variations in the definition/framework used across the studies, despite a large number of studies on meditation, including the MM, they lack an operational definition and that varies across the studies, as a result, the effect size of the intervention of a particular kind cannot be measured. Meditation has been classified under two broad categories: 1) Focussed attention (FA) (concentrative type), where the practitioner voluntarily focuses ones' attention within oneself (breathe, thoughts, imagery, etc.) or outside (candlewick, an image of the deity, etc.) to the exclusion of all other experiences e.g. Zen meditation, hath yoga, and Sudarshan kriya yoga (SKY) and 2) Open monitoring (OM), where the attention is not directed to a particular thing, but to remain aware in a non-reactive manner about whatever arises in the mental continuum of oneself e.g. MM, Vipassana meditation, etc. [ 20 ] However, this dual classification is limited because of considerable overlaps between the practices, resulting in ambiguity and inconsistencies in the definitions in the literature. Furthermore, a third category of meditation the automatic self-transcendence (AST)-which involves transcending the practice of meditation and harnessing the natural tendency of the body to attain pure consciousness (transcendental meditation [TM], Sahaj Samadhi Meditation)-has also been proposed. It is a state of complete letting go and settling into oneself [ 21 ]. Although AST-based meditations begin with the FA, the very practice of transcending the subject-object duality is effortless from the beginning itself as compared to FA-based meditations. For instance, in TM, the mantra chanting though begins with the FA, the practitioner from the very beginning learns to allow oneself to lose focus from the mantra and transcend the subject-object duality to attain self-awareness [ 22 ]. In fact, of the eight limbs of Yoga described by the ancient sage Maharishi Patanjali, one limb is Pratyahara or focussing inside e.g. focussing attention on the heart region, followed by Dhyana or meditation where thoughts/feelings/body sensations are observed and one is in a state of ‘witness consciousness’ followed by transcendence which is a deeper state where one has completely let go [ 21 , 23 ]. Yet, there is another proposed category, the guided-meditation (GM) (e.g. Love and kindnesses meditation), where the content of meditation takes precedence over other aspects of the meditation, and a practitioner is guided through a set of images, or chants to engage in a particular aspect of self (empathy, kindness, etc.) mindfully [ 24 ].

4.2. Characteristics and components of the yoga and meditation

The available research on yoga and meditation-based interventions has been criticized for not accounting for and not explicitly describing various components of the meditation under study including their key elements [ 2 , 25 ]. Likewise, these baseline differences among the participants of different interventions group can confound the research findings. Therefore, simply focussing on a particular aspect of meditation (like the degree of mindfulness achieved during the MM or level of physical exertion in the hath yoga or Qigong) and excluding other components (the practice of mindfulness in day-to-day activities including exercise, or routine work, etc.) could lead to inaccurate and inconsistent study findings [ 17 ].

Likewise, randomly dismantling the process of the meditative practice (e.g. eliminating the integral moral, or lifestyle changes associated with a particular mediation) as per convenience while developing an intervention, without considering its ontological significance, would lead to the development of a distorted or flawed intervention; the findings of such interventions would not be representative of the original contextual meditation. Consequently, the findings would be inconsistent and less-interpretable [ 14 , 26 ].

4.3. The theoretical framework of yoga and meditation

Yoga and meditations have been practiced since antiquity across different cultures. For instance, the concept of meditation in Hinduism is a practice that helps in attaining the pure-consciousness ( enlightenment or self-connection ) [ 27 ] while Buddhism considers it away to achieve emptiness ( Shunyata, skill to disentangle oneself from the defilement and dissatisfactions; state of no-attachment ) [ 28 ]. Neither of them has developed meditation merely for prevention or treatment of a particular health condition. The researchers involved in contemplative sciences have argued that simply adapting the traditional meditative practices for developing an intervention to treat a particular health condition raises validity concerns. For instance, there are now several MM-based interventions (incorporating the principles of mindfulness to varying degrees) such as mindfulness-based cognitive behavioral therapy (MB-CBT), dialectic behavioral therapy (DBT), acceptance and commitment therapy (ACT), etc. However, research analyzing the construct validity of these interventions is still lacking; similarly, the outcomes and their measures used to assess the effectiveness of these interventions also have validity concerns [ 17 , 25 ]. Such contextual issues act as a prominent hindrance in the field of the MBR. Although picking up these practices without the associated philosophical framework has increased its acceptability in the west and the medical and scientific community worldwide, however, researchers need to be mindful about the fact that such derivations, viewed only microscopically through the lens of modern science, could lead to concern over the time-tested practices that have benefitted people for time immemorial. Be that as it may, the current approach can be pursued for serving the purpose of research and science but with a clear understanding of its limitations.

4.4. Study design

Most of the studies were commentaries or perspectives of the experts followed by the review papers, including systematic review and metanalysis. In addition, one of the studies has supplemented its review paper with the findings of the cross-sectional online survey [ 56 ]. The nature of the current review, and methodological issues with the yoga and meditation-based research, however, restricted the incorporation of the original articles.

4.5. Sample size of the studies

Researchers have also suggested that MBR, especially those on MBI, suffers from the limited sample size of the participants across the comparison groups [ 26 , 29 ]. Moreover, baseline differences between the comparison groups, which often remain unaccounted, could act as confounders in assessing the effectiveness of the meditation-based interventions [ 16 , 26 ].

4.6. Assessment of the effect of the yoga/meditation as a state versus a trait phenomenon or an interaction between them

The existing evidence on the effectiveness of the meditation-based interventions has been criticized for studying and reporting the effect of the meditation only during the meditative state (a state phenomenon) i.e. trying to assess its impact merely based on the neuro-psychological findings during the practice of meditation or by comparing the mental state immediately before and after practice [ 14 , 26 ].

The impact of the meditations is also influenced by the duration of the practice (adept practitioner versus novice), both formal and informal, and the constellation of pre-existing traits of the practitioner (their level of motivation, baseline understanding and expectancies from the meditation, adherence to the practice, and the preparatory steps including the lifestyle modifications associated with the practice) [ 20 , 30 , 31 ]. For instance, in Buddhism, certain prerequisites are there before enrolling an individual into the MM which includes ones' life's goals and the baseline understanding about the Buddhist philosophy; such features determine at which level of meditation the participants to be enrolled in [ 32 ]. In contrast, simply studying the state effect of meditation without considering its long-term effect (trait effect) would limit its clinical utility in the real-world scenario. Thus, it would be prudent to study meditatation in the context of a state and trait interaction.

4.7. Participant recruitment process

Literature suggests that MBR often suffers from selection bias [ 26 ]. Research shows that most of the participants getting involved in the MBR have an inherently higher level of enthusiasm and expectancies towards the meditation than their less enthusiastic counterparts who either do not participate or exhibit lesser compliance with the instructions. Moreover, it is not uncommon for the participants to have a prior association with a particular meditation group, this may be a potential source of bias [ 33 , 34 ]. Lastly, participants’ association with the investigator, if both are part of the same yoga/meditation group, may also lead to a personal relationship effect [ 16 ]. Such samples are not representative of the population from which they are drawn and can also act as a major confounder, therefore, the results of such research have serious generalizability issues and a possibility of biased results (unduly higher effect size of the interventions) could not be ruled out [ 35 ].

4.8. Participant safety

The MBR has been criticized for not adequately accounting for and describing the potential adverse consequences of the meditation especially in the vulnerable population (those with pre-existing physical or mental illnesses) [ 26 ]. Further, MBR has been criticized for not providing adequate information to the participants while obtaining consent. This issue is particularly important as a certain vulnerable population are at risk of experiencing adverse effects which include psychological (depersonalization, psychosis, dysphoria, initial worsening of the anxiety symptoms, etc.), physical (worsening of the somatic symptoms and risk of epilepsy, et.), and spiritual-adverse effects (conflict between the philosophy behind the given meditation and the religious belief of a participant, etc.) [ 36 , 37 ]. This methodological limitation is to a certain extent has to do with the poor knowledge of investigators about the potential meditation-related adverse consequences [ 17 ].

4.9. Randomization, allocation concealment, and blinding

The randomization of the participants adds to the vigor of the study. However, the literature shows that MBR often inadequately describes the process of randomization of the participants. Another methodological limitation is the participants' selection for the study. For instance, if a given intervention is expected to affect the cognitive ability (e.g. multitasking) of the participants, then it is prudent to recruit participants for whom multitasking forms an important part of their work or life [ 18 , 38 ]. This criticism, however, stems from the belief that meditation may affect a specific cognitive ability. However, based on the neurobiological findings that show involvement of multiple areas of the brain during meditation, it is unlikely that the benefits of meditation are so specifically limited to a specific cognitive ability as would happen during a psychological intervention designed to enhance a specific cognitive skill.

The greater issue is related to allocation concealment and blinding. Lack of allocation concealment can introduce a bias in assigning participants to a particular group. This can stem from the association between the participants and the investigators and a potential tendency towards allocating the more enthusiastic participants to the active group than their less interested counterparts. Usually, the MBR follows a wait-list control design or control arm receiving the non-specific interventions like general exercise, dietary advice, self-help books, etc.; consequently, the participants are liable to exhibit demand characteristics (behaving or experiencing in a manner that is expected of their placement in a particular group) [ 26 , 39 ]. Such a bias can also occur at the level of the instructor who may have an association with the meditation group or is aware of which arm they are training to, consequently, their level of effort and commitment may vary accordingly [ 26 ], though this potential bias needs further exploration.

Similarly, the findings of the effectiveness studies are vulnerable to getting biased if the participants, the assessor, or the analyzer/statistician are aware of the group to which a particular participant belongs. Thus, for MBR, blinding at multiple levels (at the level of the participant, assessor, and analyzer) becomes essential.

4.10. Fidelity in delivering the meditation-based interventions

For MBR to progress, it becomes vital that the intervention is delivered in a way it was traditionally intended to. For this to happen, the instructor must have adequate knowledge and experience (including the theoretical framework of meditation) about meditation and its delivery [ 40 ]. However, it has often been argued that researchers often do not provide an adequate description of the characteristics of the instructor (experience, certification, etc.), and the method adopted by them to ensure the fidelity of intervention delivery. These raise concerns about the methodological robustness of the research and also act as a roadblock in replicating the research findings [ 18 , 26 ].

4.11. Outcomes of the yoga and MBR

Although researchers have shown keen interest in studying the positive effects of yoga and meditation as alternative and complementary medicine for various psychological or physical health issues and have tried to develop various interventions based on them, the outcome measures used are still in its infancy and lack validations [ 41 , 42 ]. Without understanding the ontological context of yoga/meditation and the set goals with which it was practiced, which is quite fluid (enlightenment, self-actualization, or to attain pure-consciousness), the outcomes assessed with a reductionist approach (e.g., present-moment-awareness erroneously considered to be a reflection of the psychological construct of the traditional Buddhist concept of mindfulness or any meditation) could act as a major methodological limitation in the ongoing research on meditation [ 43 ]. One major observation is that a large part of the meditation research emanates from the West rather than from the eastern part of the world from where these practices originated and where there is an inherent better understanding of its philosophy and the context. The meditation research seems to have picked up only a minuscule part of the innumerable practices available in eastern culture for research.

4.12. Assessment measures

One of the major methodological issues with MBR is to accurately measure the subjective experiences (mindfulness, relaxation, attaining consciousness, etc.) of the practitioners with any self-report or objective measure [ 14 , 17 , 26 ]. Further, the outcome measures often being used in the research are unspecific, hence cannot delineate the effects of various subtypes of meditative practices and their variations and differentiate the effect of one practice from another. Probably, the reason for this may be that the researcher may expect that the outcomes of such variations among the meditations would differ qualitatively, but not quantitatively. However, this may not be true. For instance, the Sahaj Samadhi Dhyana Yoga is specifically expected to provide relief from past traumatic memories and so, may be studied for its potential benefit in Post-Traumatic Stress Disorders [ 44 ]. Further, relying on the third persons' account for the first-persons’ experience is vulnerable to depict a distorted picture unless the former has a deep knowledge and experience in recognizing and differentiating the various subjective meditative experiences and their outward manifestations [ 41 ]. Similarly, the objective measures (neuro-psychological or electrophysiological findings) used to infer the subjective experience may not accurately capture the real change brought about by the meditation. For instance, it is challenging to accurately and reliably tap the mind wandering, or non-judgemental approaches towards ones' thoughts or other mental states with the help of neuro-imaging. Overenthusiastic and undue attempts to quantify or measure the psychological state of an individual (e.g. mindfulness, non-judgemental, awareness, mind in the present moment) through reverse-inference (a neuro-cognitive sciences' approach in which based on the functional neuroimaging findings [brain activation] the mental state of an individual is inferred) is liable to suffer from biases, a common pitfall in neuro-imaging based study, especially when the pieces of evidence are still evolving [ 45 ]. The construct validity of the measuring instruments has also been debated especially in the absence of any gold-standard reference instrument [ 14 ]. Further, the self-report questionnaires are also likely to get biased depending on the participants' expectancies and prior experience with any meditation (e.g. an experienced practitioner may be better able to delineate and describe ones’ meditative experience as compared to a novice) [ 16 ]. Thus, first-person qualitative research needs to be used more often in meditation research, especially for hypothesis generation.

4.13. Effect of yoga and meditation and sustainability of their benefits

As has been discussed, the effect of the meditation is also determined by several associated factors (such as preparatory measures and lifestyle modifications) [ 14 , 32 ]. Similarly, there are several latent factors such as duration of the informal practice of the meditation (e.g. being mindfulness), ones' personality traits, or expertise in the meditation, etc., and their interrelation, which may influence the overall effect of the meditation on the practitioners [ 17 ]. Moreover, an experienced practitioner of the meditation is vulnerable to exhibit the ‘Hawthorne effect’ (a tendency to perform better or report in an exaggerated positive manner about the effect of the meditation one has been involved in) [ 16 ]. Many studies do not account for, or at least adequately describe these latent variables, thus their results should be interpreted with some caution [ 17 ]. Some of these latent variables may be quite difficult to assess, such as depth of meditation and level of expertise over it, while others such as personality traits may be more easily measurable.

Further, in the absence of long-term follow-up studies assessing the effects of meditation on the practitioner, its sustainable effects are yet to be established. Factors like duration, quality of meditation, compliance with the recommended practice, and practice of more than one type of meditation during the same period are difficult to be ascertained, hence, could act as a hurdle in conducting longitudinal studies on meditation. Moreover, self-report measures are often subjected to recall bias.

4.14. Statistical analysis-related issues

MBR is also limited by factors concerning the statistical analysis. Literature shows that studies often do not employ an intention to treat (ITT) analysis while analysing data rather only show findings of the per-protocol analysis (those participants who followed the interventions as per the protocol), resulting in inaccurate results. This also overlooks the feasibility and acceptability aspects of a meditation-based intervention for various health conditions [ 3 , 26 ]. Hence, the issue of dropouts needs to be addressed more comprehensively. Furthermore, as several factors act parallelly, mediator and moderator analysis, though may be difficult to perform, should be attempted, whenever feasible, to explain and understand the benefits of the interventions [ 26 , 46 ]. Finally, baseline differences between the participants (within the groups or between active and control groups) are often not analyzed.

5. Measures to overcome the methodological limitations with the MBR and the road ahead

5.1. operationalizing the definition of yoga and meditation.

It is highly recommended that the MBR should operationally define the meditation under study (e.g. mindfulness, transcendental meditation), giving due consideration to its ontological definition and psycho-philosophical context [ 14 , 17 , 26 ]. This would ensure research fidelity and replicability of studies across different populations and study designs. Furthermore, the theoretical framework of the meditation should be taken into account while developing any meditation-based interventions and generating a testable hypothesis; this would facilitate the progress of MBR. Most of the research is focused on a specific kind of meditation practice and the research base needs to be widened and be more inclusive.

5.2. Component analysis of the yoga/meditative practice

Meditation involves many preparatory steps (breathing, postures, lifestyles and philosophical changes, etc.) and components (e.g., Qigong meditation includes self-awareness, stilling of the mind, and also raising the Qi energy/prana through a concentrative focus on breath and posture etc.). Hence, it is worthwhile to systematically analyze various components of the meditation (breathing exercises, asanas, chanting, meditation-proper [dhyana], etc.) and also to differentiate between otherwise seemingly similar activities (e.g. exertion due to body moments in Qigong from the exertion during the aerobic exercise), to be able to find out the mechanism of its action and its uniqueness [ 2 , 3 , 23 , 40 ]. Similarly, different modifications of a particular meditation type (e.g. mindfulness-based practices: ACT, MBSR program, MB-CBT, etc.) should be compared among themselves to be able to identify the key component of the modified meditations bringing about the desired benefit. Furthermore, exploration of the non-core component of meditation in various permutations and combinations with the core element of meditation could bring about significant insight into the effect of the individual components of meditations and the most effective combinations among them. For instance, the non-attentional component of mindfulness meditation such as breathing pattern (chaotic Vs rhythmic), sensory involvement (deprivation Vs enhancement), moral discipline, and other contextual effects, etc. should be studied alongside its core component (e.g., attentional and non-reactive engagement with the subjective experiences). One of the potential study designs to realize these objectives are a single-case experimental design where a single participant, usually an expert in meditation, is assessed on multiple occasions after performing different elements of the meditation or different types of meditations [ 47 ]. A similar methodology could also be employed on a small number of participants in an experimental design.

5.3. Participants’ recruitment using the opt-out approach

To overcome the inherent flaw with the participants' recruitment in the MBR and issues with its generalization, some researchers have suggested an opt-out approach to participants' recruitment to be more suitable. This approach has been found to be associated with a higher recruitment rate, adherence rate, and better compliance with the intended meditation-based interventions. Since the opt-out approach require a lesser activation level (required confidence over ones’ ability to change the behavior) and reasonable baseline expectation and interest from the intervention, such participants are more representative of the population, thus making the research findings more generalizable and closer to real-world scenario [ 33 , 34 ].

5.4. Setting up an effective control/comparison group

To decipher the benefits of meditation and compare its impact with other practices or placebo, we need to conduct research having effective control arm(s). Some of the limitations of the wait-list control design (demand characteristics) could be surmounted by employing the dual blinding method (in which the participants are unaware as to which arm of the study is the intervention arm) [ 48 ]. One such example is the health enhancement program, which has been used to serve as a control arm for MBSR [ 49 ]. The latter differed from the MBSR in comprising of music therapy (Vs body scan), nutrition education (Vs sitting meditation), and just walking (vs mindful walking). Other useful strategies could be dismantling strategies (where the practice is systematically broken down into various parts and the key component is replaced by a neutral activity) and by having several comparison groups [ 50 ].

5.5. Adequate description of the study

For the MBR to progress, the researchers must provide adequate descriptions of the study design including the process of obtaining the informed consent; characteristics of the participants, trainers, and the investigator (including their affiliation with any meditation-based organization, experience in meditation, knowledge, and expertise in the field of contemplative sciences, etc.) and most importantly about the meditative practice under study (FA, OM, GM, ASD or mixed; kind of breathing; the level of exertion; modification of the practice based on age and culture of the participants, preparatory steps, etc.) [ 18 , 26 ]. It is also prudent to inform participants beforehand about the meditation-based intervention under study and its potential effect in a neutral yet specific manner. For instance, telling the participants that the technique would ‘train one in stabilizing one's mind’ in place of telling them they are going perform some meditation, would prevent unreasonable expectancies among them, which otherwise could act as a confounder. The researcher can use certain instruments such as credibility and the expectancies questionnaire (CEQ) to assess the baseline expectations of the participants on the effectiveness of the meditation [ 51 ]. Similarly, the fidelity of delivering meditation-based interventions by the instructor could be examined by videotaping the training sessions.

5.6. Ensuring fidelity of intervention delivery

To overcome the issues of the fidelity of delivering meditation-based interventions by the instructors, study protocols must adequately describe the mode of delivery of the intervention, who would provide the intervention, and how?; similarly, pilot testing of the intervention delivery, video-recording of the therapy sessions, feedback from the experts and necessary course corrections become crucial.

5.7. Validating outcomes and measures

The outcomes used to assess the effectiveness of the MBR must be specific and have adequate construct and content validity. Similarly, the outcome measures (questionnaire: self-report or interview-based) developed to assess the effectiveness of the interventions should have criterion validity. It can be achieved by incorporating the theoretical framework of meditation while developing the instruments.

Further, to precisely measure the outcome of meditation, a multi-model approach would be more robust. For example, one may couple the subjective experience of the practitioner (e.g. current level of mind-wandering, affective state, etc.) with an objective measure. One of the useful methods is an ‘Ecological Momentary Assessment’ (EMA), where the practitioner while meditating is asked about his/her current state of mind-wandering and simultaneously given a cognitive task (breath counting or a series of words, etc.) to assess their cognitive performance; such objective measures could also be complemented by a neuro-imaging or electrophysiological studies [ 52 ]. Further, the first persons' account about the meditative experience should be assessed by an experienced third person rather than someone lacking sufficient insights and expertise into the meditation and its effect. This would help in assessing the nuances of the meditative experience of the practitioner. Additionally, the experience of the first person, especially in a novice, can be indirectly assessed by enquiring about his/hers' behavioral change by the second-persons’ account (a family member or an instructor who is also in close terms with the practitioner). This could avoid recall bias and subjective biases while reporting ones' experience, thus provide an accurate result. It should be possible in at least some of the research studies though may be difficult in many others.

5.8. Trait-state interaction and longitudinal assessment of the effect of the yoga/meditation

The effectiveness of the meditation to a larger extent is determined by both the quantity and quality of the meditation practice. Future research must endeavor to capture these aspects, at least over some time, in a practitioners’ routine life. This should also account for the duration of each meditation practices separately if one is involved in more than one type of meditative practices; duration of both the home-based practice and the retreat course; and informal practice during the day to day life (e.g. practicing mindfulness or breathing exercises during the period of stress and cognitive task) [ 26 ]. Moreover, the personality characteristics of the practitioners and other psychological factors that facilitate their persistency in the practice should be assessed. Furthermore, factors related to compliance with the meditation need to be assessed.

The impact of meditation should be longitudinally assessed at different time points. Although it might be difficult, but not insurmountable. To avoid the recall bias, a daily reconstruction strategy could be utilized in which the participants systematically reconstruct their activities and experience of the preceding day [ 53 ]. More robust research design and assessment measures that would be less burdensome and effortless for the participants should be developed to capture the experiences of the practitioners.

5.9. Monitoring for any adverse effects of the yoga and meditation-based interventions

It is not uncommon that various meditative practices are inadvertently advertised as a technique that is free of any potential side-effects and contra-indications, which may not be true for all the meditations and all the participants [ 37 ]. Hence, a robust research methodology should include careful participant selection, explicitly describing the exclusion criterion of the study, and adequately informing the participants about the potential side-effects or adverse effects of the practice while obtaining their consent. Having a mental health professional and yoga expert on board could address this issue to a larger extent [ 26 ]. Till the sound evidence for all meditation-based interventions in mental health problems is established, it is imperative that the individuals, particularly those with mental health problems, should also be adequately informed about the more conventional and evidence-based interventions (e.g., CBT for depressive disorders or aerobic exercise/physiotherapy for the pains).

5.10. Statistical measures

Despite randomization, considerable baseline differences may exist among the participants, such cofactors influencing the response of meditation in the real world should be analyzed by the appropriate statistical tests [ 54 ]. In certain cases, especially when sample sizes are small, it is advisable to provide findings of both the ITT and per-protocol analysis to bring about greater insights into the effectiveness of the interventions. Furthermore, to be able to accurately measure the impact of meditation (e.g. attainment of the mindfulness or level of cognitive performances) on the participants, mediator (e.g. duration of practice, participants’ baseline interest for the meditation, etc.) and moderator analysis (e.g. change in the lifestyles, association with a meditation related organization) should be performed [ 55 ].

6. Limitations

The current review has a few significant limitations. Firstly, we have only included records that are available in English; therefore, we might have missed some of the crucial literature available on native/regional languages, which otherwise could have strengthened the current review. Secondly, most of the included papers were commentaries/perspectives, which were personal accounts of the researchers that might not have undergone strict scientific scrutiny; therefore, the inferences drawn from them might not be conclusive. Lastly, our review was focused mainly on the qualitative aspect of the MBR, including methodological issues, adverse effects with the meditation practice, the effectiveness of the MBI, statistical conundrums, etc. Hence, it could not comment upon quantitative data on the MBR and associated methodological concerns, which otherwise would have been valuable for the readers.

7. Conclusion

MBR has grown exponentially over the last few decades. Meditation-based interventions have been tried extensively for various psychological and medical conditions with some are backed by high-quality research. The ongoing COVID-19 pandemic and its psychological impact have opened a new research avenue to explore the effect of meditation (and meditation-based interventions) on general well-being and for its positive physio-psychological effect in the general public and clinical populations, respectively.

Despite some of the promising findings, MBR suffers from important methodological limitations. Major methodological limitations with the MBR include ambiguity about the definitions of the meditations, lack of testable hypothesis, difficulty with participants’ recruitment, issues with allocation concealment and blinding, difficulties in setting-up the comparative groups, assessing the characteristics of the participants, trainers, and investigators, lack of the validated outcome measures, statistical analysis, etc. However, these limitations are not insurmountable and can be overcome by robust research designs. Future research must take into account these findings while trying to generate evidence for yoga and meditation and interventions.

Authors’ credit statement

SG: Conceptualization ideas, development or design of methodology, maintaining research data, writing initial Draft.

AD: Conceptualization ideas, reviewing draft.

Authors’ disclosure

Dr. Anju Dhawan is a certified teacher of the Art of Living foundation with its head quarter based in Bengaluru, India. She conducts worskshop on Sudarshan Kriya Yoga and Sajah Samadhi Meditation. However, none of the authors report any financial or other incentives from any organization in writing this paper. Nothing to disclose.

Declaration of competing interest

Acknowledgment.

We are grateful to Dr. Suresh Thapaliya, Medical Training Initiative Fellow, RCPsych, Kent and Medway NHS and Social Care Partnership Trust Canterbury, Kent, the UK for his valuable inputs and language editing of the manuscript.

Peer review under responsibility of Transdisciplinary University, Bangalore.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.jaim.2022.100620 .

Appendix A. Supplementary data

The following is the Supplementary data to this article:

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