10 YogaTherapyToday | Spring 2013 www.iayt.

org
FeatureArticle
Yoga Therapy in a Pediatric Hospital:
A Mental Health Approach
Pioneering a New
Branch of Integrative
Medicine
Working with kids in this
setting has taught me more
about the power of yoga
and its application than
any other experience.
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Jake doing fire hydrant pose
as part of a Psychiatric Day
Treatment class.
Photo credit: Tia Brayman,
Childrens Hospital Colorado
By Michelle Fury
Introduction
The combination of yoga therapy and
mental health is gaining traction in the
public eye. In a 2009 Time magazine arti-
cle, licensed clinical social worker Joan
Stenzler spoke of the natural union of
yoga and psychotherapy. She is quoted as
saying, The goal and intention in psy-
chotherapy is to support a patient to be
who they always were. And thats yoga!
(Kornfeld, A.B.E. [2009]. Psychotherapy
goes from couch to yoga mat.
Time. Retrieved from
http://www.time.com/time/health/arti-
cle/0,8599,1891271,00.html.)
Stenzler is describing what I do at
Childrens Hospital Colorado (Childrens
Colorado). I am both a licensed psy-
chotherapist and a seasoned yoga
teacher. Though it has been a challenge
to get here, I know it is possible, because
I have been doing it for over seven years
and with great results. So in this article I
will describe what I do, the current setting
in which my position exists and how it was
created, and the qualifications necessary
to fill it. I will also review the compelling
evidence that yoga therapy can and
should be used for mental health benefits.
Keep Calm, Carry On
Recently a girl attending my weekly thera-
peutic yoga group for adolescents lost
consciousness when it was her turn to
check in. The group was part of the Ado-
lescent Psychiatric Unit (APU) at Chil-
drens Colorado. My primary role in this
group is to use yoga therapy as a psy-
chotherapeutic intervention, and this par-
ticular APU yoga session serves as a
good example of how I do this.
As soon as the girl slumped over, the
other staff in the room and I sprung into
action: staff called for a nurse who arrived
quickly and assessed the girls health.
Meanwhile, the other staff and I escorted
the teens back to their unit. Once in the
units day room, I led the group in a slow
flow of gentle yoga poses that empha-
sized forward folding, followed by deep
breathing. During check out, I asked each
participant to share how she or he felt. All
teens reported a change in their affect
from the beginning to end of group. For
instance, one teen checked in as blah
and checked out as relaxed. Another
teen checked in irritated and checked
out refreshed. Though this APU group
started off unusually, the unusual circum-
stances highlight something important
about the teens response: that is, they
didnt respond much at all. This particular
group of teens presented with the blunted
affect that is common in depression. The
psychotherapist in me allowed me to
notice the teens nonreaction and to point
out to them that something extraordinary
had just occurred, while the yoga therapist
in me knew what yoga poses and breath-
ing techniques could enliven and regulate
the participants. This example also
demonstrates the combination of modali-
ties in action.
Developing a Yoga Therapy Pro-
gram in a Hospital that is Pediatric
and Psychiatric
I am a full-time yoga therapist in the
Ponzio Creative Arts Therapy Program
(PCAT) at Childrens Colorado. Pediatric
psychiatrist Marianne Wamboldt, MD, co-
founded PCAT in 2005 with a grant from
the Craig Ponzio family. PCAT offers art,
dance/movement, music, and yoga thera-
pies, and is composed of masters-level
licensed therapists. I have been part of
this team since I joined it as a psychother-
apy intern in the fall of 2005. Now, I run
weekly therapeutic groups for almost all
units within the Department of Psychiatry
and Behavioral Sciences at Childrens
Colorado. These units have inpatient and
transitional day-treatment programs. I also
see individual outpatients on a semi-regu-
lar basis. My remaining time goes to the
Integrative Headache Clinic (IHC), where I
conduct a bi-monthly yoga class for ado-
lescents with chronic headaches.
(continued on page 12)
Like my fellow PCAT therapists, I use my
modality (yoga) as a psychotherapeutic
intervention. We meet weekly to discuss
our teams policies with the units we
serve, to provide one another with peer
supervision on difficult cases, and to dis-
cuss the training of our interns. My PCAT
team as a whole has formally recorded
the check-in and check-out process via a
measure called FACE pages (Fast
Assessment of Childrens Emotions) over
two years. Because good psychotherapy
involves looking at ones negative emo-
tional states as well as the positive states,
sometimes we care less about whether an
adolescents state is positive or negative
and more about whether he or she notices
a change. Two years of collecting FACE
sheet data has shown us that teens over-
whelmingly report a change in their affec-
tive state from the beginning to end of all
the PCAT groups. More informally, I have
consistently noted improvements in mood
and emotional regulation in the teens, as
well as receiving positive reports from
their healthcare team.
The work that I (and my fellow PCAT
therapists) do with children and adoles-
cents does not happen in a vacuum.
When I see an individual patient I commu-
nicate with his or her primary psychologist
or psychiatrist on a weekly basis to coordi-
nate care. Before I see each of my regu-
larly scheduled groups, I speak with staff
on the unit to determine what interven-
tions and techniques to use for that partic-
ular group. Being clear about the scope of
ones practice is vitally important in an
environment like Childrens Colorado. For
instance, while I must be familiar and
trained in the use of the DSM-IVR (the
YogaTherapyToday | Spring 2013 11 www.iayt.org
Feature Article continued
Three teens take
part in the filming
of Childrens
Hospital Colorados
instructional yoga
video for teens in
September 2011.
Photo credit:
Randall Streiffert,
Childrens Hospital
Colorado
Revised Diagnostic and Statistical Manual
for Mental Disorders), I do not diagnose.
In addition, while I am a co-investigator on
a few studies at Childrens Colorado, my
role is to develop and deliver yoga therapy
interventions.
Unlike the art, dance/movement and
music therapies offered through PCAT,
there is not an academic masters degree
associated with yoga therapy for mental
health. Yet. We are working hard at Chil-
drens Colorado to create the structure
and the alliances foundational to a formal
yoga therapy education. To that end, I cre-
ated a yoga therapy internship that mirrors
the other PCAT modalities internship pro-
grams, which I have implemented for the
first time this academic year of 2012-
2013. I am currently supervising an intern
student who is enrolled in Naropas Mas-
ters in Contemplative Psychotherapy Pro-
gram (MACP), the program from which I
graduated. The difference between her
internship experience and mine is that I
had to do two separate internships to sat-
isfy the requirements of MACP. This was
because the structure did not exist at Chil-
drens Colorado that would allow me to
get all the clinical talk therapy experi-
ence I needed to graduate (280 hours of
direct client contact, to be exact). But
under my guidance as a licensed psy-
chotherapist who integrates yoga and talk
therapy skills, my intern is learning to do
the same while also fulfilling Naropas
requirements.
In addition, Dr. Wamboldt and I are
working closely with Hansa Knox, director
of PranaYoga and Ayurveda Mandala in
Denver, where they have created a com-
prehensive childrens yoga teacher train-
ing. By 2014, Childrens Colorado will be a
practicum site for PranaYoga students
enrolled in this program.
Job Requirements
In order to do what I do at Childrens Col-
orado, I have worked hard to meet certain
requirements. I am a Registered Chil-
drens Yoga Teacher (RCYT) who has
facilitated therapeutic yoga for children
and families for seven years, and I have
taught yoga in general for sixteen years. I
hold a masters degree in Contemplative
Psychotherapy from Naropa University
(Boulder, CO) and I am a Licensed Pro-
fessional Counselor (LPC) through the
State of Colorado. I am trained in Dialecti-
cal Behavioral Therapy (DBT), an evi-
dence-based mindfulness therapy, and
have much training and experience in
trauma therapy. At Childrens Colorado,
we require the following of yoga therapists
or yoga therapy interns:
A) Licensed in psychotherapy, psycholo-
gy, or social work, or B) currently seek-
ing an internship to satisfy graduate
school requirements in clinical practice
from one of the fields listed;
Currently an RYT-200 (Yoga Alliance),
plus two years of teaching experience;
and
Two years' experience working with chil-
dren (such as childcare or teaching).

Anatomy of a Yoga Therapy Inter-
vention for Mental Health
Though I dont think of yoga therapy and
psychotherapy as separate any more, I
understand that this is still a fairly new con-
cept for most. So I will highlight each set of
skills as I practice them in a single session.
Lets go back to that APU group I men-
tioned at the beginning to understand
which part is psychotherapy and which part
is yoga therapy. The check-in and check-
out practice with each adolescent before
and after each group is a psychotherapy
technique that helps create attunement
(my responsiveness to each teen). By
attuning with the kids from the start, I am
able to decide what yogic interventions to
use. In this particular group, the check-in
went like this: Whats your name? How
are you feeling? And if you could start any
new school club what would it be? A men-
tal health counselor developed this last
question, and its informal tone is purpose-
ful: it creates a casual atmosphere that is
relaxed and attuned to adolescents who
may be new to yoga. Through the check-
in/check-out technique, I am practicing
brief therapy (a common and well-
researched therapy model). The goal of
brief therapy is to build therapeutic rapport
with the patient as quickly as possible.
Rapport literally means relationship in
French, so therapeutic rapport refers to the
process of building relationship between
two individuals in a therapeutic relation-
ship. Attunement is one of the ways to
build therapeutic rapport. All of these psy-
chotherapeutic tools (attunement, brief
therapy and rapport building) help me to
create a therapeutic yoga environment, in
which adolescents feel they can trust me.
While Im establishing rapport, Im also
assessing each teens behavioral profile.
For instance, am I working with a group
who has eating disorders or Autistic Spec-
trum Disorder, or do their issues vary? The
APU have been admitted to Childrens Col-
orado because they are in danger of hurt-
ing themselves or someone else. Yet their
mental health issues can vary widely: in a
group of 10 teens, three teens may be
severely depressed and struggling with
suicidal ideation, three teens experiencing
hallucinations, and the other four rapidly
cycling from anxiety to depression (i.e.,
bipolar mood swings). My job is to design
a yoga intervention that helps the entire
group regulate their moods, or learn to be
present with uncomfortable thoughts, feel-
ings, and sensations.
To determine the most beneficial yoga
techniques for the group (or individual), I
think about what direction I want to guide
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-ICHELLEASSISTINGASTUDENTIN0SYCHIATRIC$AY
Treatment
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Being clear about
the scope of ones
practice is vitally
important in an
environment like
Childrens Colorado.
YogaTherapyToday | Spring 2013 13 www.iayt.org
Feature Article continued
the energy. If the majority of the group is
depressed and/or struggling with halluci-
nations (which can sap a persons ener-
gy), I want to gently increase the energy
to a more alert and awake state by the
end of the group. I can do this by introduc-
ing a slow flow of yoga poses that builds
to either headstand prep at the wall or
core-strengthening poses. If the group is
primarily anxious, I want to gently
decrease the energy toward a calm,
grounded state. In this case, I might start
the group with a more vigorous flow of
sun salutations that lead toward more
calming floor stretches and end with a bal-
ancing breathing technique like counting
breaths up to ten. My paramount objective
is to meet the person (or group) where
she or he is.
As mentioned previously, the teens in
the APU group suffer from depression,
anxiety, or a mixture of both. After we all
filed into the unit day room my main
objective was to help them regulate what-
ever emotions they might be having after
witnessing their peer lose consciousness.
I did this by starting with a slow flow of
gentle yoga movements first in their chairs
and then in a brief standing warrior flow to
release anxiety. Then I instructed the
group to sit back down for deep, calming
breaths. Both kids and staff reported feel-
ing more relaxed and refreshed than
before we started.
The Rising Star of Integrative
Medicine
Currently, the medical world refers to yoga
as complementary and alternative medi-
cine (CAM) or integrated medicine. The
Centers for Disease Control and Prevention
(CDC) reports that more and more con-
sumers are turning to CAM, especially for
chronic illnesses (http://www.cdc.gov/
pcd/issues/2004/oct/03_0036.htm). So it
makes sense that Childrens Colorado
incorporates Integrated Medicine (in the
form of yoga therapy as well as the entire
PCAT team) into its model of care.
To move forward the practice of yoga
as psychotherapy, a number of factors are
needed. First, we need to create manuals
on how to integrate yoga therapy and psy-
chotherapy more formally. I intend to write
a training manual for my interns, and
eventually a book. If you or any yoga ther-
apist you know are currently using yoga
for mental health reasons, start writing!
Second, we need to formalize yoga thera-
py training (for mental health) and collabo-
rate with other educational institutions, as
Childrens Colorado has started to do with
Naropa and PranaYoga. Third, we need to
create standardized yoga treatments for
mental health that can be studied through
research. Childrens Colorado has been
doing research and pilot studies on yoga
for years (though we have not formally
published anything yet).
Replicating the Process
For those interested in being a yoga ther-
apist in the field of mental health, here are
a few tips that may help you forge your
own path up the mountain of yoga therapy
for mental health:
Pursue formal education and licensing
in a mental health field (such as psy-
chotherapy, psychology or social work).
Pursue formal education in yoga thera-
py from a yoga therapy school that
incorporates physical and mental health
components in its training curriculum.
Create alliances between a yoga school
and a local mental health facility.
Work with individual yoga therapy
clients who have mental health goals for
their yoga therapy practice.
Write a grant for your program (you may
be able to find free classes and
resources through your local library or
the internet), or team up with someone
who writes grants professionally.
Contact a local yoga school to inquire
about space for your therapeutic yoga
groups.
Conclusion
Working as a yoga therapist at Childrens
Colorado for the past seven years has
been the hardest and most rewarding
challenge of my life thus far. On the one
hand, it has neither been easy nor simple
to fit yoga into the medical and mental
health model of a pediatric hospital. On
the other hand, the field of medicine and
mental health seems open and ripe for the
ancient albeit alternative practice of yoga
therapy. Parents, kids, psychiatrists, and
physicians alike seem to want a more
humane and individual approach to physi-
cal and mental health care. To deliver
yoga therapy effectively in the mental
health setting requires a lot of training and
cross-training of a yoga therapist. But at
this point in my career, I cannot imagine
doing anything else. Working with kids in
this setting has taught me more about the
power of yoga and its application than any
other experience. It is my greatest wish
that the field of yoga therapy in mental
health grow and expand in the coming
years. YTT
Michelle J. Fury, RCYT, LPC, caught the
yoga bug in 1992. She has taught yoga
for over sixteen years and facilitated ther-
apeutic yoga groups for over seven years.
In sharing the healing practice of yoga,
her goal is to empower kids to develop
strong bodies, sharp minds, and resiliency.
Photo credit: Tia Brayman, Childrens Hospital Colorado
Girl scouts practice
yoga to promote
positive body
image during Girl
Scout Body Image
Badge Day.
Photo credit:
Tia Brayman,
Childrens Hospital
Colorado