1
Introduction
Against the backdrop of COVID-19, mental health needs have increased while access
to affordable mental health interventions has been reduced [1,2]. In view of this,
the United Nations has recognised the need for supplementary interventions that can
support existing mental health care (United Nations Sustainable Development Group
[ [3]. Religious and spiritual (R/S) practices, such as chanting, breathwork and yoga
offer cost-effective and accessible supplementary mental health interventions [4].
There is substantial evidence for the mental health benefits of these practices, with
evidence that they may be preferred by some patients over mainstream treatment, possibly
due to the stigma attached to mental illness and shame associated with accessing conventional
mental health services [5,6]. Side effects of medications [7] and lack of response
to conventional treatments [8] are other reasons cited for why R/S practices may be
a preferred treatment approach. Despite this potential, no studies were located that
investigated the use of R/S practices as mental health interventions in clinical settings.
This highlights the need to investigate the viability of integrating these practices
in clinical mental health care.
A limited number of studies have investigated inclusion of R/S practices in counselling
and “talking therapy” [[9], [10], [11], [12], [13]]. The focus of these studies was
either addressing mental health through counselling and/or cognitive restructuring
strategies based on practices related to R/S philosophies [9,10] or by supplementing
counselling with R/S meditation and healing practices [[11], [12], [13]]. So, while
the integration of some R/S practices into mental health interventions has been explored,
to our knowledge, no study has focussed on the feasibility of using R/S practices
as standalone interventions in mental health settings. Indeed, at present, it is unclear
to what extent R/S practices are considered viable for use in these settings.
In this survey, we focus on a specific subset of R/S practices that have distinct
sensory (related to senses) and motor (body movements such as vocalisation/manipulation
of breathing/body postures and movements) components and can be termed as sensorimotor
R/S practices [14]. As body-oriented practices, sensorimotor R/S practices such as
yoga, pranayama and chanting do not pose high cognitive and linguistic demands. This
differs from many of the current conventional interventions in mental health settings
which are conversational and involve cognitive-based strategies [15]. Cognitively
mediated interventions, such as cognitive behavioural therapy, may be challenging
for people with limited cognitive or linguistic skills (including those with severe
mental illness, trauma histories, and people from diverse sociocultural backgrounds)
[5]. Body-oriented interventions (such as sensorimotor R/S practice) may be of value
for these populations [5]. Furthermore, psychological stress affects cognitive flexibility
and the ability to retrieve information from long-term memory [16] supporting the
need for interventions that do not rely on cognition.
In Australia, sensorimotor R/S practices, such as yoga, have been increasingly used
and accepted by the general population for their mental health benefits [17,18] which
suggests the possible use of these practices as potential therapeutic interventions
in mental health clinical settings. In a recent study, chanting was assessed as a
potentially useful online intervention and was shown to have mental health benefits
such as reduced stress and increased positive affect [19]. In another study, veterans
reported reductions in depression and anxiety with a yoga intervention provided through
telehealth [20]. Mental health benefits of these practices for people with severe
mental illness have also been identified, including yoga in schizophrenia [21] and
major depressive disorder [22], and pranayama [23] and chanting [24] for post-traumatic
stress disorder. Authors of other studies have recommended use of breathwork [25,26]
and yoga [27,28] as either standalone or adjunctive mental health interventions.
A review of the literature revealed three sensorimotor R/S practices with substantial
evidence of effectiveness in mental health: pranayama [[29], [30], [31]]; chanting
[19,29,32,33]; and yoga [[34], [35], [36]]. In our survey, we used the following definitions
of R/S practices: Pranayama, sometimes referred to as breathwork, is an ancient yogic
breathing practice to promote mind-body connection; Chanting is an ancient religious/spiritual
practice that involves repetition of a prayer or spiritually meaningful word or phrase;
and, Yoga refers to the ancient spiritual practice of adopting body poses and postures
to achieve mind and body connection which has physical and mental health benefits.
Despite evidence for the mental health benefits of sensorimotor R/S practices and
their apparent acceptance among Australians [37], little is known about the viability
of using these practices as mental health interventions in clinical settings. In a
qualitative study conducted in Australia, mental health professionals (MHPs) identified
the value of alternative therapies that included some sensorimotor R/S practices;
however, they felt confused about integrating these interventions in their mental
health practice and acknowledged the need for a framework and clear guidelines [38],
this study however was not focussed on R/S practices. To transfer available empirical
evidence to clinical mental health care, there is a need to understand more about
the factors that might impact the use of R/S practices. Practical considerations,
such as whether MHPs are equipped with the necessary knowledge and skills, their personal
experience with R/S practices, whether clinical settings have adequate resources for
these practices, and the need for guidelines, have not been explored in the extant
literature.
The aim of the present study was to understand MHPs' (e.g., psychiatrists, mental
health occupational therapists, psychologists, nurses) perceptions of the viability
of using three sensorimotor R/S practices (chanting, pranayama, and yoga) as therapeutic
interventions in clinical mental health settings. There were six objectives: 1) To
examine the knowledge and confidence of MHPs regarding using these R/S practices in
mental health clinical settings, including differences between professions; 2) To
understand MHPs' perceptions regarding the feasibility of these R/S practices in clinical
mental health care, and any differences between professions and health sectors; 3)
To investigate any differences in knowledge, confidence, and feasibility across the
three R/S practices; 4) To understand the training and resource needs of MHPs in relation
to these practices; 5) To examine MHPs' personal experience of R/S practice; 6) To
investigate the view of MHPs regarding the need for a guideline that may inform them
about use of R/S practices in mental health settings. The study was restricted to
Australian MHPs with a view to using the findings to support future integration of
sensorimotor R/S practices in mental health clinical settings in Australia.
2
Method
A survey was conducted with MHPs in Australia. After receiving ethical approval from
the Human Research Ethics Committee of Central Queensland University, Australia (approval
number 0000022594), the survey was conducted online using the software Qualtrics.
2.1
Survey design
Survey questions were designed to gather data specific to:
2.1.1
Demographics and professional characteristics
Demographic details and information about the professional background and current
practice setting (mental health experience, profession, current work setting, type
of health sector, and areas of mental health) of the participants were collected.
All questions were forced choice with space provided for free text should responses
not fit within the choices given.
2.1.2
Knowledge, confidence, and feasibility (KCF)
This part of the survey employed a modified version of the Knowledge, Confidence and
Attitudes (KCA) scale [39] to ascertain participants' perceptions of their knowledge,
confidence, and the feasibility of using chanting, pranayama, and yoga in clinical
mental health practice. The scale consisted of 13 questions, all scored using a 5-point
Likert scale, from 1 (strongly disagree) to 5 (strongly agree). A separate scale was
completed for each R/S practice, totalling 39 questions overall (refer to Appendix
for KCF scale). All questions regarding knowledge (five questions), confidence (three
questions), and feasibility (five questions) were identical for the three R/S practices.
Sample questions were: (1) Knowledge – I am familiar with evidence regarding the efficacy
of the R/S practice in mental health; I have personally practised the R/S practice;
(2) Confidence – I feel confident using the R/S practice for therapeutic purposes
with my clients; and (3) Feasibility – My current work setting is well resourced to
conduct therapeutic the R/S practice sessions. Internal consistency for the original
KCA scale has been shown to be adequate [39].
2.1.3
Need for a guideline
The final question on the survey invited participants to rate their agreement with
a comment regarding the need for a therapeutic guideline about the use of R/S sensorimotor
practices in mental health. This item was scored using a 5-point Likert scale, from
1 (strongly disagree) to 5 (strongly agree).
2.2
Participants
Targeted participants were MHPs (e.g., psychiatrists, mental health occupational therapists,
psychologists, mental health social workers, and mental health nurses) working in
Australia. The information sheet and consent forms were embedded in the online survey
and only participants indicating that they had mental health experience were admitted
to the survey. Participation in the survey was voluntary and no identifiable information
was collected.
2.3
Dissemination of survey and data collection
The survey was designed using Qualtrics software. It was available only in English
and was disseminated using a weblink through online platforms and social media (Twitter,
LinkedIn, Facebook). Snowball dissemination of the survey was encouraged. Data were
collected between November 2020 and February 2021.
2.4
Data analysis
Data analyses were conducted using SPSS (Statistical Package for the Social Sciences)
for Windows (version 28.0.0). Information about the sample was summarised using descriptive
statistics. Three of the thirteen questions in each category (knowledge, confidence,
feasibility) were negatively worded; these questions were reverse coded for data analyses.
Internal consistency of each category for each of the three R/S practices was measured
using Cronbach's alpha. Formal and informal analyses were conducted using the Shapiro-Wilk
test of normality, histogram, and Q-Q plots, to check assumptions. Due to missing
data, the numbers of responses in some analyses are lower. All three subscales (knowledge,
confidence, feasibility) for each of the three practices (nine variables) met assumptions
for normality, so parametric tests were employed including one-way and repeated measures
ANOVAs. Where a significant difference (p < 0.05) was noted in ANOVAs, a post-hoc
Bonferroni test was used.
3
Results
3.1
Participants
Overall, 105 individuals started the survey and 101 met inclusion criteria; four participants
could not advance past the screening question because they responded that they did
not have experience in working in mental health. Participants were aged between 22
and 60 years (M = 41.93; SD = 10.27) with experience in mental health ranging from
1 year to 40 years (M = 14.69; SD = 10.46). The largest proportion of survey respondents
(39%) were occupational therapists. Nearly half of the participants (49.58%) worked
in a community mental health setting, and most (77.08%) worked with adults. More detailed
information about participants is provided in Table 1
.
Table 1
Summary of descriptive information for categorical demographic and study variables.
Table 1
Variable
n
%
Education
Diploma or Certificate or equivalent
4
4.12
Bachelor's degree
42
43.30
Master's degree
38
39.18
PhD or professional doctorate
13
13.40
Profession
Psychiatrist and Psychiatry registrar
22
21.0
Mental health nurse
11
10.5
Occupational therapist
41
39.0
Psychologist
8
7.6
Social worker
10
9.5
Others: Counsellor, GP, Support worker
4
3.8
Current work setting
Government or public health setting
72
75
Private health setting
14
14.58
Non-government organisation
9
9.38
Training
1
1.04
Mental health setting
Inpatient mental health
20
16.81
Outpatient mental health
22
18.49
Community mental health
59
49.58
Rehabilitation centre
3
2.52
Community care centre or similar
6
5.04
Other: School, Unemployed,Suicide prevention across settings, Service wide management,
Justice system, Disability private practice
9
7.56
Area of mental health
Aged care and dementia services
7
7.29
Adult mental health
67
69.79
Child and youth mental health
16
16.67
Infant mental health
0
0
Other: Older adults mental health, Professional leadership/manager, AODS, Justice
system
6
6.25
Note: AODS = Alcohol and other drug services; GP = General practitioner.
3.2
Knowledge, confidence, and feasibility scale
Internal consistency was assessed for each subscale (knowledge, confidence, feasibility)
across three R/S practices (chanting/pranayama/yoga) using Cronbach's alpha reliability
coefficient. Cronbach's alpha was acceptable (α > 0.60) for all subscales. For chanting,
Cronbach's alpha was 0.78 for knowledge, 0.65 for confidence, and 0.62 for feasibility.
Regarding pranayama, Cronbach's alpha was 0.85 for knowledge, 0.78 for confidence,
and 0.74 for feasibility. Finally, for yoga, Cronbach's alpha was 0.70 for knowledge,
0.74 for confidence, and 0.67 for feasibility.
3.3
Knowledge and confidence regarding using R/S practices in mental health clinical settings
and difference between professions
Overall mean ratings for knowledge and confidence are shown in Table 2
for each MHP group. The mean knowledge level of respondents was almost 37 overall;
all professions revealed means below 42 (maximum possible knowledge score = 75). Confidence
ratings were proportionately similar to knowledge ratings. The overall mean for confidence
was almost 22, and all professions were below 24.5 (maximum possible confidence score = 45).
The one-way ANOVAs conducted to examine differences in MHPs knowledge of and confidence
in these practices showed no significant difference between different professionals.
Table 2
Overall mean ratings of knowledge and confidence, and differences between professions.
Table 2
Scale
Profession
n
M
SD
Min score
Max score
Between group difference
Knowledge (Possible Range = 15–75)
Overall
89
36.88
11.76
15
68
ANOVA
Psychiatrist
21
39.62
11.90
17
57
F (5,83) = 2.23, p = 0.06
Mental Health Nurse
11
38.73
11.08
22
54
Occupational Therapist
40
34.78
12.11
15
68
Psychologist
7
28.14
7.66
21
42
Social Worker
7
41.57
8.61
26
50
Profession
N
M
SD
Min score
Max score
Between group difference
Confidence (Range = 9–45)
Overall
89
21.83
7.52
9
40
ANOVA
Psychiatrist
21
22.48
8.64
9
38
F (5,83) = 1.27, p = 0.28
Mental Health Nurse
11
24.27
5.55
15
31
Occupational Therapist
40
21.38
7.23
11
40
Psychologist
7
16.00
5.41
9
24
Social Worker
7
23.57
7.32
13
34
95% Confidence Interval.
3.4
Feasibility of R/S practices in clinical mental health care and differences between
professions and health care sectors
Table 3 provides mean ratings for feasibility for the different MHPs who responded
to the survey, and for the sectors (government/private/NGOs) in which these MHPs provided
mental health care. The mean overall feasibility score was 46 (maximum possible feasibility
score = 75). Means for each profession, and for each health care sector, were below
51. A one-way ANOVA conducted to examine differences in MHPs' perceptions of the feasibility
of these practices showed a significant difference across the different professionals,
F (5, 83) = 3.04, p = 0.01. A post hoc Bonferroni test revealed that psychologists
(M = 36.86, SD = 7.33) rated the feasibility of R/S sensorimotor practices significantly
lower than occupational therapists (M = 48.30, SD = 7.69, p < 0.01). A one-way ANOVA
conducted to examine differences in MHPs' perceptions of the feasibility of these
practices based on the sector in which they were employed was not significant.
Table 3
Feasibility of three practices and differences between different mental health professions
and health sectors.
Table 3
Scale
Across different professions
n
M
SD
Min score
Max score
Between group difference
Possible Range (15–75)
Overall
89
46.31
8.65
27
69
ANOVA
Psychiatrist
21
45.10
8.46
33
62
F (5,83) = 3.04, p = 0.01
Mental Health Nurse
11
44.45
7.10
30
53
Occupational Therapist
40
48.30**
7.69
32
67
Psychologist
7
36.86**
7.33
27
46
Social Worker
7
48.00
12.16
33
69
Across different sectors
n
M
SD
Min score
Max score
Between group difference
Overall
89
46.31
8.65
27
69
ANOVA
Possible Range (15–75)
Government or public health sector
68
44.99
8.14
27
67
F (3,85) = 2.48, p = 0.66
Private health sector
13
50.92
8.68
39
69
Non-government organisation
7
50.71
10.93
33
60
95% Confidence Interval, Significance level - ** = p < 0.01.
3.5
Knowledge, confidence, and feasibility across different R/S practices
Mean ratings for each KCF subscale for each of the three practices are shown in Table
4
. A one-way repeated measures ANOVA was conducted to compare knowledge, confidence,
and feasibility ratings across three R/S practices. Mauchly's test of sphericity was
not significant for knowledge (p = 0.79) and confidence (p = 0.14). However, Mauchly's
test indicated that the assumption of sphericity was not met for ratings of feasibility
(p = 0.004); thus, degrees of freedom were corrected using Greenhouse-Geisser estimates
for this part of the KCF scale.
Table 4
Comparison of knowledge, confidence, and feasibility levels across different R/S practices.
Table 4
Scale
R/S Practice
N
M
SD
Min score
Max score
One way repeated ANOVA
Knowledge
Possible Range (5−25)
Chanting
89
10.00
4.41
5
21
F (2, 176) = 37.88, p < 0.001
Pranayama
89
12.73**
5.51
5
25
Yoga
89
14.15**
4.16
5
25
Confidence
Possible Range (3−15)
Chanting
89
6.37
2.88
3
14
F (2, 176) = 9.34, p < 0.001
Pranayama
89
7.76**
3.43
3
15
Yoga
89
7.70**
3.24
3
14
Feasibility
Possible Range (5−25)
Chanting
89
13.39
3.45
5
24
F (2,176) = 41.31, p < 0.001
Pranayama
89
16.53**
3.82
7
25
Yoga
89
16.39**
3.45
9
25
Significance levels- ** = p < 0.01.
Self-rated knowledge was statistically different across the three R/S practices, F
(2, 176) = 37.88, p < 0.001, η2 = 0.30. Bonferroni post hoc tests, using an alpha
of 0.017 (0.05/3) indicated that knowledge ratings for yoga (M = 14.15, SD = 4.16)
were significantly higher than both pranayama (M = 12.73, SD = 5.51, p = 0.017), F
(2, 176) = 37.88, p < 0.017; and chanting (M = 10, SD = 4.41, p < 0.001), F (2, 176) = 37.88,
p < 0.001. Knowledge ratings of pranayama (M = 12.73, SD = 5.51) was also significantly
higher than that of chanting (M = 10, SD = 4.41, p < 0.001), F (2, 176) = 37.88, p < 0.001.
The one-way repeated measures ANOVA conducted for confidence also showed a significant
main effect across the three practices, F (2, 176) = 9.34, p < 0.001, η2 = 0.096.
As shown in Table 4, MHPs rated their confidence levels highest for pranayama, followed
by yoga, with chanting rating lowest. Bonferroni post hoc tests (α = 0.017) showed
that confidence ratings for pranayama (M = 7.76, SD = 3.43) were significantly higher
than chanting (M = 6.37, SD = 2.88, p < 0.001), F (2, 176) = 9.34, p < 0.001. Yoga
ratings (M = 7.70, SD = 3.24) were also significantly higher than chanting (M = 6.37,
SD = 2.88, p < 0.001), F (2, 176) = 9.34, p < 0.001. There was no significant difference
in confidence ratings for pranayama (M = 7.76, SD = 3.43) and yoga (M = 7.70, SD = 3.24,
p = 1.00).
A one-way repeated measures ANOVA also showed a main effect of feasibility across
the three R/S practices, F (1.78, 157) = 41.31, p < 0.001, η2 = 0.319. Bonferroni
post hoc tests (α = 0.017) revealed that chanting (M = 13.39, SD = 3.45) was rated
as significantly less feasible than yoga (M = 16.39, SD = 3.82, p < 0.001), F (2,
176) = 41.31, p < 0.001; and for pranayama (M = 16.53, SD = 3.82, p < 0.001), F (2,
176) = 41.31, p < 0.001. There was no significant difference between ratings for yoga
(M = 16.39, SD = 3.82) and pranayama (M = 16.53, SD = 3.82, p = 1.00).
3.6
Personal experience of R/S practice
As seen in Table 5
, over 73% of participating MHPs had personal experience of practicing yoga. About
40% of respondents indicated that they had personal experience of chanting, while
over 56% had practiced pranayama.
Table 5
Participants' perspective on need for a guideline, training and resources, and personal
experience of R/S practice.
Table 5
Question
N
Strongly agree n (%)
Somewhat agree n (%)
Neither agree nor disagree n (%)
Somewhat disagree n (%)
Strongly disagree n (%)
I have personally practiced this R/S practice
Chanting
91
10 (11)
27 (29.7)
6 (6.6)
11 (12.1)
37 (40.7)
Pranayama
89
22 (24.7)
28 (31.5)
4 (4.5)
13 (14.6)
22 (24.7)
Yoga
89
41 (46.1)
24 (27)
5 (5.6)
10 (11.2)
9 (10.1)
A guideline that can inform the use of evidence-based sensorimotor R/S practices in
mental health is needed
101
60 (67.42)
23 (25.84)
5 (5.62)
1 (1.12)
0 (0.00)
To conduct therapy sessions with my clients, I require more training and knowledge
in
Chanting
91
47 (51.6)
18 (19.8)
13 (14.3)
6 (6.6)
7 (7.7)
Pranayama
89
35 (39.3)
30 (33.7)
13 (14.6)
8 (9)
3 (3.4)
Yoga
89
44 (49.4)
23 (25.8)
13 (14.6)
4 (4.5)
5 (5.6)
My current work setting is well resourced to conduct therapeutic for R/S practice
sessions
Chanting
91
2 (2.2)
7 (7.7)
17 (18.7)
28 (30.8)
37 (40.7)
Pranayama
89
10 (11.2)
23 (25.8)
18 (20.2)
21 (23.6)
17 (19.1)
Yoga
89
8 (9.0)
14 (15.7)
20 (22.5)
24 (27.0)
23 (25.8)
My current work setting would require more resources for me to be able to conduct
sessions of R/S practices
Chanting
91
28 (30.8)
28 (30.8)
22 (24.2)
6 (6.6)
7 (7.7)
Pranayama
89
20 (22.5)
31 (34.8)
20 (22.5)
10 (11.2)
8 (9.0)
Yoga
89
31 (34.8)
38 (42.7)
9 (10.1)
7 (7.9)
4 (4.5)
3.7
Need for a guideline, training, and resources in mental health settings
As shown in Table 5, most respondents (93.26%) agreed that a guideline is required
to inform MHPs about the use of evidence-based sensorimotor R/S practices in mental
health. A high proportion of respondents expressed the need for training to conduct
sessions of chanting (71.4%), pranayama (73%), and yoga (75.2%) in mental health settings.
In terms of resources for each of the practices, only 9.9% of respondents agreed that
their settings were well resourced for chanting, with 61.6% indicating a need for
greater resources in their setting to conduct chanting sessions. For pranayama, 37%
of MHPs indicated that their setting was well-resourced for this practice, but a need
for further resources was still expressed by 57.3% of respondents. The expressed need
for additional resources was highest for yoga (77.5%), with only 24.7% of participating
MHPs agreeing that their settings were well-resourced.
4
Discussion
This study was conducted to obtain a preliminary understanding of MHPs' knowledge
and confidence, and their perceptions of the feasibility of using three sensorimotor
R/S practices – chanting, pranayama, and yoga – in clinical mental health settings
in Australia. This information is needed to gain insight into the viability of using
these practices and to inform strategies to transfer of evidence regarding the mental
health benefits of R/S practices into clinical settings.
A key aim of this study was to assess the knowledge and confidence levels of MHPs
regarding the use of three sensorimotor R/S practices – chanting, pranayama, and yoga.
MHPs reported relatively low levels of ratings for both knowledge and confidence across
all three R/S practices. While no significant differences were found for ratings by
different MHPs, psychologists reported the lowest levels of knowledge and confidence
compared to other health professionals. This may be because typical psychological
interventions focus more on cognition and conversational skills [15], with minimal
involvement of sensorimotor components. This finding is consistent with a qualitative
study with 12 psychologists in which they revealed their confusion, lack of confidence,
and apprehension regarding the use of alternative therapies (including some sensorimotor
R/S practices) for mental health [38]. In our survey, across three practices, MHPs
rated relatively higher knowledge and confidence levels for yoga and pranayama than
chanting. With the greater popularity of yoga in Australia [18], MHPs possibly were
more informed about yoga compared to the other two practices. Despite overall lower
confidence levels, MHPs reported the highest confidence levels in using pranayama
as a therapeutic intervention. The apparent similarity of pranayama practice with
breathing strategies used in conventional mental health intervention [40] is possibly
attributed to the higher confidence level of MHPs for using this practice as a mental
health intervention.
Ratings for feasibility were more promising, with the three R/S sensorimotor practices
generally viewed as feasible alternative supplementary therapies for mental health.
Again, psychologists' ratings were the lowest of the MHPs, likely reflecting their
focus on mental health interventions that are cognition-based and conversational [15].
In contrast, the significantly higher level of feasibility reported by occupational
therapists is not surprising given their strong sensorimotor focus in mental health
interventions [41]. Trained in theoretical and practical aspects of sensorimotor interventions,
occupational therapists potentially had greater insight into use of considered R/S
practices as interventions, which may have attributed to their higher ratings of feasibility.
This finding aligns with the results of a survey with student health professionals
where occupational therapy students were more likely to see the importance of a sensorimotor
R/S practice yoga and refer patients to yoga than other professionals, including psychologists
(Sulenes et al., 2015).
In addition to exploring whether feasibility ratings would differ across the different
groups of MHPs, the influence of the health sectors in which MHPs worked was also
examined. Overall, MHPs' generally agreed that R/S practices may be feasible interventions
in clinical mental health care, with the private mental health sector receiving the
highest feasibility ratings and the government the lowest.
Although these practices were generally perceived to be potentially feasible, participants
indicated that mental health services lacked the resources needed for these practices.
While the need for resources was particularly evident for chanting, MHPs indicated
more resources were needed for yoga and pranayama. This finding may be related to
the knowledge that a larger percentage of MHPs in our survey had personal experience
of doing yoga and pranayama compared to chanting. Having practised yoga and pranayama
themselves, MHPs potentially had better acceptability for these two practices which
might explain their higher rating to have more resources for yoga and pranayama rather
than chanting. With less personal experience of chanting, they may have been unclear
about the resources that might be needed and defaulted to negative responses as a
result. Consistent with this explanation, in a survey with 478 health students, participants
with the personal practice of yoga showed greater acceptability for the practice than
the students with no personal experience of yoga (Sulenes et al., 2015).
The low overall levels of knowledge and confidence align with the MHPs' expressed
need for training and for guidelines to implement these practices in mental health
settings. Nearly half of the MHPs in this study reported they would need training
to conduct sessions of yoga and chanting, and about one-third indicated that training
would be needed for pranayama. While training those MHPs who may be willing to use
these practices as mental health intervention is an option, alternatively trained
experts could be hired to conduct intervention sessions. Most of the MHPs in our survey
had personal experience of yoga practice, which may have influenced their rating of
the need for training. Having practised yoga themselves, respondents potentially felt
more comfortable with using yoga as an intervention but also recognised the potential
constraints of yoga, hence requiring more training before using the practice as an
intervention. This proposition aligns with the recommendation of the authors of a
review of 52 yoga studies [28]. These authors stressed the importance of training
clinicians on potential benefits and limitations of yoga before using this practice
as an intervention in healthcare settings [28]. The perceptions of MHPs in the present
study about the need for training are also consistent with recommendations of other
authors regarding the requirement for training of MHPs should they use yoga as a clinical
intervention [28,[42], [43], [44]].
The final aim of the survey was to investigate if participants perceived a need for
a guideline to inform MHPs about the use of R/S practices for therapeutic purpose.
Most respondents strongly agreed that a guideline was needed. As noted in the introduction,
this finding is consistent with other studies [38,[44], [45], [46], [47]]. For example,
in Ref. [38] qualitative study, psychologists identified the need for a guideline
for using alternative interventions (including some sensorimotor R/S practices) in
mental health. This study however did not specifically focus on sensorimotor R/S practices.
Some studies have provided guiding information on integrating some R/S practices,
such as breathwork [25], in mental health counselling. Others noted ethical considerations
of integrating yoga in psychotherapeutic interventions [46]. Nevertheless, there is
no guideline available for MHPs that may provide detailed information or guiding principles
to support the integration of all R/S practices in mental health clinical settings.
Overall, findings indicated that the three R/S practices considered in this survey
– chanting, pranayama, and yoga – may warrant further consideration as a possible
intervention in mental health settings. While our survey did not specifically examine
the feasibility of any specific format of delivery (face-to-face or online), there
is evidence of the possible efficacy of using these practices through telehealth [19,[48],
[49], [50]], which may be especially important in the current COVID-19 situation.
For instance, an intervention trial of online chanting found this practice to be a
feasible intervention in reducing anxiety levels [19]. Yoga has also been identified
as a feasible intervention when delivered via telehealth [[48], [49], [50]]. For instance
Ref. [20], found yoga conducted through telehealth was effective for mental health
outcomes and suggested the integration of telehealth yoga in clinical programs as
an acceptable, feasible, and effective intervention for veterans. In a recent study,
tele-yoga was found to be a feasible and effective intervention in mental health [44].
While pranayama was also rated as a potentially feasible intervention in our survey,
the feasibility of this practice delivered through videoconference is unclear. In
a randomised controlled trial, breathwork, including pranayama delivered through teleconference
reduced the level of anxiety [51]. Although the authors of this study did not compare
the format of delivery (face-to-face versus online), they recommended face-to-face
delivery as a more feasible medium for pranayama (Shukla 2021), possibly due to the
complexity of instructions involved in the intervention. It is possible that the feasibility
of the R/S practices considered in this study may have been viewed higher if MHPs
had been asked to consider different delivery formats.
In considering perceptions of MHPs from our survey, evidence from cited literature,
and studies of the possible utility of R/S practices as an online intervention, sensorimotor
R/S practices may be considered as a potential supplementary alternative to conventional
mental health care. The findings of this study may be more useful in the current health
climate when access to mental health care is reduced due to COVID-19.
5
Limitations and future considerations
Three well-evidenced R/S practices were considered in this survey; however, there
are other sensorimotor R/S practices (e.g., tai chi) that may be considered in future
investigations. While the survey was distributed to a wide range of MHPs in Australia,
occupational therapists were over-represented in the sample obtained. Similarly, although
MHP respondents were from many different mental health settings, about half were from
community mental health. It is important to consider that more than two third of respondents
were from government sectors. The sample was also relatively small, with lower numbers
in some analyses due to missing data which may have affected power. As a result, the
sample may not be representative of all MHPs in Australia or relevant to MHPs in other
countries. Due to the quantitative nature of the design, the survey did not capture
the subjective opinions of MHPs, which may have provided richer and more nuanced information.
Finally, the perception of MHPs on the mode of delivery (face-to-face or online) of
these interventions was not investigated. A mixed methods design survey with a larger
number of participants, that includes MHPs from other countries and additional R/S
practices, and questions regarding the mode of delivery (face-to-face or online),
may provide a broader and deeper understanding of the viability of R/S practices as
therapeutic interventions in mental health settings. With additional resources, training
of MHPs, and the development of a clinical guideline, R/S practices such as chanting,
pranayama, and yoga, could be considered viable interventions in clinical mental health
settings. Further research is needed to consider this proposition.
6
Conclusion
Overall, knowledge and confidence ratings provided by MHPs were low, with the majority
indicating a need for guidelines and additional resources and training would be needed
if MHPs are to be considered as potential professionals to implement these practices
in mental health settings. Ratings of feasibility were more promising, with overall
ratings suggesting MHPs viewed these R/S sensorimotor practices as possible alternative
supplementary therapies for mental health. Yoga and pranayama were considered more
viable than chanting but respondents indicated that additional training was needed
to be able to use R/S practices as interventions. While all mental health services
required additional resources, clinical settings in government sectors appeared to
be the least resourced to conduct R/S practices therapeutic interventions. Finally,
the majority of MHPs strongly agreed on the need for an overarching guideline for
use of R/S practices in mental health. The findings of this survey may inform future
research and development of a practice guideline regarding the use of R/S practices
as alternative supplementary interventions to conventional mental health care. Further
research is needed to identify facilitators and barriers to integrating these practices
in clinical mental health settings in Australia.
Authorship contribution statement
SM contributed to the protocol development, overall design, survey development, data
collection and analysis, and manuscript preparation. PM and BZ contributed to the
overall design, survey development, data analysis, and review of the manuscript.
Funding
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Author note
Authors do not have any conflicts of interest to disclose.
This research project was not supported by any financial grant.
Uncited references
[52]; [53].
Declaration of competing interest
The Authors declare that there is no conflict of interest.