Yoga in addicted people – critical problem of compliance



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Yoga in addicted people – critical problem of compliance


Karel Nespor, M. D., Ph.D.

Executive member of the Czech Addiction Society

Department for the Treatment of Addictions – Males (Head), Psychiatric Hospital Praha

Institute for Postgraduate Education Praha

Address: Psychiatricka lecebna, Ustavni 91, 181 00 Praha 8, Czech Republic

nespor.k@seznam.cz, www.plbohnice.cz/nespor



J. Res. Educ. Indian Med. 2007; 13(1):17-26.

Summary


Yoga is a useful part of the complex treatment of addictive diseases for several reasons such as stress management, better coping with emotions and pain or increased self-awareness. The problem is compliance with long-term regular practice. We distributed an original questionnaire among 53 former and 103 current inpatients treated for addictive diseases. Among them 70.2 % felt that the joint yoga sessions, during in-patient treatment, improved their mental state. Despite this, only 55.0 % of current in-patients intended to practice yoga once a week or more at home. 29.5% of former in-patients reported that they practiced yoga at home once a week or more. The main obstacles included 'laziness', other interests, problems with privacy and housing, lack of time, problems related to family members and friends, health limitations, lack of information and lack of interest. Ways to overcome these obstacles are discussed.

Key Words: Yoga – Spirituality – Addictive Diseases – Compliance – Treatment – Obstacles

Introduction

Yoga and psychotherapy

Yoga is compatible with other approaches and can be combined with them, as described e.g. by Lohman (1999). The principles of modern psychotherapy and traditional Indian medicine (Ayurveda) overlap. In fact Satvavajaya or psychotherapy is one of three principal categories of treatment approaches as described in Ayurvedic classics (Nespor and Singh 1986). The classical Satvavajaya is based on three principles: 1. Replacement of emotions (an undesirable emotion can be replaced or neutralized by other incompatible emotion), 2. Assurances, 3. Psychological shock. The author had an opportunity to observe an experienced professor of ayurveda performing an exemplary psychotherapeutic sessions in English with his patients. He used empathy and unconditional positive regard, as many Western psychotherapists would. The replacement of emotions took place by gently switching emotions e.g. from the mother-in-law (anger) to children (love). He also used reframing (a negative event was presented in a more positive way), and employed various stories and metaphors that directly or indirectly related to patients’ problems and possible solutions. Such an approach was used e.g. by M. H. Erickson in the West.

Advantages of Yoga


There are many relevant reasons why addicted people should practice yoga.

  • Stress, anxiety and depression relieving effects of yoga (e. g. Michalsen et al. 2005, Pilkingtona et al. 2005).

  • Safer social network. According to the author’s experience yoga-minded people are less prone to addictive behaviour.

  • Yoga enables safe management of some psychosomatic problems such as insomnia, headaches, and some painful problems. It may be possible in this way to avoid addictive analgesic or sedative drugs (Goyeche 1979).

  • In the author’s experience, yoga and relaxation, as the part of a complex treatment programme, can counterbalance less pleasant aspects of treatment, strengthen therapeutic relationship, and decrease the number of patients leaving the programme prematurely (Nespor and Frouzova 1985).

  • Yoga and meditation develop and emphasize self-awareness, which is important in many ways. It is a common experience that sufficient self-awareness is required e.g. for early identification of internal or external clues triggering craving for alcohol or drugs.

  • Yoga compensates for long sitting during psychotherapy. In-patients are frequently obliged to sit during psychotherapeutic activities for up to 4.5 hours. This can prove tiring and uncomfortable. Yogic practices, especially those with the spine in the horizontal posture such as “cat" or marjariasana variations are useful to counterbalance this.
  • The author presumes that yoga also enhances spirituality. The term spirituality, however esoteric it may look, has become the serious topic of medical research. In September 2006 the Database of American National Library of Medicine contained 2496 references to the search word “spirituality”. Lower occurrence of daily smoking in spiritually minded people has been identified in the Czech population (17.6 % in those believing in God and 28.6 % in those not believing) (Sovinova et al. 2006). Among substance-dependent individuals, higher levels of religious faith and spirituality is associated with a more optimistic life orientation, greater perceived social support, higher resilience to stress, and lower levels of anxiety (Pardini et al.. 2003).

Some problems with yoga


When the author was 26 years old he visited a noted Czech professor to whom he suggested that all his addicted patients could be cured by means of yoga. Having been offered the opportunity to test the claims the author found that it was not quite so easy; and that there were some problems, such as:

  • Long-term compliance of patients (the enthusiasm for yoga of most patients was much less than the author expected).

  • Systemic (domestic) interactions (e.g. lack of understanding of yoga by family members).

  • Practical problems (for some patients it was difficult to find time and place to practice).

  • The trainees were competitive and not patient enough.

  • The need of a qualified teacher to modify the practice according to the needs of an individual. As somebody said: “An individual should not adapt to yoga, not yoga should adapt to him.” It is especially important in physically or mentally challenged people.

Despite these problems, the author still believes that yoga is useful for this patient population. The aim of this paper is to investigate the above mentioned problems in more detail.

Formal sessions of yoga


The yoga protocol has been described in a previous paper (Nespor 2000). The structure of two typical 30 to 45 minute sessions is outlined below. Regardless of the duration, the lesson is usually divided into three roughly equal thirds. This scheme is not rigid and can be modified according to the situation.

  • 1st third: Physical exercises of Yoga

  • 2nd third: Full yoga breath and/or some simple pranayama and some short story symbolically related to common patients’ problems.
  • 3rd third: Relaxation with sankalpa (resolve)


Most of the following practices are described according to Satyananda (1996).
An example of a yoga session (30 minutes)

Marjariasana (Cat stretch pose): Instructions: Place the hands flat on the floor beneath the shoulders with the fingers facing forward. Inhale while raising the head and lowering the spine and create a hollow between your shoulder blades. Exhale while lowering the head and stretching the spine upward. The trainees may be instructed to emphasize the movement of the thoracic spine while inhaling, and the lumbar spine while exhaling.

Vyaghrasana (Tiger’s stretch): This usually commences from the marjariasana (cat’s pose) which is for trainees easy enough. Instructions: While inhaling straighten the right leg , stretching it up and back. Bend the right knee and point the toes toward the head. Look up and try to touch the toes to the back of the head. Hold the breath for a few seconds in this position. While exhaling, straighten the right leg, bend the knee and swing the leg under the hips. At the same time arch the back up and bend the head down. The right foot should not touch the floor. Press the knee against the chest and, if possible, touch the nose to the knee. Fix the eyes on the knee for few seconds while holding the breath out. With the next inhalation start to repeat these movements 5 times or so. Then repeat it with the left leg.

Shashankasana (Hare pose): This is also started from marjariasana. Instructions : While exhaling move downward and back so that the head and the arms rest on the floor in front of the knees. If you want to relax, just observe your natural nasal breath As you breathe deeply be aware of your abdomen. After a while return back to marjariasana.

Sphinx asana and its variations: Instructions : Lie on the stomach. Bend the arms and place the forearms on the floor with the palms facing downward. The upper arms are vertical. Raise the head but relax all the muscles which are not necessary to maintain correct pose. The possible variations include hitting one’s buttocks with the heels, gentle rotations of the head and spine. Backward bending should be increased during inhalation and relaxed during exhalation.


Jyestikasana: Instructions : Lie down on your belly with the legs straight and the forehead resting on the fingers, with both hands interlocked, palms facing up. Be aware of your body and let it relax. Then observe your breath.

Supta udarakarshanasana (sleeping abdominal stretch pose or supine rotation with the knee bend): Lie on your back, bend the knees and place soles flat on the ground in front of the buttocks. Keep the knees and feet together. Interlock the fingers of both hands and place the palms under the back of the head. While breathing out slowly lower the legs to the right. The knees move down to the floor. At the same time move the head in the opposite direction. Hold the breath in final position for few seconds. While breathing in move the legs back to the upright position. Repeat to the opposite direction. Repeat 5 times.

Spontaneous abdominal breathing: I usually let the trainees to be aware of their spontaneous abdominal breathing on the back with the legs bent. Only after that we practice deep abdominal breathing, as something based on spontaneous abdominal breathing. Eventually we also add thoracic and clavicular breathing.

Full yoga breath

Stories symbolically related to common patients’ problems. An example of a story: Swami Satyananda often received visitors who sought his advice in spiritual or personal matters. Some visitors were satisfied with his advice but some were not. They objected “Yes, but it can be done so and so.”

“It is also good,” replied usually Swami Satyananda.

A disciple once asked Swamiji doubtfully: “Is it really also good?”

“Of course,” replied Swamiji. “Karma of some people does not allow them to accept good advice. They have to commit mistakes, to suffer and to learn through their painful experiences. That is why it is also good.”


This story is liberating. It shows that even our mistakes can be instrumental to our ultimate awakening. In the same time it shows that it is better to avoid these mistakes and related suffering.


Brief yoga nidra or yogic relaxation. During yoga nidra, I tend to offer to the trainees three sets of images they can choose from. Images for vata types (air and ether prevail; these people need grounding, stability, the feeling of safety): You are looking at the quiet surface of a lake. Its firm reliable banks are full of flowers whose fragrance is sweet. Somebody at the bank is singing a calming, sweet song. Images for pitta types (fire and water prevails; they need calmness and detachment): You are in rocky maintains at night. You see a pine, rooted firmly in the stony soil. There is plenty of free space around. Far away above your head Moon and stars spill their silver light all around. You feel pleasant breeze bringing to you cool fragrance of jasmine from some distant valley. Somebody is playing there a flute and its melody is detached and calm. Images for kapha types (earth and water prevails; these people need stimulation): You are looking at Sun high at sky. It shines brightly and colours the clouds by its orange and yellow light. The clouds move to the horizon. You smell sharp fragrance of eucalypt. Somebody is playing fast and skilfully a drum far away. Alternative symbolic imagery for everybody: You see a quiet surface of a lake reflecting nature around it. Similarly your mind, calm and sober, perceives things as they are. Now see a river, mighty and moving on and on. Similarly you are able to overcome every obstacle if pursuing good and appropriate goals. Finally you see a strong, healthy pine tree with strong roots in the soil and its branches open to the sky. This tree is resistant against storms and winds. Similarly you are grounded in reality and in the same time open to positive spiritual influences. You are able to cope with all challenges in this way.

Namaste: Beforehand I usually explain that this mean „I bow to the highest in you which is the same as the highest in me.“ I found this simple practice very useful. Our patients need very much to learn to respect themselves and others. They like this practice.


An example of a yoga session (45 minutes)

Marjariasana (Cat) on forearms. This variant diverts blood from pelvic area which is useful after long sitting.

Vyaghrasana (Tiger’s stretch)

Shashankasana (Hare pose):

Sarpasana (snake): Lie on the stomach, interlock the fingers and place them on top of the buttocks. Raise the head, neck and chest from the floor. Push the hands back and up. Squeeze the shoulder blades together and look forward. Hold for as long as comfortable. Then return to the starting position and relax the whole body.

Tiryaka Bhunjangasana (twisting cobra).

Ardha shalabhasana (a variant of half locust pose): Lie on the stomach, legs are together and the forehead touches the floor. Stretch the arms above the head and place them and the chin on the floor. Simultaneously raise the stretched left leg, the head and right arm. Hold for as long as comfortable. Then lower the leg, head and arm. Repeat the same movement with the right leg and left arm.

Jyestikasana: Lie down on your stomach with the legs straight and the forehead resting on the fingers of both hands interlocked and palms facing up. Be aware of your body and let it relax. Then observe your breath for a while.

Supta udarakarshanasana.

Spontaneous abdominal breathing and full yoga breath.

Seetkari. Cooling pranayamas seetkari and sheetali, according to Satyananda (1996) cool the body and the mind as well and decrease thirst. They are recommended in ayurveda especially for pitta (fire) personalities. Maybe they can also help to cope with craving for alcohol. The advantage of Seetkari compared with sheetali is, that seetkari can be performed in its mild form, inconspicuously, even during daily activities. Seetkari is practiced as follows: Hold the teeth lightly together and separate the lips. The tongue is passive in khechari mudra. Breathe slowly and deeply through the teeth. At the end of inhalation close the lips and keep the tongue where it is and breathe out slowly through the nose. Inconspicuous variant: Lips are separated very little and breathing is not as deep as during the normal practice of seetkari.


A story, yoga nidra and namaste.

Yoga outside formal sessions


Beside formal practice of yoga, I frequently use the elements of yoga during other activities. E.g. we may practice a little at the end of psychotherapy workshops. It is especially useful after long sitting or when we have dealt with some difficult and heavy psychological material. This “miniyoga” is also helpful to deal with tiredness and boredom. It works not only in addicts. Once I gave a lecture to business people. When I arrived, I found them tired and bored. We exercised a little bit and their mood instantly changed. When these people gave their feedback to the organizers of the workshop, my lecture was considered the best. I suspect that it was because of what we did, and not because of what I said.

Some examples of “miniyoga“

Heavenly stretch or dynamic Tadasana

For our purposes I call it “Delights of abstinent life”. Begin in standing position with the feet slightly apart. The weight of the body is equally distributed on both feet. Raise the arms over the head. Interlock the fingers and turn the palm upwards. Place the hands on the top of the head. Fix your eyes at the point on the wall slightly above the level of your head. Inhale and stretch the arms, shoulders and chest upward. Raise the heels coming up onto the toes. Stretch the body from the bottom. Hold the breath and the position for a few seconds. Lower the heels while breathing out and bring the hands to the top of the head. Practise 5 to 10 times.


Chopping the wood or Kashtha takshanasana

For our purposes I call it “Hammering the pillars of abstinence”. The only difference from the practice as it is described in Satyananda (1996) is that I do not practise in squatting position but in standing posture and bend the knees slightly while moving the hands down and exhaling. The full posture would be too difficult for most of my patients.


Wings

Begin in standing position with the feet slightly apart. Lift the arms sideways to the level of shoulders. While inhaling move the hands stretched backwards, and let the chest expand. While exhaling the stretched hands move to the front of the body so that the palms and fingers touch each and the head bow with the chin touching the chest at the end of exhalation. Practise 5 times or so. I usually add to this practice that the patients leave behind them all the problems which alcohol or drug abuse caused in the past, and move on to the better future.



Bow and arrow (Akarna dhanurasana)

We practice as described in Satyananda (1996). Usually I ask the patients to target a positive aim in the external world when the right hand is pulling the bow-string, and an aim in the internal world when the left hand is pulling.



I am

Begin in standing position with the feet apart on distance of the width of the shoulders. During inhalation move stretched arms sideways. At the end of exhalation the palms are on the level of the head. During exhalation beat your chest gently with the fists and pronounce long “I“. Repeat this once more and during next exhalation repeat in the same way “am“. A variation: Instead of “I am“, we laugh at all drug dealers and alcohol or gambling industry because they will get nothing from us in the future.



Hero

Step with the right foot askew forward a slight bend the right knee. Arch the back, expand the chest and push it forward. Clasp the hands and stay for a while breathing naturally. Repeat this with the other side. Those who try to overcome addiction are heroes. The first bravery is to acknowledge one’s addiction; the second one is to cope with it and the third one to persist.

Tadasana (static)

Sometimes I use it instead of relaxation, if it is - not possible to lie down. At the end I often suggest: You are standing in a firm, steady and relaxed manner now and you can stand so in your life as well.”


Adding colour to aura

It is not a yogic practice. With the legs widely apart we pick up balls of colour energy from the well on the floor and improve with them our auras (yellow is intellect, green health, blue calmness and detachment, violet spirituality and abstinence, pink youthfulness, orange independence and rainbow gives beauty and strengthens immunity.


The problem of compliance


As mentioned earlier, the main challenge when using yoga in substance dependent patients is the long-term regular practice outside the hospital. The aim of this paper is to identify possible barriers which hinder regular unsupervised practice and to consider the ways how these problems can be overcome.

Material and methods

A questionnaire


I prepared an original questionnaire which was administered to in-patients and former in-patients. They were asked to answer a set of simple questions such as:

  • How do your feel after yoga session?

  • Do you intend to practice yoga outside the hospital?

  • Are there any possible hindrances in regular yoga practice at home?

  • If so, how these hindrances can be overcome?

Subjects


The subjects were:

1. The group 53 current male in-patients treated for addictive diseases and 50 current female in-patients treated for the same problems. Their age was on the average 38.2 years (SD=11.8).

2. The group of 44 former male in-patients treated for addictive diseases and 9 female former in-patients treated for the same problem. Their age was on the average 43.1 years (SD=12.7).

Results

Most patients felt after yoga session better or much better. That is why it is surprising that most of them do no intend to practice yoga regularly.

Former and current in-patients: Feelings after the yoga session during in-patient treatment (n=156, missing answers: 5)


  • Much better: 47 (31.1 % of relevant answers)

  • Better: 59 (39.1 %. of relevant answers)

  • The same: 37 (24.5 % of relevant answers)

  • Worse: 3 (2.0 % of relevant answers)

  • Much worse: 2 (1.3 % of relevant answers)

How often in-patients intend to practice yoga at home (n=103, missing answers: 3)

  • Not at all: 23 (23 %)

  • Less than once a week: 19 (19 %)

  • Once a week: 24 (24 %)

  • 2 – 4 - times a week: 19 (9 %)

  • 5- 6 - times a week: 5 (5 %)

  • Daily: 7 (7 %)

How often former in-patients practice yoga at home (n=53, missing answers: 0)

  • Not at all: 32 (64 %)

  • Less than once a week: 5 (9.4 %)

  • Once a week: 11 (20.1 %)

  • 2 - 4x times a week: 3 (5.7 %)

  • 5- 6x times a week: 0 (0%)
  • Daily: 2 (3.7 %)



The obstacles

The main obstacles included laziness (29), other interests and sports (14), lack of time (12), problems with privacy and housing (11), health limitations and age (9), problems related to family members and friends (8), lack of information (6), lack of interest (3) and that it is difficult to practice alone (3).



The obstacles in practicing yoga are summarized in table 1.

Discussion


The feeling after a yoga session predictably improved in most patients. It is in accordance with our previous paper written many years ago (Nespor and Frouzova 1985). It is surprising that many patients, even if they feel better, do not intend to practice every day and they do not practice. I believe that the above mentioned obstacles are not specific to the people with addictive diseases. Many of these obstacles are relevant also to the general population of yoga trainees.

Regularity: Most patients like yoga and did not mention any obstacles to regular practice. Despite this, they do not intend to practice regularly in the future. Maybe it should be repeated more often that regular practice is one of the crucial factors of successful use of yoga in health management.

Laziness and indolence: This most common obstacle it not easy to overcome. It may be useful if trainees are able to motivate themselves, e.g. to remind themselves that after investing some effort and inconvenience (such as getting up early) in yoga they will be rewarded by pleasant feelings afterwards.

Other interests, sports: Our aim is not to replace healthy and useful interests by yoga. But most of our patients have unhelpful hobbies which should be substituted. It may help to contemplate ways how their healthy interests can be accommodated with yoga or sometimes even integrated with yoga (e.g. mantra repetition during walking).


Lack of time: Time can be organized better. For example, yoga can be practiced instead of unnecessarily long sleep or even better instead of watching TV. A 2004 report estimates that young Americans aged 13-24 years watch nearly 14 hours of television a week (Brier 2004). 73.4% of Czech population watched TV daily in 2005. The problem of lack of time has more specific context. Some addicted people want to pay their debts (both financial and moral) as soon as possible. Because of that they become exhausted. Their self-control deteriorates. Such life-style increases the risk of relapse. It is absolutely necessary for them to maintain balance between duties and rest. Yoga fits well into this. It is also possible to emphasize, that regular practice of yoga can increase productivity.

Family members, friends: It may be difficult to explain to relatives why one practices yoga, and a trainee may feel ashamed. This obstacle is mentioned frequently and may be also serious. The relatives, if possible, should be informed about yoga by a therapist. The aims of yoga in addicted people should be explained. Alternatively trainees should be encouraged to explain the reasons why they practice to their relatives themselves.

Privacy, housing: This may be a serious problem. It was much more often mentioned by current in-patients than the former in-patients. This can be explained by the excessive anxieties of in-patients regarding their future. Such apprehension decreased with continuing abstinence outside the hospital; beside this, the social situation of the people who abstain from alcohol usually radically improves. Possible solutions to the problems of privacy may be to practice silently early in the morning when other people sleep, information about yoga, its meaning and usefulness to family members may also help. There are also many practices which can be used inconspicuously (e.g. mantra) or outside home in parks, etc. It is also possible to include yoga practices into normal daily activities (relaxation during waiting, mantra or full yoga breath during walking etc.) sometimes.


Health problems, pain: Assurances can be given that carefully selected yoga practices are safe and helpful. Even very old or physically challenged people can benefit form suitable yogic practices.

Lack of information: To assure that basic principles and practices are simple. To give the trainee addresses of yoga classes outside hospital. Trainees should be recommended practical books about yoga.

It is difficult alone: Patients should be supplied with contact details of yoga classes or clubs that are willing to accept them. They may also attend our yoga class after their dismissal, but it may be rather complicated for them because these classes do not take place in the evenings.

Religion: It is possible to argue that yoga is compatible with any religion and that yoga is practiced by people of different confessions both in India and all over the world. This problem seemed to be negligible for most patients. Yoga may deepen the individual's religious and spiritual life.

Unpleasant feelings: This objection appeared rarely. Yoga is usually perceived as pleasant. The reasons somebody may feel pain includes overstretching and competitiveness, lack of experience or lack of mental and physical flexibility.

It is not interesting: This objection was rare. I try to include interesting elements and colourful stories in the lessons.

Commuting: This obstacle was mentioned only once. Perhaps emphasizing that the practice in private is most important and to enhance it by retreats etc. from time to time.
Acknowledgements

Author is grateful to Bihar School of Yoga where he received his training in yoga. The linguistic assistance of Ms. Helen Greatorex is gratefully appreciated.


References

Goyeche, J.R.: Yoga as therapy in psychosomatic medicine. Psychother Psychosom. Vol, 31, 373-381 (1979).

Lohman, R.: Yoga techniques applicable with drug and alcohol rehabilitation programmes. Therapeutic Communities. Vol. 20, 1, 61-72 (1999).

Michalsen, A., Grossman, P., Acil, A., Langhorst, J., Ludtke, R., Esch, T., Stefano, G.B., Dobos, G.J,: Rapid stress reduction and anxiolysis among distressed women as a consequence of a three-month intensive yoga program. Med Sci Monit. Vol 11, 555-561 (2005).

Nespor, K.: Yoga in addictive diseases - practical experience. Alcologia. Vol. 13, 21-25 (2001). Available at www.plbohnice.cz/nespor

Nespor, K., Frouzova, M.: Changes of psychological state after relaxation in patient treated at alcohol treatment unit. Ceskoslovenska psychiatrie. Vol. 81, 313-319 (1985).

Nespor, K., Singh, R.H.: Experience with ayurvedic psychotherapy. International Journal of Psychosomatics. Vol. 33, 29-30 (1986).

Pilkingtona, K., Kirkwooda, G., Rampesc, H., Richardsona, J.: Yoga for depression: The research evidence. Journal of Affective Disorders. Vol. 89, 13-24 (2005).

Pardini, D.A., Planteb, T.G., Shermanc, A., Jamie, E., Stumpd, J.E.: Religious faith and spirituality in substance abuse recovery. Determining the mental health benefits. Psychology of Addictive Behaviors. Vol. 17, s159-162 (2003).

Satyananda Swami Saraswati: Asana pranayama, mudra, bandha. Bihar Yoga Bharati, Munger, India (1996).

Sovinova, H., Sadilek, P., Csemy, L.: The trends in smoking in Czech adult population. Research report (2006).


Table 1. The obstacles in practicing yoga.




Current in-patients

Former in patients

All patients

Laziness, indolence

13

16

29

Other interests or sports

8

6

14

Lack of time

8

4

12

Privacy, housing

9

2

11

Health problems, age

5

4

9

Family members, friends

4

4

8

Lack of information

2

4

6

It is not interesting

3

0

3

It is difficult alone

1


2

3

Unpleasant feeling

1

0

1

Commuting

1

0

1

Other

1

0

1



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