Although yoga has the explicit aim of guiding the flows of consciousness (Hartranft 2003), it was only in the last decade, and alongside the growing public interest in the discipline, that the psychiatric field paid closer attention to yoga’s relevance in recovery from mental ill-health. Yoga has no side effects; it can be low-cost and can be practiced by anyone throughout their lifetime.
In India, the therapeutic applications of yoga in mental health problems are currently being explored at the Integrated Centre for Yoga at the National Institute of Mental Health and Neurosciences (NIMHANS), Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA) in Bangalore, Morarji Desai National Institute of Yoga in New Delhi, and Patañjali Yogpeeth in Haridwar. Research conducted at NIMHANS, for example, has focused, amongst other issues, on developing yoga-based therapeutic models by shortlisting yogic practices described in both classical and contemporary yoga texts and exploring their efficacy in the treatment of depressive symptoms (Gangadhar et al. 2013; Naveen et al. 2013) or improving cognitive functions among the elderly (Hariprasad et al. 2013a, 2013b). Other investigations of yoga’s therapeutic potential focused on functional disorders such as schizophrenia (Manjunath et al. 2013; Bhargav et al. 2014), cognitive functions in geriatric patients, (Umadevi et al. 2013), mental health generally (Nagendra 2013), treatment of children (Uma 1989) or distress relief among victims of natural disasters (Telles et al. 2007; Telles et al. 2009).
While the existing research tends to focus on assessing the outcomes of yoga “interventions” in targeting particular conditions or symptoms, very little attention has been paid to the subjective perspectives of patients, their families as well as therapists and medical professionals involved in yoga training. Quantitative data might verify the effectiveness of yoga but it fails to account for how people engage with its practices and philosophy. Current research in the field can, thus, be enhanced by attending to personal motivations, meanings given to and struggles in personal practice as well as the particularities of the context in which yoga is introduced. This current account makes an initial step in this direction by discussing a pilot research conducted at a psychiatry clinic in Tamil Nadu, South India where inpatients have been introduced to yoga practices. For a period of twenty-five days an exploratory participant observation was conducted with psychiatric patients and their families, yoga therapists, clinicians, nurses as well as postgraduate college students. Rather than discussing effects of yogic practices, this report accounts for the meshwork or relations, interdependencies and inhibitions that this particular therapeutic setting comprised. With specific regards to the subjective accounts of patients and clinical staff, and in anticipation of the forthcoming period of the research, I discuss existing opportunities and limitations in introducing yoga to the local population in rural India. Concurrently, this report hopes to open up a discussion regarding the relevance of anthropological approaches in the field of yoga therapeutics and research and calls for a closer cooperation between specialists working in the field of psychiatry, yoga and anthropology.
Methodology, Material and Ethics
This piece draws on an anthropological pilot study conducted in January and February 2016 at a psychiatric ward in the coastal part of the South Indian state of Tamil Nadu in collaboration with the Centre for Yoga Therapy, Education and Research (CYTER). CYTER, an integral part of Sri Balaji Vidyapeeth Medical University, provides individual and group yoga therapies for patients; yoga training for medical and nursing students; and daily yoga classes for staff. Furthermore, staff members at CYTER conduct research into therapeutic uses of yoga and run a popular postgraduate diploma course in yoga therapy attended by both local and foreign students. By cultivating yoga in medical and educational settings, CYTER strives to fulfil the mission of AYUSH, the Indian ministry of indigenous medicine, to develop a holistic approach to healthcare.
During the period of collaboration with CYTER, participant observation took place prior to, during and after yoga classes, during the departmental rounds and at the hospital’s yoga therapy centre. The research also entailed open-ended discussions with psychiatrists and nursing staff at the clinic and doctors and therapists at the yoga department. In addition to daily conversations and interactions on the ward, open-ended unstructured interviews with eighteen patients as well as their families focused on their experiences of both yoga classes and their life situation. These interviews were conducted with the help of trainee medical students who translated from Tamil to English and vice-versa. Due to the scheduling of rounds, interviews with patients took place after the yoga practice. Discussions with clinical and hospital staff were conducted in English which is the language of teaching and lecturing at the institution.
This research evaluated patient care in anticipation of extending the yoga training to rural health centres. Patients in the study were informed about this goal and asked whether they are willing to share their accounts. Verbal informed consent was collected and no identifiable information is presented here. The material collected during the pilot in form of detailed fieldnotes, photography and video focused on patients’ experiences, hopes and limitations as well clinical staff’s expectations and opinions on providing yoga as a therapeutic activity on the ward. The pilot anticipated a more extensive anthropological research by contemplating feasible research questions and methodology that would be suited to the specificities of the context. The study was conducted as part of an inquiry into applications of yoga in mental health problems in a variety of settings including hospitals that offer yoga therapy as well as yoga ashrams and schools that run yoga therapy courses. The material collected in these locations is not discussed in this blog piece but provided the necessary background for understanding the therapeutic uses of yoga in contemporary India on one hand and the scope of as well as challenges in psychiatric services in the country on the other.
A film documenting a project with children who experience intellectual development difficulties conducted collaboratively between researchers at CYTER, Kaivalyadhama Yoga Institute and the author of this blog piece can be watched here.
Modes of Instructions
Although yoga lessons are available to both patients and staff at the CYTER, it was proposed, bearing patients’ safety in mind, that classes would also be provided directly at the psychiatry ward. The treatment model was devised at CYTER under the guidance of Dr. Ananda Bhavanani and introduced by the centre’s therapists alternatively on the female and the male ward. On most days, patients of both genders practiced alongside each other. Only once a female patient expressed a concern about this mixing of patients and, on that day, men were not invited to join. Occasionally, patients would come to either a regular or an especially scheduled class at CYTER. On the ward, yoga sessions would last forty-five minutes during which patients practiced a number of techniques drawn from the Gitānanda yoga tradition. These included, among others, kayakriya (shaking of legs and hand, neck and torso movements to left and right combined with conscious breathing), chattis (shaking and throwing extremities in the air) or śavāsana (relaxing supine pose) lying on the hospital bed. Patients were also introduced to nasargemuka bastrika, a practice that entails nasal inhalation and forceful exhalation through the mouth combined with dynamic movements of limbs all of which aims at a release of bodily and mental tensions. Participants also gave attention to their breathing by learning various pranayama techniques including relaxing chandranāḍī (left nostril breathing), bhrāmarī (bee-like humming exhalation with closed mouth) as well as A-U-M chanting in both sitting and supine positions. Vyagaragage (observing inhalation and exhalation) as well as mudra (actions) such as bhramamudrā (chanting A-U-I-M with head movements) were also taught (Giri 1976; Bhavanani 2013).
While each of the two therapists took a slightly different approach to sequencing the class, introducing particular techniques as per patients’ requirements and space availability, an upbeat and accepting approach was always required in building a trusting relationship with patients. By being kind and approachable, therapists encouraged patients to commit to their practice with confidence. Bearing this in mind, only minor postural corrections were given, for example, when participants would show little interest in the practice or low body-parts awareness. Individual assistance was provided upon request. As a researcher I maintained a helpful co-presence by practicing alongside a therapist with the aim to encourage patients and their carers to participate. Patients, but also staff and relatives, were clearly intrigued by a European person following the sequence of positions.
Patients at the Ward
Just over a hundred patients attended the yoga classes during the period of the research in addition to over fifty family members who joined in at one point or another. Most patients participated in three or four sessions although some received only one and one male patient participated in seven classes. The majority of the participants lives in the rural areas of the surrounding district and mentioned sustenance agriculture as the basis of their livelihood. Almost all female participants described themselves as homemakers, although, in addition to cooking, cleaning and childcare, many of the women interviewed also tended the fields. Males had more options working as drivers, builders or business owners. Almost all of the patients below the age of twenty-three were in further or higher education.
Patients suffered from a wide range of conditions ranging from schizophrenia and bipolar spectrum disorder to depression. Instead of focusing on these criteria, however, I asked the patients to describe how they felt. They usually answered “nervous”, “stressed”, “uncertain about the future”, “overworked” and “tired”. Understandably, sessions would start slowly and sometimes patients needed a lot of encouraging to stand up from their bed. As a practice would progress, smiles and laughs indicated that the patients found it enjoyable and worthwhile. Some, however, were not able to practice due to lethargy or inertia, which clinical staff interpreted as side effects of medication. Patients who were administered electroconvulsive therapy, which is still commonplace in Indian hospitals including the one where the pilot research took part, did not participate on the day of the treatment. Some patients, but also relatives, would join only after some minutes or even on the next day having watched others practice first.
While female patients and family members would be less keen to engage in the more vigorous parts of the class, male participants found the dynamic āsana and kriya to be their favourite. A gendered difference was also noted in terms of attitudes towards relaxation techniques. Female patients, in general, enjoyed the repose more easily, whereas male patients pulled out of the experience quickly and, for example, found lying down with their eyes closed and stilling their body much more difficult than females. Even in relaxing poses, male patients would tighten their muscles, especially in their extremities. In spite of these difficulties, participants of the same gender encouraged each other and several staff members made positive remarks about bonding well as a sense of comradeship that yoga practice brought to the ward.
Patients’ Personal Accounts
Patients reacted positively to yoga practice already after the first class. On that occasion, a male patient started crying and, while it initially seemed he felt despondent, he claimed to have experienced happiness. Throughout the research, participants reported that practicing yoga had brought them a sense of “joy”, “peace”, “satisfaction”, “relaxation”, “lightness” or “feeling of ease”. For many, becoming aware of their breath and movement or exercising self-kindness was unfamiliar yet it appeared to free them, at least temporarily, from tensions and worry. One young male patient called yoga sessions an “important social service” while patients who had practiced yoga in the past were happy to see it introduced in a hospital. Junior medical practitioners at the ward recounted that their patients spoke highly of the yoga classes.
In order to prompt a sense of ownership over their practice, interlocutors were asked to devise their own questions. In a conversation with a middle-aged male participant, who first elaborated on the joys and difficulties of the training as well as his daily struggles, the following exchange ensued:
Patient: Why do we do yoga?
Krzysztof: Why don’t you tell me?
P: (pause) To clear impurities from our mind…?
K: Yes and, perhaps, to give self a space to think, to reflect?
P: I’m not ready to introspect… to look into my life. I just want the time to pass…
K: Isn’t yoga a good way of passing time?
P: (smiles) I will have to find out…
Indeed, yoga classes provided a lively alternative to the otherwise mundane flow of life at the ward and some patients eagerly anticipated the next practice. On one occasion when none of the therapists were available, a male participant expressed his disappointment: “I would feel much better if we had the class”, he said. Given these positive responses, a pivotal question of continuity emerged. In the course of the pilot project only one patient said that, once discharged, he would be able to attend regular yoga classes provided free of cost at the hospital centre. Other patients saw the distance between the hospital and their places of residence, lack of funds or time, work and family obligations as preventative.
As a methodological experiment for future work, photographs and short films were taken during the practice. These were used in the ensuing discussions with patients to encourage them to reflect on their participation. Upon seeing himself in a film, a male patient in his thirties opened up about his experiences; he told of his life struggles and history of substance abuse but also about being reluctant to join the class. At first, he thought yoga was too energy consuming but, “by doing it”, he actually felt “calmed” and “relaxed”. Notably, it was found that the patients asked to reflect on their practice engaged with more vigour and enthusiasm during the following session. Film and video recordings, in particular, made participants realise that both yoga classes and the research project had their best interest in mind. However, on one occasion, when a female patient became increasingly anxious about the camera, the filming was stopped.
Participating in yoga classes also provided a space for thinking about some more fundamental live issues: “would yoga make me more outgoing?”, “can I improve my communication skills with yoga?”, “can yoga help me relax” were some of the questions asked. Subsequently, it emerged that in their day-to-day lives, participants rarely engaged in sports or unwinding practices. Furthermore, the patients who worked as farmers or labourers considered partaking in physically demanding or sporting activities as neither desirable nor feasible. While most patients chose to socialise as their preferred way for relaxing, some also attended either Hindu or Muslim temples. Notably, however, a number of male patients claimed to have recently stopped participating in religious activities. When asked to explain his reasons for doing so, one participant, who also recently shifted from working in agriculture to driving, responded: “I felt that I could rely on myself more”. He then added that he enjoyed having a disposable income that his new employment generated. In a similar vein, another male participant whose financial situation had also recently improved asserted: “I became stronger, so I did not need someone to tell me what to do anymore.” While these participants did not make an explicit link between loss of interests in religious activities and loss of hope in life, it appeared that abandoning their spiritual framework impeded their capacity to deal with mental distress.
Regardless of how patients approached matters of belief, from ambivalent to downright rejection, there were no explicitly negative attitudes towards yoga. When asked whether he finds yoga to be incompatible with Islam, one elderly Muslim patient claimed that on Friday evening he first went to a mosque and then a yoga class: “Prayer and yoga are the same”, he explained, pointing out that both are a form of “surrender to a higher force” and “both are (concerned with) Manidhaneyam”, the notion that is best translated as a sense of or platonic love for humanity. “Islam is asking (you) to do yoga, by doing yoga I care for myself, I become myself”, he continued. Although this particular participant thought that yoga and Islam are spiritually parallel, due to popular perceptions and also political and religious tensions in India, other patients might express more oppositional attitudes towards yoga.
Family and Staff
In the context of the research, relatives would often motivate patients to participate in yoga. Particularly inspiring was a 12-year-old boy who accompanied his mother. Everyday he urged her, as well as other patients on the ward, to practice. Both mother and son came to anticipate yoga sessions and both would finish with a smile. Similarly, a 4-year-old daughter of another female patient participated in practice with no inhibitions commonly observed among the adult population. Some relatives refused to join explaining that only their sick relatives needed yoga. They were also keen to rest from their daily duties: an elderly female explained that since her daily job was farming, she preferred to rest and avoid exertion while taking care of her hospitalised son. In cases when relatives would pressurise a patient to join in, they were encouraged to practice together. While family members often appeared shy to become involved, whenever they overcame their inhibitions they found joy and contentment in the class.
It also became clear that in order to successfully propagate yoga amongst psychiatric, or for that matter any, patients, there needs to be a thorough understanding of yoga amongst the staff. In other words, without medical professionals being enthusiastic towards and knowledgeable about the discipline, patients were unlikely to approach their practice with confidence. Notably, introducing yoga at the ward was met with a variety of responses. Consultants (psychiatrists), for example, were extremely supportive and open to the idea. They shared a conviction that no pharmacological treatment can lead to a full recovery and thought that patients could improve their low levels of awareness through yoga without any side effects. One senior member of the faculty noted that, in addition to the practical element, both staff and patients needed to understand yoga’s philosophical foundations. Another senior member of the department complained that so-called alternative forms of medicine are hardly taught as part of the medical curriculum. This became apparent as some students expressed scepticism towards, or appeared unfamiliar with, the discipline: “All this clapping and running is not yoga?!” pondered one postgraduate trainee when asked about his opinions on the project. “Isn’t yoga a silent meditation” added another. Similarly, the nursing staff reacted to patients who practiced A-U-M chanting for the first time with surprise and a giggle. However, as time progressed and the novelty factor waned, the nurses came to encourage their patients and to assist them during practice. Female nurses and patients bonded particularly well. Seeing patients enjoying themselves in practice, both nursing staff as well as medical students thought that they should also join the staff yoga classes.
A concern with providing modifications has emerged, as consultants at the ward would ask therapists to suggest individual patients with techniques to alleviate some particular symptoms. Since there was a concern that patients might not be able to remember how to practice, we reached out to their families or fellow patients. A mother of a severely anxious female patient in her twenties was taught Brahmari pranayama and encouraged to practice together with her daughter. Another female patient, also in her twenties, complained about insomnia. On a Saturday morning, she was introduced to some relaxing breathing techniques such as chandranadi. During a follow up after the weekend, the patient reported that her sleep only improved on Sunday night even though she practiced on Saturday only. This incident clearly highlighted the need to pay more careful attention to how patients adhere to and evolve in their yoga practice. Clinical staff at the Department of Psychiatry shared this concern with practice continuity as they explained that patients often wanted a quick fix such as a tablet or an injection and, even though they rested during their hospital stay, they were also keen to return to their everyday lives.
Patients hospitalised at the psychiatry clinic where this research took place experience considerable stress in their day-to-day lives and expressed concerns about their future. This is in response to work- or education-related pressures, family expectations as well as changes in employment especially moving away from sustenance agriculture towards wage labour or, in case of female patients, carrying a double burden of agricultural work and family care. For some male patients, their decreasing interest in religious matters preceded their loss of hope. Furthermore, some saw personal income as a chance for both personal growth and family prosperity. Participants, in general, enjoyed few opportunities to talk about their mental health problems to others and, as mental illness continues to remain a taboo subject. Most patients come to the hospital as a last resort, when their ill-health had already advanced.
Following yoga classes, patients reported to be more “comfortable”, “relaxed” and “at ease”, feelings they experienced all too rarely. Even though some participants were initially reluctant to join, through practicing they could loosen up without getting fatigued. Arguably, participants found yoga practice useful because, through “doing it’” they developed awareness of self in the world, removed tensions through sequencing of movements and breath and found a sense of freedom as well as satisfaction in simplicity but also repetition of practice. Patients also appreciated that therapists were positive and accommodating and did not force them into practice. By spelling out what yoga meant to them during interviews, patients gained further motivation to practice. They were considerably more willing to discuss difficulties they experienced, both in their life and yoga practice, once they had realised that the therapists and the researcher had a genuine interest in their accounts.
Using stills and film as a feedback mechanism was particular useful in this as, rather than trying to meet the researcher’s expectations or patients’ subjective perceptions thereof, participants were able to focus on their own feelings and experiences. This speaks to the observation made across the extensive literature on illness accounts, namely, that control of narratives is crucial in recovery processes (Kleinman 1988; Charmaz 1992; Frank 1995; Skultans 1998, 2004; Rapport) or even a form of recovery in itself (Rosen 1983; Antze & Lambek 1996). Yoga practice, as the next stage of the research hopes to explore, might provide psychiatric patients with new ways of telling their stories: not only verbally but physically, mentally and communally too. In particular there is a great potential in employing visual methods to collaboratively generate personal accounts and stories of yoga practice.
It is widely accepted that the stigma against mentally ill perpetuates a sense of vulnerability and social inadequacy (Goffman 1963) and, as such, prevents healing. This is also why mental health movements, organisations and campaigns around the world have focused on eradicating discriminatory and stigmatising attitudes (Crossley 2006; Bierski 2015). One method of removing stigma is to engage a broad spectrum of social actors in the recovery. The role of family in this process cannot be overstated, especially in India where patients are admitted to psychiatric wards only with an accompanying relative. In the course of this research, it was found that families played a crucial role in encouraging patients to practice. Yoga could be brought out of the psychiatric ward into the patients’ day-to-day lives by encouraging families to practice together. This would prevent relatives from putting pressure on the patient to recover faster, usually because engaging in care duties at the hospital leads to a loss of income. Providing training to patients and relatives could give them a sense that the time spent at the hospital was useful. First, however, a number of perceptions needs overcoming such as that yoga is only for the patient, that it is physically demanding, that illness requires a “quick fix”, and that responsibility for healing rests on the shoulders of medical professionals.
While recording and publicly displaying patients’ accounts in the form of posters and leaflets but also films could be helpful in providing more accurate information about yoga and its aims, this research identified a need for a systematic model of yoga education for patients and their families as well as for staff. Nurses who maintain extensive contact with patients are in the position to effectively guide and support them during practice. The existing yoga training that nursing students receive as part of their undergraduate degree at the medical college where the research took place provides such important educational opportunities. However, staff at the psychiatric clinic explained to require further training in yoga in order to bring a closer understanding between staff and patients. All in all, yoga’s practical philosophy of living life with awareness could serve as a framework for coping with the transformations and demands of life in modern India.
Yoga as a Skill
The pilot study presented here breaks with the tendency to employ multiple regression analysis to understand therapeutic value of yoga practice by offering what, in this field, is an innovative anthropological approach. As a conclusion, limitations of this study and an outline of the intended plans for the next phase of the research are discussed. One major drawback of this pilot was its relatively short time frame. More extensive interviews with the patients and clinical staff and longer period of participant observation, also in local villages, would provide a more comprehensive picture of mental health needs and practices in the population. Translation posed another concern and, in the future, interviews with patients will be conducted in Tamil only.
While the research revealed no particular issues with implementing the yoga module itself, it exposed a concern with how patients could benefit from yoga on a long-term basis. This aim could be achieved by brining yoga training, and with it, this research, out of the clinic and to patients’ everyday milieux. In their 2001 report on the scope of mental health problems in rural West Bengal, Chowdhury et al. explained that the significant disparities in access to health care between urban and rural populations of India necessitate the development of localised mental health services. More than a decade later, their call pertains to the situation in the southern state of Tamil Nadu. The authors (ibid.) propose “cultural epidemiology” as an opportune tool for understanding the conditions in which localised health care could be provided. This ongoing research, meanwhile, draws on Ingold’s (2000) suggestion that cultural difference is, essentially, a variation of skills or adaptations to the broadly defined environment that includes social life (see also Bierski 2016). Presented with yoga as a skill, patients could develop proficiency within the realm of their own possibilities while approaching their wellbeing as an ongoing process of transformation.
The next stage of the research will, thus, employ visual methods to trace, together with patients, how they progress in practice over time. Patients will also be invited to devise mood charts, write diaries and participate in the filming process. As learning yoga in the context discussed here entailed collective effort, the next stage of the research will necessarily focus on the role patients’ family and hospital staff can play in developing and maintaining yogic skills. Such a participatory and skill-oriented framework of yoga practice and research could, in turn, serve as a blueprint for therapeutic yoga investigations in India and beyond. The author invites comments, questions and suggestions regarding the same from any interested parties.
I would like to express my heartfelt gratitude to all staff members at the Sri Balaji Vidyapeeth Medical University, in particular at the Centre for Yoga Therapy, Education and Research and the Department of Psychiatry for a warm welcome, the opportunity to conduct this research and always stimulating discussions. Special thanks go to all the patients who agreed to share their stories. I would also like to thank Hansjörg Dilger, Dominik Mattes as well as the reviewers of the Blog Medizinethnologie for their invaluable insights and comments on this piece. This research has been funded by the Freie Universität Berlin DRS POINT fellowship, which is gratefully acknowledged.
As a postdoctoral fellow at Freie Universität Berlin’s Institute of Social and Cultural Anthropology and Centre for Area Studies, Krzysztof Bierski explores transnational developments in therapeutic applications of yoga. He has previously conducted anthropological research with mental health activists in the United Kingdom and online. His work explores ecological dimensions of health, correspondence between skilled movement and wellbeing and the use of participatory media in health practices and research.
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