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Teaching Yoga to mentally ill students

General ideas

What I have written here is the result of my own thoughts and experiences in teaching in hospitals for the acutely mentally ill over many years. I have taught in a general hospital and a semi secure forensic unit. In the semi secure forensic unit, most patients have been sent there by the court as a result of criminal acts. Sometimes they are there for assessment before sentencing, and sometimes longer term, because prison is not a suitable place for their condition to be handled. Although officially classified as “semi-secure” the security is, in fact, very strong. In the general hospital unit, most patients were there voluntarily and for a short stay.

Patanjali describes Yoga as Chittavrittinirodah.(1:2) There are several translations of this – all of which throw light on the process

• Yoga is the suspension of the fluctuations of the mind Gregor Maehle “Ashtanga Yoga”
• Yoga is the restraint of mental modifications Rama Prasada “Patanjalis Yoga Sutras
• Yoga is the ability to direct the mind exclusively towards an object and sustain focus in that direction without any distractions TKV Desikachar “Reflections on the sutrs of Patanjali”
• Yoga is the restriction of fluctuations of consciousness Georg Feuerstein “
• Yoga is the neutralisation of the alternating waves in consciousness Paramahansa Yogananda
• Yoga is the cessation of mind Osho
• Yoga is the cessation of movements in the consciousness BKS Iyengar
• Yoga is the settling of the mind into silence Alistair Shearer

Also Patanjali speaks of asmita – the sense of self- as one of the hindrances produced by ignorance. One could regard mental illness as a disturbance of the sense of self --- assuming, for convenience, the conventional parameters of our society as the norm (though of course some will question this). So one thing we could be doing is to allow students to “see” their accustomed way of enacting the self as an artefact which can be remodelled, and to realise that this is not necessarily the true self, or even useful social self. This ,I think is the meaning of ahamkara – the “I maker” in the yoga writings.

Who are the students

If this was an article called “Yoga for the ill” you would ask me “what ailments?”. There are several different forms of mental illness with very different symptoms, so how could we lump them all together? However, they are all lumped together in a psychiatric unit so the students the teacher will meet can have any, or more than one, condition.

Brief description of mental illness:-

Non-psychoses --- depression, anxiety, alcoholism, drug abuse, personality disorder, esp. anti- social personality disorder and borderline personality disorder (experiencing life as fragile and flickering. Little sense of substance or permanence. Sometimes intensely feeling, sometimes bored, with no consistent picture of values or behavioural cues.)

Psychoses –schizophrenia, paranoid schizophrenia, (considered as thought disorders) and bi polar disorder (often considered as a mood disorder)

Mental illness is not just one phenomenon. If we talk about yoga for the organically or structurally ill, we usually break it down into yoga for arthritis, or yoga for diabetes. Although these disorders may have common elements, there would also be differences in adaptation and emphases when teaching. So it is with mental and emotional disorders.

NB This is my own analysis for teaching purposes. I don’t need to have diagnostic accuracy as I am not recommending treatment. Also many of the diagnostic analyses are controversial and views of researchers are constantly shifting. One of the main areas of controversy is dimensionality --- how far mental symptoms are related to or an extension of “normal” behaviours in the community.

Brain areas which may be affected - see DANIEL AMEN “Changing your Brain, Changing your Life”

Clinical depression:- deep limbic system (thalamic structures, hypothalamus and surrounding tissues) overactive. Sets emotional tone at negative thinking.

Anxiety and fear:- basal ganglia. Sets body’s ‘idle speed’ or anxiety level.
Inattention and Impulsivity:- prefrontal cortex.

Worry and Obsessiveness:- Cingulate system

See also.JEFFREY m SCHWARTZ and SHARON BEGLEY “The Mind and the Brain”

What sets these students apart from others

What has brought them to the attention of the medical profession is the lack of ability to function “normally” within society. This has been perceived by themselves or others. The usual criteria for normal function include:-

1. Most people expect to be happy some, if not most, of the time, to understand what others require from them, and to live lives in which most adverse circumstances are coped with in the long term. One student said “how can I live when I am afraid all the time?”
2. We expect that most people can care for themselves, supporting themselves and other family members financially unless physically unable to do so, (or that they are able to apply for, and receive, state benefits). Some people are unable to do this because of learning difficulties, but they are not usually considered “ill” – unless they have other conditions.
3. We require that people in society are not a random danger to self or others. The motive behind harm to others should be explicable if not excusable. There is some debate as to where criminality ends and mental illness begins

Two questions

I’m usually asked one of two questions:-

• Aren’t you afraid
• Isn’t it depressing

Answered by:- No to both

Teacher requirements

The four qualities mentioned by Patanjali – friendliness, compassion, gladness, equanimity.
Meta studies show that what makes the most difference in any intervention is the quality of the carer’s attitude
see MARK A HUBBLE, BARRY L DUNCAN, SCOTT D. MILLER “The Heart and Soul of Change; What really works in Therapy”

Teacher’s own preparation

Often can’t prepare a class routine because you don’t know who will arrive, therefore teacher must be self prepared in a very general way.

Some experience of posture modification for the individual

Some study of the actual experiences of mentally ill students –from discussion or reading if no personal experience available.

Teacher’s atmosphere is “catching”. Opening and closing session ritually.

Quotation from Dr. Yang Jwing Ming (Famous Tai Chi Master)

• Morality of Deed: humility, respect, righteousness, trust, and loyalty.
• Morality of Mind: will, endurance, perseverance, patience, and courage

Possible aims of a programme for psychiatric patients

1. Developing the “Witness Consciousness
   Patanlali (1:2,3) Yogash chitta vritti nirodhah. Tada drashtuh svarupe avasthanam.
   “Yoga is the mastery of the activities of the mind-field. Then the Seer rests in its true nature.” This seems to me to indicate that there is a part of the mind which is not disordered. Perhaps through yoga techniques the student can access this and “rest” in it even if only for a short time.
2. Spiritual aspects of Yoga(?)
   Swami Jnaneshvara Bharati on his website SwamiJ.com says that the sole purpose of a Yoga programme is spiritual. And there are many teachers who would agree with this. He says that the reason for working with the physical body is so that it will not be an obstacle in meditation or prayer. I keep my ideas about the spiritual side of Yoga out of my teaching delivery, though I do explore some philosophical ideas as appropriate. For example, I sometimes quote from the Bhagavad Gita which contains practical descriptions of the Yoga state.
3. Symptom relief
   1. This is the major thrust of my lessons. Symptoms include:-
   2. Agitation
   3. Stiffness and pain
   4. Inability to focus
   5. Poor self image
   6. Depersonalisation – melancholic loss of affect. Schizophrenic loss of sense of body as themselves.
   7. Hardly breathing.
   8. Poor breathing habit
   9. Lateralisation problems? --- during alt. nostril breath, many mentally ill students are left nostril dominant. I am not sure why this is, so am cautious, as I don’t know whether it is a symptom, or the body’s attempt to balance up the mental states.
4. To affect the quality and quantity of attentional focus at will.
   See JEFFREY M. SCHWARTZ “The Mind and the Brain”
5. To separate the witness consciousness from reactivity.
   This is a very useful function of a more challenging asana programme.
6. To increase stress tolerance.
   Article on www.WebHealthCenter.com says “it is easier to protect the body than the mind” This is another product of asana and later, with great caution and supervision, of pranayama
7. To produce a transformation in the way one experiences oneself.
   see DAVID FONTANA “The Lotus in the City”.
   This can come from increased strength, stamina and ability to change one’s reaction through preventing too much contraction or expansion. This is ananta or space perception. Ananta can also mean boundlessness, endlessness (see Patanjali)
8. To give grounding when patient is unsure “what is reality”

I have actually been asked the question “how can I know what is real, when I can’t trust my own thoughts or perceptions?” I found this a moving indication of the terror some students must feel. Asana and breathing can be worked on as bodily perceptions which can be wilfully changed. Cf Bhagavad Gita (2:40) “even a little progress in Yoga brings freedom from fear”.

Possible Mechanisms for effectiveness of programme

1. Pleasure – endorphins
2. Tying up the thinking process to eliminate negative thoughts. It’s difficult to concentrate on a complex technique and have ANTS (automatic negative thoughts)
3. Decrease in cortisol
4. Increase in alpha waves
5. Increase in general health and metabolism
6. Expanding ways of seeing, thinking, and experiencing. NB except in mania where you often want contraction.
7. Giving a better vocabulary for coping with events and experiences.
8. Altering samskaras.—(can be defined as the automatic thought patterns, subliminal activators, unconscious imprints, or innate tendencies inherited from a past life) – because of neuroplasticity – ( which describes the brain's ability to reorganize itself by forming new neural connections throughout life). Neuroplasticity allows the nerve cells in the brain to compensate for injury and disease, and to adjust their activities in response to new situations or to changes in their environment.

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