We have dealt with the use of yoga in substance dependence in previous papers. We have also included a brief yoga course in the self-help manuals for alcohol and drug dependent persons and for pathological gamblers. The number of people with addictive problems is increasing in many parts of the world. Professional services alone are often unable to provide treatment which is readily available, sufficiently intensive and acceptable to everybody. This is one of the reasons why self-help organizations, such as Alcoholics Anonymous or Narcotics Anonymous, are so important. I believe that sooner or later yoga may well fit into this situation and that suitable yogic practices may enhance the recovery of many people.
Most alcohol and drug dependent patients we meet suffer from additional health and mental problems. Beside this, they are often not accustomed to practising physical exercises and their self-confidence is weak. It is obvious that under these circumstances we offer them exercises that are easy and simple enough.
The group consists usually of 10 to 20 patients of different ages and physical abilities. We often offer simpler alternatives or comparatively more difficult practices. During the early stages of abstinence a patient is often in distress, and yoga and relaxation should help him or her to cope. A therapist should be good humoured, friendly, respectful and calm, even if there are problems and even if the performance of the exercises is far from perfect.
We have had experience with different lesson durations (from 30 to 60 minutes). Most of our patients are not willing or able to participate in longer workshops (such as 5 hours during a day). Regardless of the duration, the lesson is usually divided into three roughly equal thirds. The first consists of the physical exercises of yoga; the second of the full yoga breath and/or some simple pranayama and a short story; and the third of relaxation with sankalpa (resolve).
Before I describe these parts in more detail, let me emphasize that this scheme is not rigid and can be modified.
I usually start with the question: 'Do you have any special wish?' The patients' responses may considerably influence the structure and course of the lesson. Typical responses to this question are as follows:
'No response.' In such cases I thank them for their trust that I will select the most suitable practices, and proceed with my program.
'We want relaxation.' This request is readily accepted. The group may be tired, anxious or distressed, and a short relaxation (shavasana) is appropriate. After the short relaxation (shavasana), we may continue with simple hand exercises from pawanmuktasana part 1 while lying down, such as mushtika bandhana (hand clenching) and manibandha naman (wrist bending), and supta pawanmuktasana (leg lock pose) from pawanmuktasana part 2. This makes the transition from relaxation to exercise smooth and easy. Following this, we proceed with other practices.
'Yoga smiles.' I collected eight ways of smiling (see appendix), some of which are very expressive and open up patients emotionally.
'Something for the back, something against headache' or similar answers. Such requests are accepted and appropriate practices with an explanation included in the lesson.
As mentioned above I use pawanmuktasana part 1 and part 2. Alternatively marjari-asana (cat stretch pose) and its variations, such as vyaghrasana (tiger pose) or marjariasana with forearms on the floor. After this, we usually assume shashankasana (the hare pose) from marjariasana rather than from vajrasana, because vajrasana is too difficult for most of our patients. Then we may practise some backward bending asanas such as ardha ushtrasana (half camel pose), with one arm stretched above the head, or sarpasana (snake pose) and ardha shalabhasana (half locust pose).
We use bhu namanasana (spinal twist prostration pose) as the twisting pose because it is easier than ardha matsyendrasana (half spinal twist). Alternatively, if it is rather cold, we may start with standing positions and practise tadasana (heavenly stretch pose), tiryaka tadasana (swaying palm tree pose), akarna dhanurasana (bow and arrow pose), hasta utthanasana (hand raising pose), some simple trikonasana (triangle pose), padahastasana (forward bending pose) or dwikonasana (double angle pose).
We usually start with observing the natural movements of the upper abdomen while lying down and after a while I ask the patients to increase inhalation and to prolong exhalation. The reason is obvious: the patient should understand that the yogic breath is based on their natural breathing. Upper (clavicular) breathing we usually do not practise separately, instead I ask the trainees to use both the middle and upper parts of the chest.
Occasionally we also use bhramari (humming bee breath), ujjayi (psychic breath) or Om chanting. They have a calming effect and the sound produced during them gives the trainees a self-awareness about the fluency and length of their exhalation.
Before relaxation I often ask: 'Do you want a story?' The answer is always 'Yes.' I use stories from different traditions. Let me give an example.
The monks in one old monastery were in total awe of the elder monk because nothing ever seemed to upset him. One day they decided to test him. A bunch of them very quietly hid in a dark corner of one of the hallways, and waited for the monk to walk by. Within moments, the old man appeared, carrying a cup of hot tea. Just as he passed by, the students all rushed out at him screaming as loud as they could. But the monk showed no reaction whatsoever. He peacefully made his way to a small table at the end of the hall, gently placed the cup down, and then, leaning against the wall, cried out with shock, 'Ohhhhh!'
The stories are usually accompanied by an explanation relating them to the patients' situation. In this case the explanation may be as follows: You should first overcome the dangerous situation and remember your safety. After this you should also deal with your emotions and share them with somebody who will understand. It may be your therapist, a group and/or a good friend.
Our relaxation usually lasts 10-15 minutes and it is closer to shavasana than long yoga nidra. Imagination and sometimes also suitable music may or may not be included. We offer some examples of suitable sankalpa (resolve) for substance-related problems, such as:
The sankalpa is used at the end of this practice, even if the relaxation is rather short (e.g. 10 minutes).
Besides regular yoga classes, I include a brief yoga practice in group therapy or other psychotherapeutic programs. It may increase the alertness and energy levels of participants and help to overcome their passivity.
Standing poses can be used in this way, e.g. akarna dhanurasana (bow and arrow pose). Before this practice, I may ask the patients to select a good external aim (such as attaining a new qualification) and hit it three times with an arrow when holding the bow in the right hand. Then they should select a good internal aim (such as increased self-control) and hit it three times when holding the bow in their left hand.
To alleviate heroin withdrawal we use medication and auricular acupuncture. These patients' typical problems include muscular aches, abdominal cramps, insomnia, craving and increased heart rate. Simple practices from pawanmuktasana part 1 while lying down and especially relaxation (shavasana) can be used together with other treatments and are well accepted.
Patients with addictive problems are prone to injuries and health problems. This is caused by their previous lifestyle, lack of concentration (especially during early abstinence), and sometimes also by autoagression. Yoga, when compared with sports, is safer, but even so the yoga teacher should be careful and proceed slowly.
Relaxation, even if pleasant and calming for most patients, may increase anxiety in some. This is not uncommon among the patients dependent on stimulants (methamphetamine) or those abusing hallucinogens. Yoga may bring back the intoxication-related memories.
Another reason why yoga can cause anxiety is transference. For example, a female patient told me almost at the end of her treatment that the relaxation practice with me often caused great anxiety as she remembered her sexual abuse by her father.
It is advisable to inform patients that things like this may happen and that they should discuss them with the therapist. During the experience they should try to observe it passively (witness attitude), and, if necessary, they may open their eyes.
Some young drug dependent girls consider Om chanting or bhramari pranayama as very funny practices, not to mention e. g. simhagarjanasana (roaring lion pose). Some patients may chat even during relaxation. The explanation that during yoga it is better to be internally rather than externally focused, and that after the lesson there will be plenty of possibilities for discussion is usually sufficient. If it is not, I may ask the patient to change places and to practise beside somebody less communicative.
A typical substance dependent patient has a degree of depression, is rather passive and not very interested at the beginning of his/her treatment. If yoga is a regular part of the program, he/she usually complies. But he/she probably would not actively seek the opportunity to learn yoga. After some time, he/she may find the practice rather pleasant, relaxing and invigorating, but he/she probably will not continue to practise regularly at home. We give written materials, offer tape recordings with relaxation and/or provide addresses of yoga teachers to patients. We invite them also to participate in Saturday yoga workshops in our hospital (usually 2-3 per year), which are open to the general public.
Even so, we are not terribly successful in this respect, and the long-term regular practice outside the hospital is probably the main challenge when using yoga in substance dependent patients. I know some former patients who have continued to practise yoga regularly and this has helped to transform their lives, but so far it is definitely a small minority.
Morning smile: Obviously it is practised in the morning. After rising, the first thing we should do is to smile at our picture in the mirror. Somebody may feel that this is silly and smile even more.
Smile with the stomach: We smile in a choking way with the mouth closed.
Smile with the legs: We lie flat on the back, raise both legs and make cycling movements with them. We make similar movements with the hands. At the same time we repeat the syllables ha, ha, ha ho, ho, ho he, he, he hi, hi, hi ha, ha, ha ho, ho, ho he, he, he hi, hi, hi ha, ha, ha ho, ho, ho he, he, he hi, hi, hi ..., etc. This practice is rather physically demanding and has similar contraindications as pawanmuktasana part 2.
Smile with the hands: We stand with the feet together and move the fists toward the shoulders. When exhaling, we stretch the arms forward forcefully, stretch the fingers and repeat loudly: I am cheerful. We move the fists back to the shoulders when inhaling. When exhaling, we stretch the arms sideways in a similar manner and repeat: I am jolly. We move again back to the shoulders, and when exhaling, we stretch the arms above the head, raise the heels coming up onto the toes and repeat: I am zealous.
Smile with breathing: It can be practised also when walking. During inhalation, we are aware of the incoming breath in the nostrils and repeat mentally, I breathe in peace. When exhaling, we repeat, I breathe out and smile.
Buddha smile: It is practised in an upright sitting position. Eyes are closed and the muscles not necessary for maintaining the posture are relaxed. We pull the corners of the mouth slightly sideways and upwards and at the same time draw the auricle (external ear) to the head. The psychological effect of the practice should be peaceful joy, but some patients just laugh at this idea.
Inner smile: It is again practised in an upright sitting position. The muscles which are not necessary for maintaining the posture are relaxed, and the eyes are open. We imagine that the retina glows with gold light and this light is sent out from the eyes. A more difficult variation is to practise with the eyes closed and to send the gold light to various parts of the body.
Smile with colour: We imagine that the inner space of the body is filled with clear fluid. Then we put into this fluid a drop of a joyful colour such as orange. The colour moves, expands and fills the whole body.