According to the International Classification of Diseases (see appendix) it is possible to diagnose substance dependence only with regard to certain types of substances. To fulfil the diagnostic criteria for substance dependence one has to meet at least three of six symptoms:
Besides substance dependence, there are various forms of addictive diseases such as pathological gambling, workaholism and compulsive shopping. These addictive diseases obviously cannot be diagnosed as substance dependence, but their symptoms are very similar (craving, impaired control, etc.). The treatment approaches to these addictive diseases are in many respects the same as in the treatment of substance dependence. Some yogic and meditation practices are useful both as prevention and treatment (e.g. Lohman, 1999, Lavasa, 1992), usually as part of broader treatment strategy.
What kind of addictive tendencies have you noticed in yourself and what kind of consequences has it had?
We have dealt with craving in more detail elsewhere (Nespor and Csemy, 1999). Strategies which our patients considered useful to cope with craving are as follows:
It is clear that some of these approaches are similar to some yogic and other traditional techniques. For example, passive observance of thoughts is part of the practice of antar mouna but is present even during simple yogic relaxation (shavasana). It is interesting to mention here the five ways of overcoming negative thoughts according to the Buddhist tradition:
Overcoming negative thoughts: Compare the effects of the above-mentioned methods. Generally speaking, the second method (to realize adverse effects) is very effective for overcoming an acute crisis, but the least pleasant. The most inspiring and pleasant may be, on the other hand, the first method (opposite thoughts, or pratipaksha bhavana in yoga). The fourth method can enhance self-understanding, but sometimes it may open up unresolved traumatic experiences.
Seetkari and sheetali pranayama: According to the Hatha Yoga Pradipika, these practices can help to overcome hunger, thirst, sleep and laziness. Sheetali may even 'counteract poisons'. It is not certain whether these practices can help overcome cravings as well, but it is worth trying, especially in alcohol dependence, where craving for alcohol and thirst are often related. Seetkari can also be practised inconspicuously with the mouth only gently open during normal daily activities.
Impaired self-control and craving are not identical. One can experience intense craving and still maintain self-control; on the other hand, people who are not sufficiently aware of their feelings may not recognize craving and behave in an uncontrolled addictive manner.
One factor which contributes to impaired self-control is learned helplessness. An addicted person may have tried to overcome his/her problem, but because it had no positive effect he/she gave up. That is why it is important for him/her to experience just the opposite: that his/her effort can make a difference and that he/she can influence his/her mental and physical state and his/her life. Yogic relaxation, sankalpa and many other practices can be useful in this respect. On the other hand, the passivity of many addicted patients should be accepted in the beginning. Their treatment program should have a clear structure. When using yoga, the therapist should assume an active role (e.g. he/she should guide the patients during relaxation training).
Decreased control may be enhanced further by the futile effort of many addicted persons to try and change things which cannot be changed. Maybe because of this, the Serenity Prayer is often used in Alcoholics Anonymous meetings: "God give me serenity to accept the things I cannot change, courage to change the things I can and wisdom to know the difference."
There are many ways to improve self-control in yoga:
Self-awareness: To make this topic more attractive, we may ask the patients what Buddhist realm of existence they are experiencing now. These realms include the craving hungry ghosts' realm, the hell, the instinctive animals' realm, the humans' realm with the best potential for growth, the realm of jealous and fighting demigods, and the heavenly realm.
Physical self-control: The relationship between slowing down and self-awareness and self-control can be demonstrated by physical movement. For example, it is possible to compare the experience of assuming shashankasana from marjari-asana during one exhalation and during five breath cycles.
Counteracting negative emotions: Both physical exercise and relaxation improve depression, anxiety and anger. Similar effects also come from certain yogic postures (such as shashankasana) and breathing practices.
Antar mouna: First three stages.
Increased self-confidence and self-esteem: It is better for people with low self-esteem and the tendency to harm themselves to meditate on their eternal inner Self, their Buddha nature or on a kind loving God instead of meditating on the universality of suffering and death in some lonely graveyard. Mantras such as So-Ham (I am That) and suitable stories can be used.
Acceptance of things which cannot be changed: Beside the above mentioned Serenity Prayer, Upekkha Bhavana (see appendix) can be used.
Surrender: The Twelve steps of Alcoholics Anonymous and similar organizations for drug addicts and pathological gamblers deal with powerlessness and surrender:
Admitting the powerlessness and surrender paradoxically enhances self-control and coping with addictive problems.
In yoga, surrender is most often emphasized in bhakti yoga, but Swami Satyananda mentions it as one of the ways to arouse kundalini. Surrender is accepted even by jnana yogis such as Ramana Maharishi.
Let us surrender for a while to our Inner Self or God as we understand Him. You may or may not use your mantra at the same time. Maybe you will find that the surrender with which Alcoholics Anonymous begins is rather a challenging topic, even for people who have practised yoga for many years.
Serious withdrawal syndromes require medical aid, but some simple yogic practices can also be useful. Practices should be rather simple, pleasant and relaxing.
Yogic relaxation (shavasana) and pawanmuktasana part I. Yoga can be combined with psychotherapy. For example, when working with substance dependent patients, first we discussed the various substance-related problems which they experienced. After this, we practised shavasana. During relaxation I asked the patients to see themselves as healthy and free of their substance dependence. Afterwards they should ask their subconscious mind what should be done to achieve this state.
This means that in order to achieve effects originally produced by lower doses, increased doses of the substance are required. A sharp increase in tolerance is typical of heroin dependence - the heroin dependent person often uses doses of the drug which would be lethal for somebody with normal tolerance. This is why after detoxification patients should be informed that their tolerance will have decreased and that they should avoid high doses of the drug.
Naikan: Naikan was developed by the Japanese monk Yoshimoto Ishin and it is practised in many countries all over the world. The three basic questions of a Naikan practitioner are:
In this way, on a given day a practitioner may reflect on a relationship with a certain person, a certain period of life or a certain life event.
It is quite common that substance dependent persons are increasingly demanding and increasingly less grateful to their parents, relatives and good friends. Alcoholics Anonymous mentions self-pity and perceived injustice as a sweet poison which is too dangerous for them. On the other hand, the self-confidence of substance dependent persons is low and it may not be the best idea to increase their feelings of inferiority. Therefore, I have modified the above mentioned technique in the following manner.
Thankfulness meditation: Reflect for a while on how other people have benefited you, what they have taught you and how they have helped you. Of course, they have also harmed you sometimes, you need not deny it, but do not think about it and pass by it broadmindedly. You can practise this meditation on a person, life period or some event.
When treating substance dependence, we usually recommend a return to previous healthy hobbies and interests and/or to find new ones. Yoga can definitely be one such safe and helpful interest.
Your favourite exercise: Which yogic exercises do you like most? If it is appropriate, you can practise them right now.
(Part 2 of this article appeared in the November issue.)
*1 Dr Karel Nespor is a psychiatrist with the Dept of Addictions, Prague Psychiatric Hospital, Czech Republic. This paper was presented in Prague in March, 2001.