Yoga: One physician's experienceHARVEY ARMSTRONG FRCP[C]

Yoga is becoming more and morepopular with Canadians, and it be-hoves our profession to know some-thing more about it. Its critics saythat yoga is a very destructive, evendangerous diabolic cult that threat-ens the moral fabric of our society.Its supporters praise its positive ef-fects on people with tension, anxiety,depression, and psychosomatic ill-ness. In this climate of confusion,and as a physical education graduate,physician and practising psychiatrist,I would like to report on my own3-month stay at a yoga ashram orretreat, where I took a yoga teacher'scourse from January to March 1977.

Despite a healthy scepticism en-gendered by my scientific training, Ienrolled in the course because mywife was planning to attend, andfrankly, regardless of my fears andfantasies, the ashram with my familyseemed better than a winter alone inToronto. Besides I had observedmany psychologic and physicalbenefits to my wife during her 7years of increasing interest in teach-ing and practising yoga, and thereseemed to be no harmful effects. Imust emphasize that my experienceis limited, that this article does notexpress all my experiences as manyof them are difficult to put intowords, and that my experience islimited to one particular ashram ata specific period of its development.

I will leave it to your imaginationto conjure up the anxiety that I feltonce I had committed myself to the

Reprint requests to Dr. H. Armstrong,Clarke Institute Family Court Clinic,950 Yonge Street, 8th floor, Toronto,Ontario M4W 2J4

idea of spending 3 months at a yogaashram. What would my erstwhileteachers of basic science in medicalschool think of such a venture? Theirattacks on quackery and irrationalitystill echoed in my mind as did mypsychiatric colleagues' adherence toscience and its tenets. Maybe I toowould be labelled as a weirdo whohad lost his emotional balance andhad plunged unthinkingly into a cult.My fantasies of dark, skinny peoplein loincloths standing on one leg orspending lifetimes contemplatingmysteries that could not be solvedall multiplied as I approached theendeavour. I nearly abandoned theventure, but persisted because it wasthe only feasible way to understandwhat my wife was involved in. All Ihad were prejudices and ignoranceto go on. My wife's enthusiasm wasmatched by my reluctance. Tempersrepeatedly flared! Finally to ease thetension, we decided to stop discussingthe trip, and we made our prepara-tions incommunicado.

Fear of fanatics

Visions of a sparse vegetarian dietgnawed at my gut. Would our quart-ers be heated? Would I have to ad-just to cold and other unpleasantconditions? Who were these otherpeople who were to be part of oursmall group? Would this small groupof fanatics (as I already picturedthem) pressure me to give up myrational view of the world? At othertimes I was reassured by my wife,who is usually sensible, and by thefact that I'd already met several ofthe other people who appeared to

me to be quite attractive. At a meet-ing with some of them I receivedmore welcome reassurances. Whatgreeted me on arrival was a verypleasant surprise.The ashram is idyllically situated

in a rugged mountainous region ofCanada on the shores of a very largeand picturesque lake. There were 24of us on the course, and the othersappeared to be solid citizens of onetype or another. Most of the peoplecame from different parts of Canada.There were professional men andtheir wives, a chairman of the boardof a large Canadian corporation,students, housewives - people fromall walks of life. There was only onepersor. who, with effort, could beclassified as a hippie. Soon we wereformed into two groups of 12, andwe remained that way for the 3months except for some joint lec-tures.Our accommodation was a mod-

ern guest lodge equipped with allamenities. The food looked, smelledand tasted the way I like it, and itwas prepared and served with a careand skill that few first-class hotelscould match.The staff turned out to be dressed

just like- people; they were friend-ly, considerate, supportive individu-als of great maturity. For a whilethey seemed to be addressing myfears and fantasies as they madesome jokes about the nature of theashram and the course, but soon Idiscovered that my anxiety wasshared by many of my fellow stu-dents. Some of them were simplyfeeling threatened by a strange en-vironment and people on which they

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were dependent. Others had magicalexpectations of the course which alsoproduced tension.The course itself proved to be

rigorous. We rose just after 6 am andbegan Hatha Yoga exercise classesat 7 am. This class lasted for 2 hours.We breakfasted in a common dining-hall where we socialized briefly andthen proceeded to classes that oftencarried on into the late evening,broken only for meals and stretch-ing. Besides the exercise class, wehad courses on the history, devel-opment, and philosophy of yoga, andthere were endless group sessions.Through all of the activities, whichI describe below, free discussion wasencouraged, in which we were askedto be personal rather than to intel-lectualize. Though there was somegroup pressure from other studentsto conform to what they at first as-sumed were the "correct" views, thegroup leaders encouraged us to chal-lenge this pressure and questionthese assumptions.

The philosophy of yoga

Yoga means "union,. in Sanskrit.Our word "yoke" derives from theoriginal term. A yoke typically bringstogether the efforts of two beasts ofburden so that their energies can beharnessed to do useful work. In mostof us there is a diffusion of energyin many directions, much like theunharnessed and undirected draughtanimals. We strive for incompatiblegoals. The conscious and unconsciousare often in conflict. Self-acceptanceis hindered by lack of self-knowl-edge, taboos, and socialization. Mar-ketplace values struggle with moralcodes and emotional needs. Socialpressures and expectations distortour ability to perceive and fulfilour personal needs. Ideologies clashwithin ourselves, and each of usbecomes unsure of what is mostworthwhile in our lives.The goal of yoga is to integrate

and synthesize life through its philo-sophy and techniques. All of theactivities labelled as "yoga.. seemedto be directed at developing self-awareness, accurate self-evaluation,an improved sense of reality, clearercognition, improved emotional con-trol, heightened intuition, better so-cial relationships, clearer shaping ofimmediate and longterm goals, andthe development of a sense that exist-

ence is a mystery and all understand-ing of existence is theory which hasutility, but not ultimate validity.

These are also the aims of manysystems of psychotherapy, but inaddition we had the physical activityof Hatha Yoga which was stated tohave a direct effect on our emotional,intellectual, and spiritual function-ing. The body, mind and spirit werepresented as a whole, which couldbe separated only in thinking andcommunication: we cannot influenceany one part of the whole withoutaffecting the others.Yoga is Vedantic in origin. It is

mystical and religious. The centralbelief of the yoga philosophy is thatthe cosmos, the world, and the in-dividual are outward manifestationsof a formless God, an underlying or-ganizing factor, energy or force thatcreates, directs and harmonizes allmatter and energy. Yogis believe thatit is possible to be aware of and torelate directly to that force as itexists within each of us by stillingthe interference created by our pet-tiness, our activity, our emotionalityand our intellectual pretensions. Ifwe develop awareness of this force,life becomes integrated, more satis-fying and less exhausting. Contactwith this force brings increasingawareness of the self, other people,and all things that we come in con-tact with. Conflicts within ourselvesdiminish; uncomfortable emotionalblocks to learning and developmentare overcome; and life becomes moreproductive and more pleasurable.Those humans who have developedthe capacity to relate to that forceoften become remarkable individualswho affect the lives of others in verypositive ways. Saints and teachersof religions are presented as thosewho have rediscovered these ele-mental truths and have shared theirtechniques for developing awarenessof God.

The origins of yoga are lost intime, and began before the writtenword, and before life and knowledgebecame encapsulated into definedareas. Science and its methods andcomplexities did not exist then, andthe language of yoga originates intheistic concepts of reality, ratherthan rational ones.

Perhaps because of the high es-teem in which humanity has heldscience, or their confusion betweenprecision of ritual and precision of

measurement, many yoga enthusiastsclaim that yoga too is a science.These practitioners substantiate thisclaim by pointing out that there isno need for a novice, or for thatmatter an advanced practitioner, toaccept anything on faith. The be-ginner is asked to suspend finaljudgement until he has personallyexperienced an activity before dis-carding it as useless. Of course thisview of the validity of self-evaluationof outcome of a personal experiencedoes not take into account the effectsof suggestion, group pressure, place-bo or avoidance of cognitive disson-ance as factors that may influenceevaluation of a subjective ex-periment. Yoga technique, havingevolved empirically over literallythousands of years through trial anderror, is in my opinion an art ratherthan a science, but even as an artit has helped many people withmany aspects of their lives.

The techniques of yoga

I will only say a little about someof the techniques that I have ob-served or participated in, which Iwill try to interpret in languagepalatable to my colleagues. Thereare many techniques that I knownothing about.* Hatha Yoga involved a com-

plex series of individual exerciseswhich we did on a blanket on acarpeted floor. The exercises at firstseemed very contorted: we assumedmany unusual body positions whichwe held for varying periods. Thesepostures or asanas stretched myjoints and muscles while the anta-gonist muscles were much contracted.The exercises made my body moreflexible. From being barely able totouch my knees, I was soon touchingmy toes with ease. I worked musclesthat I normally never used with mytennis, squash and jogging. My localmuscular endurance increased asdemonstrated by my increased abilityto hold a position, but my cardio-pulmonary condition deteriorated,and soon I supplemented the yogawith running. I often found myselflooking at parts of my body froma new perspective, and my body-awareness increased. After the exer-cises, the teacher had all of us lieon the floor while she instructed usto relax each part of our bodies ina standard, ritualized way. This state

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of relaxation brought with it an endto all physical and emotional tension.I am sure that the mental stateis like that which behaviourallyoriented psychiatrists attempt to at-tain in their patients with whom theyare doing systematic desensitization.In this body-mind state, I found thatnothing bothered me, and that mymind wandered over a variety oftopics that normally provoke anxietywithout so much as a quiver of un-easiness. Solutions to personal prob-lems seemed to arise quickly afterI had clearly conceptualized them -something I had been unable to dobefore.

Rapid improvement

I was surprised to find that in ourHatha Yoga class there were alllevels of conditioning and experi-ence. Even the most out-of-shapeparticipants seemed to improve ra-pidly from their very low level.There was very little competition,and it was discouraged. I kept dis-covering that rather than striving tobe as good as or better than thenext person I began to accept myown body and its limitations. Ithought that the inflexibility that Ihad arrived with at first began toimprove in both my body and mypsyche at the same time.Some of my classmates told me

that they meditate during HathaYoga and during the subsequent re-laxation. I am not sure if the stateI described above was related tomeditation, but it really felt good.

During the classes I heard manyunfounded claims for the value ofyoga in health and happiness. Theyirritated me as did the commands torelax my pancreas, spleen and liver.At first I protested loudly about theinaccuracy of such statements, andthe teacher stopped making them.She gave me some articles thatseemed to demonstrate that someyogis have had a remarkable degreeof control of their autonomic systemlong before the days of biofeedbackmachines and techniques. I no longerprotest so loudly about the strangestatements that I occasionally hear.0 Karma Yoga is work and serv-

ice. It is founded on the belief thatall of life, but especially work, con-tains opportunities to learn aboutoneself and to reverse previous mis-takes; that life is full of chances to

either learn or make the same mis-takes. The belief is like the psycho-analytic concept of repetition-com-pulsion. All of us repeat early liferelationships with the intent of "hav-ing them turn out right this time".I was told that if in a work-relatedactivity I constantly focused on thepersonal gains that I might get fromthe work, I would have little energyleft to watch myself at work and tolearn about myself from the work.I found that when my only goal inwork was to enjoy the process andto learn, then the work went easilyand was full of pleasure for me.* Bhakti Yoga is overtly religious:

it is an emotional, devotional andworshipful approach to self-develop-ment. It involves incense, rituals, andprayer and identification with reifiedimages of the formless Vedantic God.One aspect of this is Mantra Yoga.This involves the repetition of shortprayers in any language, but usuallySanskrit, over a long period - up toseveral hours.

I can reassure you that to thisparticular scientifically trained maneven the thought of this practice wasvery distasteful. Having lost severalconfrontations between my view ofreality and theirs, I had planned toevade this part of the program andnot to make an issue of it. My teach-ers would not let me avoid it. Theyasked me how I could ever commentknowledgeably without having hadany first-hand experience. I was re-minded that millions of North Amer-icans are using transcendental medi-tation, and that none had come toharm because of it. I capitulated andlearned about mantras and chantedmany of them.

I chanted mantras in a groupgathered for a religious service. Ichanted them when going for a walkalone. I chanted them out loud andunder my breath. I have whisperedthem. I have been told that they aregood for my spiritual growth, buteven if I don't have a spirit, they dohave some effects that made me feelgood right away.

Chanting a mantra produced acalm state of concentration. This re-laxed mental and vocal focusing wasfor me incompatible with my usualneurotic ruminations about the pastor worry about what the future wouldbring for me. Chanting the mantrasseemed to exclude future- or past-orientated worries and allowed me to

be very "here and now" oriented.This state of mind produced an acutestate of perceptual and emotionalsensitivity. Things that I had nevernoticed before became etched on mymind in a very crisp and beautifulway. On several occasions whenchanting in the period after I hadlearned that my dog had died, I foundtears spilling out of me in a way thathad not happened since I had beena young child. Somehow or other,chanting a mantra lowers anxietyand defences to the point where newperceptions, feelings and conceptionscan grow.

Intellectual approach

* Jnana Yoga was presented tome as the intellectual approach towhat I am, God, growth and prob-lem solving. It seemed to involve ananalytical approach to understandingand integrating the events of everyday into a pattern of continuouslearning. Part of this pattern mightbe to keep a diary with each day'spersonal goal and achievements out-lined together with their personalmeaning. Another might to be toanalyse each day to see which eventscould have been altered by mypersonal approach. Dialogue with ateacher might well be a part of thisapproach.* Kundalini Yoga: there is much

that I do not know about KundaliniYoga. I do know that one of its as-pects is that it is a structured theoryof human development in which thereare at least seven stages. As the out-line proceeds from primitive to ad-vanced, there is an increasing numberof developmental lines. The energyfor the development seems to comefrom aggressive and sexual drives,which become more socialized andaltrustic in their aims and activitiesas one moves along this developmen-tal scheme.

Kundalini energy was referred tofrequently. This was supposed to bean energy that arises from near thebase of the spine, travels up the spinealong metaphysical channels, andemerges from the top of the head.Many yoga techniques are supposedto awaken this energy and its awaken-ing is said to be accompanied by thedevelopment o.f supernatural powersincluding extrasensory perception, in-creased ability to think intuitively,ability to predict future events and

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even more far-fetched claims thanthese. I feel a little embarrassed abouteven referring to these claims, andof course, I can neither endorse themnor for that matter refute them as Ihave no basis to do either, other thanmy scientific training. But I feel thatI should mention these claims in casethey are mistaken for delusionalthought in a yoga devotee rather thanpart of the shared religious belief thatthey actually are.* Rajah Yoga was presented as

a series of techniques that integratedthe others by focusing on the per-sonality and character of the studentand developing self-knowledge andinsight. Under this heading we studiedand interpreted our dreams, partici-pated in sensory awareness training,examined our own psychodynamicsand those of our group members,watched ourselves on videotape re-cordings and examined our thinking,our identity, our sources of anxietyand the qualities of relationship toothers members of our group.

Dream interpretation

* Dream interpretation has longbeen part of psychotherapeutic prac-tice within psychiatry and outside ofit. Yoga predictibly did not miss outon this aspect of growth enhance-ment. Dreams are received as mes-sages from parts of the psyche thatare normally shut out of awareness.

I was retaught that dreams can beused to develop insight and to solveproblems. I learned how to wake my-self up by making suggestions to my-self in a drowsy state that I shouldawaken after each dream. I foundthat I was sitting up in the darkwriting out my dreams by flashlight,and I even found myself asking ques-tions to be answered in my dreams.We were taught to interpret ourdreams by free-associating to everyobject, event or person in the dream.Then we interpreted these associa-tions as projected aspects of ourselveseven if the objects were other peoplein real life. The meaning was thenmodified until it had a sense of fitnessfor the current life of the dreamer.During this time I observed recurrentthemes that seemed to appear in myown dreams and in the dreams ofother members of my group. Thoughmystical interpretation was preferredby one group member, this was dis-couraged by our teachers in favour

of the more psychologic methodoutlined above. Dream interpretationwas extended to us as a safe and easyway of developing insight without de-pendence on others.

* Sensory training: I participatedin examining and training my senseperceptions and those of other groupmembers. This demonstrated to methat each member of my group hada different ability to perceive theworld through his senses, and thatthe world is different for each of us.Even when examining a simple sourceof stimulus through one sense organthis proved to be universally true.These senses were presented as win-dows through which each of us canreceive and organize aspects of theworld. Our teachers stressed thatthere are many gaps in the humansensory apparatus, but that these gapscan be narrowed through the practiceof sensory awareness. The teacherspromoted the belief that there aremany subliminal stimuli that do notusually reach my awareness, but thatthese do reach my sense organs, andthat I can increase my sensitivity tothese.* Psychologic insight: we were

given many opportunities to examineand understand some of the psycholo-gic forces affecting our own livesand those of our fellow group mem-bers. Dream interpretation was oneway. Projective techniques were usedin two other ways. In one, each of usdrew, coloured, and pasted up on alarge sheer 26 smaller pictures, ac-cording to simple standard instruc-tions. The themes, structure, contentand arrangement of the drawingswere scrutinized by the creator underthe guidance of the group leader.From this a clear picture of the in-dividual's strengths, weaknesses, earlylife conflicts, family dynamics andcurrent problems emerged.A third technique used to help us

develop insight using a projectivetechnique involved walking slowly upand down a limited space and thenrecording from memory all thethoughts, feelings and behaviour gen-erated by this activity. I reviewedthis record in the group setting, andwas then asked to generalize parts ofthe experience to other aspects of mylife. I was surprised how effectivethis was. I was also pleased to seethat the individual, not the leader,made interpretations, and the leader'srole was to ask for more information

and clarification, assisted by a sup-portive group.* Videotape recording and play-

back: I was surprised and pleased tosee such a modern technique used insuch an archaic context. I was video-taped three times, once alone doingHatha Yoga exercises, once whilediscussing a mildly stressful topic withanother person and once while amember of a small group discussingcontroversial questions. Each time werecorded the experience in writing,discussed our recall of the experiencewith group members and then re-viewed the tape. The contrast betweenthe tape and the private memory ofeach individual was often immense.The degree of distortion that each ofus applied to the events was shock-ing and very clearly opened up thepossibility that other memories andcurrent perceptions might also besubject to the same degree of dis-tortion.

Group leaders and pressures

To reduce the potential for distor-tion by memory, each of us wasrequired to put down our currentthoughts in black and white, handingin a copy to the group leaders. Wewere encouraged to review this writ-ten record with a view to studyingand understanding ourselves. Wherethere seemed to be overemphasis onone aspect of life, or on one way ofthinking, balance was encouraged.

In the teachers, I witnessed mini-mal anxiety or competitiveness withother belief systems or methods offostering psychologic growth. Infact, there was enthusiastic encour-agement of other religious philosoph-ies, and other systems of personaldevelopment, as they were all seenas having the same end, providedthat they encouraged insight, prob-lem solving, and independence. Theywere less positive about systems inwhich great dependency developed.The staff also helped us to uncover

and confront the factors that gaveeach of us an identity. The value ofthese identifications was challenged,and we were pressed to develop anidentity with a religious basis. Onmany occasions I felt the discomfort-ing pressure of a group of peopleagainst whose belief system I wasprejudiced and whose theory of hu-

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prevents the provision of suitabletreatment, it is important that thephysician or hospital have concreteevidence of this inability to act inaccordance with sound medical prac-tice.

However, where a patient refusestreatment and there is some indica-tion that he may not be competentto make an informed judgement, adetermination of his capacity in thisregard should be made. If the at-tending physician's judgement, sup-ported by a consulting opinion, is thatthe patient is competent, then heshould be asked to execute a releaseform. This form should reflect thepatient's understanding of the conse-quences that may result and releasethe physician and hospital from re-sponsibility. If the patient refuses tosign this form, a notation should beplaced in his chart with statementsfrom witnesses confirming his refusalto accept treatment. (The optionsavailable where a determination ofincompetency is made were discussedin an earlier article, dealing withconsent and competency. [CMAJ117: 1215, 1977])No physician is obligated to com-

ply with treatment conditions laiddown by a patient when this wouldbe sufficiently contrary to sound med-ical practice to jeopardize the pa-tient's health. Where practical, thispatient should be released from hos-pital. If your private patient refusesto follow your advice, you may de-cide to terminate your relationshipwith him. In this instance, the patientshould be given the names of other

available physicians and should re-ceive all possible assistance in ob-taining the services of another doc-tor. There is a legal obligation tocontinue treating the patient untilcare has been undertaken by anotherphysician competent to provide it.A physician should be extremelycautious in terminating the doctor-patient relationship, especially whena patient is under treatment of aserious nature, as is usual in hospital.A conflict develops where a psy-

chiatric patient is involuntarily de-tained and refuses to accept treat-ment. In law, an individual's statusas an involuntary psychiatric patientdoes not create a presumption thathe is incompetent to consent to treat-ment. Physicians operating undersuch conditions are in the dilemmaraised through detaining this individ-ual in hospital but being unable tocomply with the standard of reason-able practice to administer the ampropriate treatment. This situationdoes not arise in those provincesthat have legislation granting phy-sicians and hospitals authority totreat involuntary psychiatric patientswith or without consent. In prov-inces lacking this provision, wherethe competency of the individual hasbeen affirmed and the required treat-ment is refused, physicians who pro-ceed are in legal jeopardy. The safestlegal advice would be not to treat inthese circumstances. Although thepatient's release from hospital is notan option here, appropriate releaseforms should be used in any eventto provide evidence of his refusal.

Despite all this, physicians andothers should not attempt to developmultipaged consent forms for everymedical procedure. American courtshave failed to support such forms,because no reasonable patient couldbe expected to assimilate them. Itshould be possible to devise formsfor commonly performed procedureswhich clearly and succinctly set outthe necessary information. Theseforms should not exceed two pagesin length.

Sample form

Forms provided by one Ontarioteaching hospital include the follow-ing:

* Consent for special proceduresor treatment other than operations.

* Consent to several commonlyperformed operations.

* Consent to anesthetic.* Consent for sterilization.* Consent to termination of preg-

nancy.* Consent for blood specimens

for research purposes.* Consent for use of organs and

tissues for transplantation.* Refusal to permit blood trans-

fusions.* Authority for post mortem

examination.* Consent for audio and video

recordings.* Consent for release of informa-

tion.* Statement by patient leaving

against medical advice, refusing treat-ment or both.*

YOGA

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inanity seemed foreign. My personalconcepts about most things werechallenged, including my values, myconcepts of reality and my personalboundaries. At times I felt verystrained. There was a lot of grouppressure, but I am glad to say thatit was identified as such and kept incheck by the group leaders. At timessimple fatigue became a mind-numb-ing factor, in dealing with the pres-sure to accept a reality that is notacceptable in my culture. I was out-spoken in my dissent, and received alot of pressure, but none of it from

the staff who displayed only themost mature behaviour and attitudestoward me.

I find it difficult to evaluate theeffects of a 3-month stay at an ash-ram. My wife and I both feel that weknow each other a little better, andthat we are more tolerant, warm andconsiderate to each other. I am alittle more aware of the mystery ofthis world than I have been beforeand certainly gained new insights.I think that I have more respect andacceptance for people and things thatare very different from me.

I believe that a less stable indivi-dual might have suffered more strainthan I did and might even suffer an

episode of psychologic illness, butI am quite sure that the staff wouldhelp that person to disengage and toseek appropriate treatment. Showingvery private information in the groupdid not prove the serious problemI had anticipated.The numbers of Canadians in-

volved in yoga seem to be ever in-creasing, despite what seem to bealien and outlandish trappings andexterior. At first it seemed to be acult with strange rituals and jargon,but with further exposure I began toperceive a religiously based, very an-cient, but very adaptable system forpromoting personal growth, which in-cludes impeccable physical and men-tal health ideals in its philosophy.u

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