Editor's note: This article highlights a yoga therapy approach for working with people with psychotic vulnerability and reflects the experience of a yoga therapist who is also a medical professional. It is not intended to serve as a "how to" article for yoga teachers. If you are interested in attending a training with Anneke or learning more about her approach, please visit the Network Yoga Therapy Academy website.
It’s Monday morning. I place two mats and two pillows on the ground as Chris walks into the room, mumbling. He seems a bit absent.
Chris is a 27-year-old man who has been diagnosed with schizophrenia. Chris likes basketball and music. He was a rapper before his diagnosis. When he was 17 years old, he experienced his first psychotic episode after a stressful time in his life. His mother (who Chris had lived with) died of cancer when he was 16. At 17, he dropped out of college and started to experiment with marijuana. It's always difficult to say what caused what exactly. Life experiences, the use of drugs, and a possible vulnerability to psychosis that the drugs may provoke may be triggers for his psychotic episodes. He now takes daily antipsychotic medication, which makes him feel tired and has caused him to gain weight, which frustrates him.
I see Chris weekly as part of my work as a registered nurse and yoga therapist in a mental healthcare institute. When I began working with Chris, he didn’t really believe yoga was going to help him, but he wanted to give it a try anyway.
Schizophrenia and Psychosis
Schizophrenia is one of a number of schizo diagnoses. Its symptoms can affect quality of life quite a lot, as can the social stigma attached to the condition.
Symptoms of schizophrenia typically emerge in adolescence and early adulthood. There are both, what we call “negative” and “positive” symptoms. Negative symptoms refer to those that consist of a decrease or absence of function, including flat expressions or little emotion, poverty of speech, inability to experience pleasure, lack of desire to form relationships, and lack of motivation. Positive symptoms are those that consist of increased or distorted function, including symptoms associated with psychosis such as hallucinations.
The term “positive symptoms” can be confusing because the word "positive" gives the impression that it concerns symptoms that are pleasant. This is not the case. In case of a psychosis you can suffer from positive symptoms. The word "positive" refers to the fact that these symptoms are phenomena that, in addition to normal functioning, have been added extra. These are experiences that were not there at first, but were added to it.
Psychosis is one of the main symptoms of schizophrenia. Typically, in psychoses, people experience delusions (for example, extreme suspicion) and hallucinations (for example, perceiving voices beyond control or seeing things that others don’t observe). However, a psychosis is a syndrome consisting of different types of symptoms, and the mix of symptoms looks different in everyone. For example, one person may experience, in particular, feelings of distrust while another hears (perhaps violent) voices. Another may experience mood swings that sometimes cause depression and at other times cause a manic state. Still others experience a lack of motivation to perform daily tasks, a lack of attention and concentration, and others cognitive problems.
Consider this scenario: To be able to learn how to react in a flexible way to the world around us, we must constantly give meaning to what we experience. For example, we may wonder, Are the other passengers on the bus laughing at me? In order to learn how to respond skillfully to such questions, it's sometimes very healthy to be a little suspicious.
But extreme suspicion (delusions) make proper functioning difficult. Then, for example, we think, Everyone in the bus or on the street is looking at me, laughing at me. We speak of a “full” psychosis when psychotic experiences control a person’s life so much that they do not function well on a daily basis.
In modern mental healthcare, we start to look at these experiences on a spectrum. Every human being can have some experiences to one degree or another: Perhaps hearing voices on one end of the spectrum to possibly being bugged by a very strong inner critic on the other end. Some people have intense spiritual experiences, for example, that can lead to a particular state of consciousness and growth. In other cases, psychosis might be a way to deal with traumatic events for a person who is trying to cope and survive. These experiences should, of course, be taken seriously, and a person should receive optimal care, (professional) guidance, and support as needed.
Treatment for schizophrenia seeks to give a person back their ability to function. Although current treatments provide control of, rather than a cure for, schizophrenia, long-term hospitalization is generally not required, and one’s prognosis is much better than traditionally assumed. The general treatment for schizophrenia is medication, which often must be taken for a very long time.
Unfortunately, the medication often comes with numerous side effects and it’s hard to find the optimal balance of meds. Common side effects include stiffness and shakiness in the body, restlessness, weight gain, and movements of the jaw, lips, and tongue. Fatigue and constipation are common too.
The healing process is different for every individual, but full recovery from psychosis and schizophrenia is possible.
Where Yoga Comes In
As a supplement to standard treatment, yoga can give a person living with schizophrenia tools to cope with the symptoms of psychotic vulnerability and the side effects that they may experience from treatment. The tools that yoga provides, applied in daily life, may assist a person in connecting to their body and finding their own inner resources (for example, through breathing) that help them to be more confident and trust their inner wisdom in the often challenging journey toward recovery. To this end, yoga may be a great addition to current treatments.
It’s important to highlight the need to identify, assess, and address trauma in this population, which for too long has been overlooked and undertreated. It is therefore especially important that the yoga that is offered to people living with schizophrenia be trauma-sensitive.
Compassion-Based Yoga Approach
In my yoga therapy work with people with psychotic vulnerability, I use a method of my own design—Compassion-Based Hatha Yoga. In this approach, I prioritize two elements: providing a sense of safety, and normalizing a person’s psychotic vulnerability in spite of social stigma. For each person I work with, I seek to balance these two priorities as I customize a yoga practice that is appropriate for that individual.
In this approach, I prioritize two elements: providing a sense of safety, and normalizing a person’s psychotic vulnerability in spite of social stigma.
Creating a sense of safety means ensuring that a person feels safe both internally (in the body) and externally (outside of the body—in the room, for example). That sense of safeness allows me to work with my students on being aware of and connecting to their bodies—and to all their experiences—as a first step in making positive changes such as cultivating compassion, patience, and acceptance toward oneself. Yoga practice offers a lot of opportunity to practice self-compassion of this kind. Then, when awareness becomes a little easier and trust is gained, we might move on to observing the body and all experiences, thoughts, and behavior while we practice, if this feels safe enough. I constantly evaluate a person’s sense of safety and go back to a “safer” place, if needed.
Normalizing the disorder means contextualizing the physical symptoms on a broad spectrum (as discussed above) and acknowledging them as coping mechanisms so as to destigmatize mental health conditions.
In addition to realizing these two priorities, I also try to ensure that every yoga session I teach for this community is trauma-sensitive since, as noted, trauma is so often an underlying cause of psychosis. The teacher’s choice of words (for example, not using words such as “patient” and “psychosis”) is very important for making a class trauma-sensitive and also for destigmatizing the condition.
Not only do I use the Compassion-Based Hatha Yoga approach in my own one-on-one and group sessions, I also train other healthcare providers in it and speak about it at conferences all over the globe.
Through our sessions, Chris has been able to observe himself and his experiences (symptoms) to increase his awareness of them. He has learned to use the tools of yoga (asana, mantra, breathwork, and gentle meditation) to foster that awareness.
He has also learned how to cultivate more compassion toward himself and his experiences. In our sessions, we don’t try to deny his symptoms or experiences; rather, we are learning how to understand the messages behind them.
Yoga also helps Chris to manage his experiences. It seems that accepting and managing the experiences, instead of trying to push them away, decreases the intensity of them: He feels a bit lighter after a session, as if his experiences have “dissolved” a little bit. The voices become less loud and hostile. Using what he learns in class in his life, and seeing the positive results of his efforts, has been very empowering. He’s been motivated to change his eating habits, which has resulted in losing some weight, which was something he really wanted to do, and it has made him feel more confident.
The practices have strengthened his cognitive functions as well. As I supported Chris in gradually beginning to practice small exercises from the session even outside of class, his growing awareness and the techniques he’d learned helped him to make small changes in the patterns of his daily life, creating new, healthier samskaras (habit patterns) that include hope, optimism, and self-acceptance. He has learned to focus and concentrate better and how to manage his stress levels on his own.
This particular use of yoga (i.e., in the complementary treatment of schizophrenia) still remains in its very early phase, but the case reports and research results are promising.
I teach yoga for psychosis with an attitude of great optimism and hope, as optimism and hope are the most important predictors for a good recovery from schizophrenia. There hasn’t been very much research done on the therapeutic effects of yoga in the complementary treatment of conditions like schizophrenia, but that is changing. In the last few years, researchers have increasingly recognized yoga’s ability to support people with conditions like this one. This particular use of yoga (i.e., in the complementary treatment of schizophrenia) still remains in its very early phase, but the case reports and research results are promising.
My personal evidence is seeing Chris motivated to join almost every class and progressing noticeably every time. That is the reward of working as a yoga therapist in mental healthcare. I am wholeheartedly committed to continuing to do this work and to teaching more and more teachers and therapists in both yoga and healthcare communities about Compassion-Based Hatha Yoga, which is useful for everyone, but especially for this population who stands to benefit so much from it.
When working with this population, I strongly advise those that I train and educate to keep an open mind, listen well, do not make any assumptions, and optimize your attitude of hope and optimism. If a client feels seen by you, this might have a bigger positive effect than you can imagine.
Visceglia, E., & Lewis, S. (2011). Yoga therapy as an adjunctive treatment for schizophrenia: A randomized, controlled pilot study. Journal of Alternative and Complementary Medicine, 601-607.
David P. G. van den Berg, Paul A. J. M. de Bont, Berber M. van der Vleugel, Carlijn de Roos, Ad de Jongh, Agnes van Minnen, Mark van der Gaag (2016). Trauma-Focused Treatment in PTSD Patients With Psychosis: Symptom Exacerbation, Adverse Events, and Revictimization. Schizophrenia Bulletin, 693–702.