Adapting Yoga for Specialized Populations

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For the past decade, Dr. Mala Cunningham has been educating, training and certifying medical personnel (including staff from the Mayo Clinic) and Yoga instructors to work with cardiac patients and other specialized populations. In this article, she shares her insights on the burgeoning field of Yoga therapy and how medical Yoga can be integrated into the western medical model.

Integral Yoga Magazine (IYM): When did you first become interested in the Yoga therapy field?

M. Mala Cunningham (MC): I studied Yoga before my academic or professional career so I had a foundation of what Yoga could offer as far as managing stress, bringing vitality into the system and the totality of what Yoga had to offer. As an undergraduate majoring in psychology, I would always find ways to include the therapeutic benefits of Yoga in the different research projects I was doing or papers I was writing. Then, in graduate school, I focused on integrating the benefits of Yoga into the western health models of behavioral medicine.

IYM: What led to your developing Cardiac Yoga ™?

MC: A colleague in grad school had a heart attack at age 40. At that time, there was nothing out there to help him with the depression or anxiety he was going through. The focus for cardiac rehab was exercise and a little diet education. It didn’t make sense to me. I knew the preventative as well as the rehabilitative aspects of what Yoga had to offer, so early on I was exploring ways to intertwine Yoga and cardiac rehab.

I reviewed our existing Integral Yoga Hatha course and recognized that heart patients (as well as other patients) needed to have a more therapeutic model applied to their Yoga practice. Then, I met with Sri Gurudev and discussed modifying the Integral Yoga class for particular populations, and he said it was okay to  modify it into a medical model. He was always very supportive and encouraged these efforts.

The Cardiac Yoga medical model began in the early 1980s and kept getting more refined. In the late 1980s, I became involved with the University of Virginia and pulled together a complimentary and alternative medical course for their medical school. I was blending and creating a bridge between complimentary medicine and what Yoga had to offer heart patients and others dealing with some kind of medical condition. Then, in the mid-1990s, I  put together a curriculum, training manual, competency test and formatted the therapeutic Yoga program for heart patients.

IYM: Do you think medical Yoga or Yoga therapy fits well with the western medical model?

MC: Almost every hospital that has a heart or cancer center is looking at prevention initiatives. So, I think the whole concept of medical Yoga interfaces very well with preventive models that many medical fields are promoting now. A medical Yoga model contains the concept of stress management, life management and patient accountability for changing one’s lifestyle. That is one of the things that have changed over the last 30 years.

Earlier, patients weren’t working with prevention or accountability in regard to their health. Now the whole focus, in many departments (and, in particular, cancer and heart centers) is on prevention. What’s wonderful about Cardiac Yoga and medical Yoga is that it contains  models for prevention, for rehabilitation and for palliative care. So, it fits very nicely in all the different stages of where a patient is with their disease process.

IYM: Have you seen a change in funding for research in this area?

MC: Over the last decade, there has been a huge increase in research funding for preventive initiatives. All the concepts in Yoga work well with the preventive model and the behavioral health model. What is similar across the models is patient responsibility for changing one’s lifestyle and improving one’s health status.

In behavioral health, they use cognitive revamping, guided imagery and assessment of a patient’s lifestyle—and all these are in the Cardiac Yoga, Yoga therapy and medical Yoga models. These models address the same issues using slightly different semantics and some slightly different interventions, but, basically they use the same concepts of mindfulness, stress management and awareness of changing one’s lifestyle.

IYM: Do you see Yoga therapy becoming mainstream?

MC: I think it already is in the mainstream of medical care. In almost any hospital you will see courses, classes and initiatives dealing with lifestyle changes, stress management and so on. You will see more use of guided imagery and positive affirmations. I produced a CD that incorporates positive affirmations and relaxation strategies for patients to use before and after surgery. A lot of hospitals utilize these concepts for surgery patients. They may not necessarily call this “Yoga therapy,” but a lot of what is being utilized now in hospitals come from the Yoga therapy model. Also, over the past decade, the number of specialized Yoga programs, trainings and certification programs has exploded.

IYM: Are you expanding your certification programs?

MC: I may in the future. Right now I’m formatting a medical Yoga program for sleep enhancement in collaboration with the Keswick Sleep Institute in Charlottesville, Virginia. Sleep disorders have risen about 60 percent over the past 20 years. There are so many populations challenged by sleep problems. In addition to the general population, we’re seeing sleep disorders experienced by those serving in the military dealing with PTSD, police and firefighters and those in high-level executive positions. Yoga helps people enhance sleep and have better sleep hygiene.

I have developed a medical model of sleep enhancement that we are taking right to the patient population. It’s a two-tiered intervention. The first part provides individuals with strategies that help them assess what affects disrupted sleep. The second part provides various interventions for inducing relaxation and enhancing sleep patterns. So, Part One is review and assessment, and Part Two uses a Yoga model as the major part of the intervention process.

There are a lot of studies being done using Yoga as a specific intervention—even if they don’t explicitly state so, they are using aspects of Yoga therapy. In particular, there are several sleep disorder studies underway. Our goal is to offer the concept to various medical spas. Medical spas are a new concept that has come into existence in the last decade. These spas usually target a specific population with medical concerns and then they bring in specialized staff to a retreat-like setting where the clients receive education and treatment during their stays.

IYM: What other applications of Yoga therapy are you using or do you see on the horizon?

MC: There are so many ways that Yoga can be used as an intervention. Yoga is a therapeutic model of health care—that’s the bottom line. It can be applied to any disorder, whether emotional, physical or mental. It can be applied to any disease process. The benefits of Yoga are extensive—they impact us on the physical, mental and emotional aspects. So, the medical benefits are waiting to be used and not just for maintenance of health but also when there is a disease process happening.

I’m using Yoga within the behavioral health model— for mental and emotional disorders as well as physical concerns. I’ve been utilizing Yoga psychology for years. I developed a Yoga psychology model of care for individuals struggling emotionally with particular disorders. I use it with  practically all the patients coming into my practice. Half of my practice is couple’s counseling. I use a mindfulness practice with couples struggling with their relationship and bringing into play different concepts of Yoga such as the yamas and niyamas, a sense of service to each other and themselves.

I really do think mindfulness, awareness consciousness and waking up to the consequences of our thoughts and actions enables us to pause. I love the concept that what Yoga is really all about is putting the pause button on between the stimulus and our response—being mindful before we respond and not allowing ourselves to get triggered and act unconsciously. If I were to collapse Yoga psychology into a basic concept, it would be bringing awareness or mindfulness into daily life, and that’s what I try and work on with my clients.

IYM: You are being invited to do Cardiac Yoga certification at medical centers and hospitals. Who attends these and do they have prior Yoga experience?

MC: In medical settings, I’m training exercise physiologists, cardiac rehab staff, cardiac nurses, cardiologists and others in the cardiology field. The components in Cardiac Yoga include anatomy and physiology of heart (but, when I’m training at medical centers they have that component in place, so we don’t go as in depth), psychosocial aspects of heart disease and a complete modification of poses for patients who have limited mobility. The program also includes chair-assisted Yoga, wall-assisted Yoga and modified poses. Those not certified in Yoga have had to take Yoga classes. We send out the manuals early on, so they are practicing the Cardiac Yoga model before the program starts. When we do the condensed programs, they have to meet pre- and post-course requirements. They have to teach a certain number of classes and get feedback, and there’s a lot of modification in their skill levels as they finish the course.

Many of the individuals who take Cardiac Yoga certification are already teaching in cardiac rehab. They have already honed their teaching skills, and they are teaching things like stretching and safe movement to their patients already. They sometimes have a solid background for moving into a modified Yoga program. They may be offering some Yoga therapy components to patients, but without the breathing, meditation or mindfulness. Some cardiac rehab programs have stress management programs, but some don’t, so we bring in the relaxation and stress management portion as well as cognitive revamping with the Raja Yoga aspect of conscious awareness and meditation.

IYM: Are hospitals looking for Yoga teachers with specialized training?

MC: Hospitals are looking for teachers who have specialized training in the cardiac or medical Yoga model because of the preventive initiatives they are involved in. I think more and more hospitals are going to be looking for teachers and therapists trained, not just in a standard Yoga format, but also in a medical Yoga format because it will expand one’s anatomy and physiology knowledge and will include contraindications for medical problems that patients may present, which is critical.

IYM: You’ve expanded your services to include Yoga, stress management training and education to businesses and hospital staff?

MC: Yes, it’s called Positive Health Solutions®, and the program is based on a Yoga model. It includes concepts pertaining to time management, positive lifestyle choices and breaking old patterns. Some of the concepts of Yoga transition well into health psychology. Although the asanas are important, a critical part of Yoga practice, it’s not the only part of Yoga practice that can be utilized in management and wellness programs. The whole cognitive-behavior mindfulness component is a critical piece that enables an individual to learn better life-management skills, which include time management, diet and exercise awareness, tuning into the body and other things that help the body and mind to de-stress. Employee wellness programs like these all point to productivity. When the employees are happy and well, they are more productive and that helps the company’s bottom line.

IYM: Could you share any other guidance Sri Gurudev gave you about adapting Yoga to various settings?

MC: One thing I always admired in Gurudev’s approach to bringing Yoga to the West was that he was always open and supportive of individuals adapting Yoga to the specific populations they were serving. I remember a time in the mid-1990s when specialized Yoga programs were beginning and someone asked Gurudev if it was right to modify Yoga in these ways. He gave the person an incredulous look and said, “Of course, we should modify Yoga to serve these populations.” I’ll never forget that. Ultimately, it’s about service to humanity, and we can’t do it if we don’t modify the practice to serve the population in need. For me it was a beautiful lesson in how supportive he was about bringing Yoga into the educational, medical, even political field. He was a rare leader and spiritual guide in the field of adapting Yoga to serve particular populations.

After he had reviewed the whole curriculum for Cardiac Yoga, I asked if there was something else we should add or emphasize. He looked at me and said, “The only thing that really needs to be emphasized is to remind your students to have love and compassion for those they serve.” While we need to have a western model of understanding and instruction regarding the specialized areas, he was always reminding us that love and compassion are most important because therein lies the true source of healing.

About M. Mala Cunningham, PhD

Dr. Cunningham is a leading speaker, author and educator in the field of mind-body medicine and health psychology. She is president of Positive Health Solutions® and is the founder and director of Cardiac Yoga®. Dr. Cunningham is also a counseling psychologist in private practice and a certified Yoga teacher from two traditions. She has taught and practiced in these areas for over twenty-five years. Her Cardiac Yoga Teacher Training course is offered annually in Yogaville. For more information, please visit: cardiacyoga.com.

Reprinted from Integral Yoga Magazine, Fall 2008

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