Brigham & Women’s Hospital
Harvard Medical School
Yoga as an Intervention for Mental Health
within the High School Curriculum
Februaryy 23,, 2011
Prevention Research Center
Spring 2011 seminar series
Penn State University
Sat Bir S. Khalsa, Ph.D.
Assistant Professor of Medicine
Brigham and Women’s Hospital, Harvard Medical School
Director of Research, Kundalini Research Institute
R
Research
h Di
Director, K
Kripalu
i l C
Center ffor Y
Yoga and
dH
Health
lh
Yoga
Physical Postures
and Exercises
static postures
z isometric
z stretching of trunk
and limbs
z wide
id variety
i t off limb
li b
and trunk
movements
z
Physical Postures
and Exercises
Breathing
Exercises
long, slow and deep
z abdominal
z patterned and paced
z segmented
z alternate nostril
z
Meditation
relaxed focused attention on breathing, words, senses
z passive exclusion of ruminating thoughts
z
Philosophy / Psychology
z
z
z
z
yoga as mysticism
contemplative practice for
personal growth
experience
i
off a unitive
iti
state of consciousness as
g
the ultimate goal
psychology of detachment
and expanded identity
Benefits of Yoga Practice
z
Arousal reduction, physical/mental well-being
z
Mind/body awareness, resilience, self-regulation
z
Psychological / philosophical transformation
Reasons for Practice
in a Beginners Program
From: Yoga in the real world: Motivations and patterns of use
use, Quilty MT
MT, Saper R
R,
Goldstein R, Khalsa SBS, Abstract, NARCCIM 2009.
Prevalence
of Yoga Practice
Popularity of Yoga Practice
Yoga Practice in the United States
I do yoga
oga in m
my ssuite.
ite
Doctor’s orders.
It’ss a good conversation
It
starter at breakfast.
Almost as good as the
complimentary waffles.
Deep Breathing
M dit ti
Meditation
Yoga
From: Complementary and Alternative Medicine Use Among Adults and Children: United
St t
States,
2007,
2007 Barnes
B
PM,
PM Bl
Bloom B
B, N
Nahin
hi R
R. CDC N
National
ti
lH
Health
lth St
Statistics
ti ti R
Reportt
#12, 2008.
Yoga Use in the Last 12 Months
Perce
ent of P
Populattion
7
6
5
4
6.1%
3
2
2.1%
1
0
Adults
< 18 yr old
From: Complementary
F
C
l
t
& Alt
Alternative
ti Medicine
M di i Use
U Among
A
Adults
Ad lt & Child
Children: U
United
it d St
States,
t
2007, Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12, 2008.
How Do We Reach All of Society?
Two systems are in place in society that
penetrate to all levels of the population
z
The healthcare system
z
The education system
Both systems require validation of techniques
and procedures before implementation
Yoga Research
Brosse, 1936
From: Documents recueillis aux
Indes sur les “Yoguis” par
l’enregistrement simultane du
pouls,
l d
de lla respiration
i ti ett d
de
l’electrocardiogramme
[Data gathered in India on a Yogi
with simultaneous registration of
the pulse, respiration, and
electrocardiogram]
Laubry C, Brosse T
L P
La
Presse M
Medicale
di l 44
44:16011601
1604, 1936.
Das and Gastaut
Gastaut, 1955
From: Variations de l’activite electrique du cerveau, du coeur et de muscles squelettiques
au cours de la meditation et de l’extase yogique [Variations in the electrical activity of the
brain heart
brain,
heart, and skeletal muscles during yogic meditation and trance]
trance], Das N
N, Gastaut H
H,
Electoencephalography and Clinical Neurophysiology, Suppl. 6:211-219, 1955.
Anand et al
al.,
1961
From: Some aspects of
electroencephalographic studies
in yogis, Anand BK, Chhina GS,
Singh B, Electroencephalography
and Clinical Neurophysiology,
13:452-456, 1961.
Bagchi and Wenger
Wenger, 1957
“…physiologically
p y
g
y
Yogic meditation
represents deep
relaxation of the
autonomic nervous
system without
drowsiness or
sleep …”
From: Electro-physiological correlates of some Yogi exercises, Bagchi BK, Wenger MA,
Electroencephalography and Clinical Neurophysiology, 7 (Suppl):132-149, 1957.
Physiology of Meditation
From: The physiology of meditation,
Wallace RK & Benson H,, Scientific American 226:85,, 1972.
Stress Behavior Scale
2.6
2.8
2.4
2.6
Average
e Score
Average
e Score
Perceived Stress Scale
2.2
20
2.0
1.8
1.6
14
1.4
2.4
22
2.2
2.0
1.8
16
1.6
Pre-treatment
Post-treatment
Pre-treatment
Post-treatment
Urinary Noradrenaline
350
Average Level
Stress
p
in a Corporate
Setting
300
250
200
Pre-treatment
Post-treatment
From: Stress management: A randomized study of cognitive behavioural
therapy and yoga, Granath J, Ingvarsson S, von Thiele U, Lundberg U.
Cognitive Behaviour Therapy, 35(1):3–10, 2006
Long-term
g
Meditation & Cortical Thickness
From: Meditation experience is associated with increased cortical thickness, Lazar SW, Kerr
CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, McGarvey M, Quinn BT, Dusek JA,
Benson H, Rauch SL, Moore CI, Fischl B, Neuroreport 16:1893-1897, 2005.
MBSR and Gray Matter Density
L Hippocampus
Posterior Cingulate
C
Temporo-parietal
Junction
C b ll
Cerebellum
…participation in MBSR is associated with changes in gray matter
concentration in brain regions involved in learning and memory processes,
emotion regulation, self-referential processing, and perspective taking.
From: Mindfulness practice leads to increases in regional
g
brain g
gray
y matter density,
y
Hölzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, Lazar SW,
Psychiatry Research Imaging, 191:36-43, 2011.
Yoga Thalamic GABA,
Yoga,
GABA Mood & Anxiety
From: Effects of yoga versus walking on mood, anxiety, and brain GABA levels: a
randomized controlled MRS study, Streeter CC, Whitfield TH, Owen L, Rein T, Karri
SK, Yakhkind A, Perlmutter R, Prescot A, Renshaw PF, Ciraulo DA, Jensen JE.
Journal of Alternative and Complementary Medicine, 16:1145-52, 2010.
A Review of Yoga Therapy Research
http://www.ijpp.com/vol48
p
jpp
_3/vol48_no3_spl
p _invt_art.pdf
p
Chronology of Yoga Therapy Research
50
45
40
35
30
25
20
15
10
5
0
1963- 19691963
1969
1974
19741979
19791968
1973
1978
1983
1984- 19891984
1989
1994
19941999
19991988
1993
1998
2003
20042004
2008
Rationale for Yoga
in the Schools
Rationale for Yoga
g
in the Schools
● Reach
Compulsory Education
Hygiene Education
The time when the preparation of teachers can be made by a study of
psychology
p
y
gy and methods ought
g to p
pass. When it does it will mean
that the health and welfare of a child will then be regarded as one of
as much importance as arithmetic and geography, and then a
knowledge of the elements of child hygiene will be regarded of as
fundamental importance in the training of every teacher.
From: The Hygiene of the School Child, LM Terman, 1914.
… school health programs and the general academic curriculum, aim
to help
p the child reach his maximum state of health and well-being,
g
motivating him to assume responsibilities for his own welfare as an
adult.
…basic objectives:
1. To help every child to attain his optimal state of physical, intellectual
emotional and social well-being.
From: Program
F
P
off dental
d t lh
health
lth education
d
ti iin N
New Y
York
k St
State
t public
bli schools,
h l
Gutman RE, Journal of School Health, 25: 229-232, 1955.
Dental Hygiene Education
The teaching of mouth hygiene.
The instruction should be extended over several
years
years…
Health rules for the teeth could be pasted in the
back of all schoolbooks.
Special effort should be centered on making the
instruction carry over into action. Health instruction
without health habits is vain. Children should be taught
in the school how to rinse the mouth, to gargle and to
brush the teeth. Actual drills for this purpose are to be
commended.
commended
From: The Teeth of School Children
Children, Chapter 9
9, pg
pg. 167-196
167 196, in The Hygiene of the
School Child, LM Terman, 1914.
Dental Hygiene Education
•
Initial measures for a state-wide school program by the
State Education Department in 1913 state law
•
•
Dental hygienists performing health instruction
•
•
Program has been state-wide since 1944
Shortly after an office of oral hygiene was established in
the Division of Medical Inspection and Health Services
1955 p
personnel exceeding
g 450 dental hygiene
yg
teachers
From: Program of dental health education in New York State public schools,
schools
Gutman RE, Journal of School Health, 25: 229-232, 1955.
Rationale for Yoga
g
in the Schools
● Reach
● Prevention
Genesis of Adult
Mental Health Problems
z
Majority
M
j it off seriously
i
l iimpairing
i i and
d persistent
i t t
conditions have child-adolescent onsets and
hi h comorbidity
high
bidit
z
Need for treatment of largely
g y untreated childadolescent disorders
From: The descriptive epidemiology of commonly occurring mental disorders in the
g PS, Annual Review of Public Health, 29:115-29, 2008.
United States. Kessler RC, Wang
Rationale for Yoga
g
in the Schools
● Reach
● Prevention
● Need
Adolescent / School Challenges
z
Stress
z
Behavior
z
Mental Health (depression,
(depression anxiety
anxiety, substance abuse
abuse, trauma)
z
Attention
z
Academics
z
Physical Health (obesity, diabetes)
(developmental, family, social, academic, societal)
(apathy, violence, social skills, bullying, absenteeism)
(ADD, ADHD)
(grades, dropouts)
Adolescent / School
Mental Health Challenges
z
7.5%
7
5% adolescent prevalence for one or more
DSM-IV disorders
z
The most consistent factors involve indicators
of stress
z
Personal resources (e.g. mastery) enhance
resilience to onset
From: One-year incidence of psychiatric disorders and associated risk factors among
adolescents in the community
community. Roberts RE,
RE Roberts CR
CR, Chan W
W., Journal of Child
Psychology and Psychiatry. 50:405-15, 2009.
Adolescent / School
Mental Health Challenges
Youth Risk Behavior Survey (YRBS)
z
z
z
z
36% (HS) attend home parties allowing teen alcohol use
25% (HS) show evidence of binge drinking
36% (MS) report having been bullied
15% (HS) report having actually attempted suicide
Meditation in
Education
Meditation in Education
“…the faculty of voluntarily bringing back a
wandering attention, over and over again, is the
very root of judgment, character and will. No one
is compos sui if he have it not. An education
which should improve this faculty would be the
education par excellence.”
From: William James, The Principles of Psychology, 1890.
Meditation in Education
“The p
practice of meditation leads to mental
concentration.
The very essence of education is concentration of
mind, not the collection of facts. If I had to do my
education once again
again, I would not study facts at
all. I would develop the power of concentration
and detachment,
detachment and then with a perfect
instrument, collect facts at will.”
From: Swami Vivekananda, in Education, Compiled from
the speeches and writings of Swami Vivekananda
Vivekananda, T
T.S.
S
Avinashilingam,1943.
Mental Hygiene Education
Self reliance does not grow out of habits of dependence,
nor does steadfastness develop out of uninhibited
impulses. If we would free children from bondage to their
whims, we must train them to concentrate, to attend.
Perhaps all of us have reserves of energy which we
habitually fail to use and rich capabilities which we have
failed to realize. The gates to these treasures are closed
and sealed by the low opinion we entertain of ourselves,
by the discouragement and self-distrust incident to failure,
and by other inhibitions or repressions. As a means of
tapping the hidden treasures of power…the loosening of
the inhibitory stresses by suggestion, by hypnoidization…
From: Preventive Mental Hygiene, Chapter 18, pg. 318-334, in The Hygiene of the
School Child, LM Terman, 1914.
From: Increases in positive psychological characteristics with a new relaxation-response
curriculum in high school students, Benson H, Kornhaber A, Kornhaber C, LeChanu MN,
et al., Journal of Research & Development in Education, 27:226-231, 1994.
From: Mindfulness training for elementary school students: The attention academy,
academy Napoli
M, Krech PR, Holley LC, Journal of Applied School Psychology, Vol 21:99-125, 2005.
Yoga
i Education
in
Ed
ti
Why Yoga?
● Yoga may be more effective than meditation alone; the
exercise, breathing and relaxation components of yoga
may facilitate
f ilit t a more effective
ff ti meditation
dit ti practice
ti
g and relaxation components
p
of
● The exercise, breathing
yoga provide additional benefits
● Yoga may be more acceptable to adolescents
● Yoga may be more acceptably integrated into schools
● Yoga has been shown to be effective in children
Why Yoga?
Perrcent off Popula
ation
2.5
2.0
1.5
2.1%
2 2%
2.2%
1.0
1.0%
0.5
0.0
Yoga
Deep
Meditation
Breathing
From: Complementary & Alternative Medicine Use Among Adults & Children: United States
States,
2007, Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12, 2008.
Kripalu Yoga for Performance Anxiety
MPAI-A
A Avera
age Sc
core
Music Performance Anxiety Inventory
f Adolescents
for
Ad l
t (MPAI-A)
(MPAI A)
50
Control
48
46
44
Yoga
42
40
Baseline
End Program
From: Yoga
F
Y
R
Reduces
d
P
Performance
f
A
Anxiety
i t iin Ad
Adolescent
l
tM
Musicians,
i i
Khalsa SBS, Butzer B, Shorter SM, Reinhardt K., Cope S, under review.
Research on Yoga
i Schools
in
S h l
Dental Hygiene Research in the Schools
…to
to determine whether a short course of instruction in dental health
health,
including brushing the teeth in the class room, produced any
measurable effect on the cleanliness of the teeth of upper
elementary grade children in the Baltimore Public Schools
elementary-grade
Schools.
- 2 groups of children, 5th grade
- 491 children
hild
iin 13 schools
h l vs. 283 iin 8 schools
h l
- month-long course of instruction, 15-20’/day for 20 days
- to motivate good general dental health practices/habits
- principles of dental care, proper brushing
- organized toot brushing drills in the class room
- daily
y home use with daily
y record of use
From: Effect of oral cleanliness produced by dental health instruction and
brushing the teeth in the class room, The 1953-1954 Baltimore Tooth Brushing
Study, 25: 250-254, 1955.
Reduced breath rate and heart rate
Reduced aggression, helplessness, improved stress coping
Fewer negative behaviors in response to stress
Improved stress, rumination, intrusive thoughts, arousal
concentration, mood, ability to function under pressure
Improved self-esteem
Yoga Ed / Kripalu Yoga Studies
● 12-week 1-hr Yoga Ed/Kripalu classes 2-3 times/week
● RCT, yoga vs. physical education, N ~ 100
Qualitative interviews post-program
p
p g
● Q
● Self-report pre-post mental health questionnaires
Qualitative Study
Sample
• 28 Students
• 17 male, 11 female
• 13 in 9th ggrade,, 15 in 10th grade
g
Interview Themes
• Yoga research administration
• Experience of yoga
• Practical integration/ application of yoga in school
Qualitative Data
Improved stress, attitude and mood:
• stress management
• focus and concentration
• energy levels
• overall optimism
• academic and social performance
• sleep
Quotes: Stress,
Stress Attitude & Mood
“Yoga
g helps
p us become more aware of our bodies…I notice
myself being more into my physical well-being…yoga is a
break, rejuvenation, and when I return to class after yoga I
am refreshed and have a new outlook on things.”
“If yyou had a lot of stuff on yyour mind or something
g yyou
could just use some of those exercises... I just felt calmer
and stuff, if I was stressed out or angry for some reason, I’d
use that at some point. I’d do their breathing exercises and
they’d calm me down.”
“Yoga definitely helped with sleeping…it would take me a
long time to get to sleep. When I was doing yoga it was
much easier to fall asleep and stay asleep…”
Qualitative Data
Continuing Yoga Practice:
M
Many
students
t d t would
ld continue
ti
yoga if offered
ff d in
i school
h l
Common b
C
benefits
fit noted
t d ffor yoga continuation:
ti
ti
• break from regular classroom routine
• improved
i
d stress,
t
attitude
ttit d and
d mood
d
• physical flexibility
• performance and reduced injury in sports
• social activities with peers
Quotes: Continuing Yoga Practice
“It was nice to be out of a desk and blackboard
environment and nice to come to yoga class to regain
f
focus
from
f
tiredness
ti d
and
db
boredom
d
off school.”
h l”
“In the beginning
g
g I didn’t like [yoga],
y g but over time, in the
middle I started to notice results… I began to like it
because it started to work…”
“Friends who are doing yoga with me are kinder…if they
y theyy breathe before talking…My
g
y
are mad or annoyed
relationships with people are getting stronger.”
Rating of the Intervention
Do you think the yoga was valuable enough
that you would recommend it to your friends?
Number o
N
of Subjectts
20
15
10
5
0
0
Not
at
all
20
40
60
80
Average Visual Analog Score
100
Very
much
so
From: Khalsa SBS, Noggle J, Cohen D, Steiner N, Cope S, in preparation.
Mental Health Outcomes - Yoga
Worsening
Improvement
Social Stress
Attitude to School
Anger
Resilience
Negative Affect
Anxiety
Anger Expression
Mental Health Outcomes - Control
Worsening
g
Improvement
p
Social Stress
Attitude to School
Anger
Resilience
Negative Affect
Anxiety
Anger Expression
Mental Health Outcomes
Worsening
g
Improvement
p
Social Stress
Attitude to School
A nger
Resilience
Negative Affect
A i t
Anxiety
Anger Expression
Ongoing Study
● Waltham High School
● 325 grade 9 students
● Kripalu Yoga vs. Phys Ed
● 12 weeks of yoga across school year
● Pre, Post, Mid
Mid-intervention
intervention questionnaires
● Pre/post cognitive testing
● Physical fitness metrics
Future Studies
Mental Health
z
z
Substance abuse, depression & suicidality, bullying
Self-esteem, maturity, independence, values, positive
psychology, spirituality
P f
Performance
z
z
z
z
Attention, memory, cognitive processing
Grades and attendance
Creativity
Sports
Physical Health
z
z
z
Risk factors for diabetes, obesity, hypertension
Immune function
Flexibility, injury prevention
Long-term
Long
term Longitudinal Changes
z
Yoga throughout high school followed by adult followup
The Challenge of Funding
Reviewer Bias and Paradigm Shift Resistance
z
z
z
z
"It does not appear to be innovative since there is mention of an established
Yoga Ed Program for adolescents that the interveners will be trained in. There
evidentlyy is an existing
g classroom based yyoga
g p
program
g
that has been tested.“
"This process goes against most IRB requirements for research in children. …it
is unclear how the process for study recruitment and participation will be
handled if the IRB turns down the concept of "passive consent" which is not
usually
ll permitted
itt d by
b IRB's
IRB' for
f this
thi special
i l population."
l ti "
"Requires testing within a controlled environment before it can be used safely
within a school system."
“…yoga and other techniques serve a similar role as OTC medications do in
getting relief from a cold. They temporarily relieve symptoms, but don’t address
the underlying
y g cause. Once the medication wears off, the symptoms
y p
((in this
case a dysfunctional amount of emotion) often return because the cause is still
there…does not contribute something that would be a practical way to address
this pressing gap in curricula, and if published, might only send some in a
relative
l ti d
dead
d end
d and
dd
delay
l progress ttoward
d fifinding
di a b
better
tt solution.”
l ti ”
– Reviewer, Journal of School Health
Kripalu
i l | center for yoga & health
A k
Acknowledgements
l d
t
C ll b t /C
Collaborators/Consultants
lt t
•
•
•
•
•
Lisa Conboy, Ph.D. – Harvard Medical School
St h Cope
Stephen
C
– Kripalu
Ki l C
Center
t ffor Y
Yoga and
dH
Health
lth
Jessica Noggle, Ph.D. – Harvard Medical School
Lynn Schultz, Ph.D. – Harvard Graduate School of Education
Naomi Steiner, M.D. – Tufts University
Instruction and Research Assistance
•
•
•
•
•
Torrey Baldwin
Iona Brigham
Deborah Cohen
Janna Delgado
Angela Wilson