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Evaluation of a Residential Kundalini Yoga Lifestyle Pilot Program for Addiction

in India

Article in Journal of Ethnicity in Substance Abuse · April 2008

DOI: 10.1080/15332640802081968 · Source: PubMed

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Evaluation of a Residential Kundalini Yoga Lifestyle Pilot Program for Addiction
in India

Running Title: Yoga Program for Addiction

Sat Bir S. Khalsa1,2, Ph.D., Gurucharan S. Khalsa, Ph.D., Hargopal K. Khalsa, Mukta K. Khalsa,
L.P.C.

1. Division of Sleep Medicine, Department of Medicine

Brigham and Women’s Hospital, Harvard Medical School
2. Kundalini Research Institute

PRIVILEGED COMMUNICATION:
NOT FOR CITATION OR DISTRIBUTION WITHOUT AUTHORS' PRIOR PERMISSION

In press: Journal of Ethnicity in Substance Abuse

Address all correspondence to:

Sat Bir S. Khalsa, Ph.D.

Assistant Professor of Medicine
Division of Sleep Medicine @BI
Brigham and Women’s Hospital, Harvard Medical School
75 Francis Street,
Boston, MA 02115

Phone: (617) 732-7994

Fax: (617) 701-1296
Email: khalsa@hms.harvard.edu

SSK was supported in part by grant K01AT000066 from NCCAM.

Yoga Program for Addiction Page 1 of 20

Abstract
Previously reported substance abuse interventions incorporating meditation and spiritual
approaches are believed to provide their benefit through modulation of both psychological and
pyschosocial factors. A 90-day residential group pilot treatment program for substance abuse
that incorporated a comprehensive array of yoga, meditation, spiritual and mind-body techniques
was conducted in Amritsar, India. Subjects showed improvements on a number of psychological
self-report questionnaires including the Behavior and Symptom Identification Scale and the
Quality of Recovery Index. Application of comprehensive spiritual lifestyle interventions may
prove effective in treating substance abuse particularly in populations receptive to such
approaches.

Key Words: yoga, meditation, India, lifestyle, spirituality

Introduction
Historically yoga is a set of mind-body practices whose ultimate goal is the achievement of a
higher state of consciousness. The three main techniques in yoga practice include meditation,
breathing exercises and physical postures. Practice of these techniques is well known to elicit
the relaxation response associated with a reduction of arousal, deactivation of the stress response
system and the generation of a state of physical and mental well-being (Granath, Ingvarsson, von
Thiele, & Lundberg, 2006; Michalsen et al., 2005). From the meditation component,
practitioners also develop an increasing self-awareness of both their psychological and physical
state, which can lead to an increase in self-control and self-efficacy (La Forge, 1997; Waelde,
Thompson, & Gallagher-Thompson, 2004). Not surprisingly, yoga and meditation have also
been widely adopted as therapeutic practices for a wide variety of psychological conditions such
as anxiety and depression, medical conditions, which have an underlying stress-related
component and a number of neuromuscular conditions (Khalsa, 2004; Bonadonna, 2003).
Yoga and meditation have been proposed as an effective treatment for substance abuse and
addictive behavior through their potential impact on a number of factors in this complex
condition, which has numerous psychological, behavioral and physical components: 1) reduction
of stress (and/or tension) and its overt behavioral and underlying neuroendocrine components
(Walton & Levitsky, 1994; Calajoe, 1986; Klajner, Hartman, & Sobell, 1984; Kremer, Malkin, &
Benshoff, 1995); 2) improvement of impaired mood such as reduction of depression and anxiety
and a resulting increase in psychological well-being (Calajoe, 1986; Kremer et al., 1995); 3)
induction of a peak experience or higher state of consciousness, effectively replacing the
attraction of a substance-induced high (Neiss, 1993; Calajoe, 1986; Dohner, 1972; Galanter,
1976; Lohman, 1999); 4) improvement in self-awareness of personal psychological and
psychophysiological state allowing for improved self-efficacy through the ability to intervene
and prevent destructive or maladaptive behavior before its onset (Calajoe, 1986; Dohner, 1972;
Lohman, 1999); and 5) the establishment of improved self-esteem and a better philosophical
relationship and understanding between the individual and his/her internal and external (social)
worlds (Calajoe, 1986; Dohner, 1972).
A number of research studies have evaluated the effectiveness of yoga and meditation
techniques alone or as part of a broader treatment, with a majority of these studies on meditation.

Yoga Program for Addiction Page 2 of 20

In particular there is a good deal of research showing the effectiveness of Transcendental
Meditation alone on a wide variety of abused substances addictive behaviors (reviewed in ref.
(Hawkins, 2003)). However, studies of other meditation interventions either alone (Murphy,
Pagano, & Marlatt, 1986) or in combination with other techniques (Denney & Baugh, 1992;
Rohsenow, Monti, Martin, Michalec, & Abrams, 2000) have also shown benefit. Several
addiction treatment programs have incorporated yoga as a contributing technique in a
multicomponent treatment (Agne & Paolucci, 1982; Cernovsky, 1984; McClellan, 1975), but
there have also been treatment programs in which yoga or a yoga lifestyle approach has been a
more central element in the therapy (Sharma & Shukla, 1988; Lohman, 1999).
Only a few substance abuse research studies have evaluated the effectiveness of yoga. An older
study evaluating a wide variety of outcome measures in alcoholics in which a yoga treatment
was one of 4 treatments compared revealed that the yoga treated subjects showed normalization
of their cortisol and catecholamines (Subrahmanyam, Satyanarayana, & Rajeswari, 1986). In a
study of withdrawal symptoms in drug addicts, a 15-day yoga exercise intervention had
statistically greater improvements in these symptoms than did an untreated control (Chauhan,
1992). In another randomized controlled trial, an 8-week yoga intervention applied to alcohol
dependent subjects showed a statistically greater improvement in the severity of their alcohol
dependence than that observed for subjects in a physical training exercise control group (Raina,
Chakraborty, Basit, Samarth, & Singh, 2001). Finally, in a randomized controlled trial of clients
in outpatient methadone maintenance treatment, subjects undergoing a weekly yoga class
showed equivalent improvements in a variety of psychological, sociological and biological
measures to subjects undergoing a group psychotherapy intervention over a 6 month period
(Shaffer, LaSalvia, & Stein, 1997).
It is believed that the prevalence of drug abuse in India is on the increase due to India’s
geographical location and due to changes in social structure and attitudes over the past few
decades (Dorabjee & Samson, 2000; Benegal, 2005). A recent comprehensive survey study has
indicated that in 2001 there were about 62.5 million alcohol users, about 8.7 million cannabis
users and about 2 million opiate users in the country (Ray, Mondal, Gupta, Chatterjee, & Bajaj,
2004). A recent report has indicated a high prevalence of drug abuse in the state of Punjab in
northwestern India (Anonymous, 2006).
The 3HO Foundation SuperHealth program on addiction is a residential group addiction
treatment program based on yoga and meditation lifestyle practices and has been running
programs in Tucson, Arizona since the early 1970’s (Lohman, 1999). This report describes a
preliminary pilot program of a pilot 3HO SuperHealth yoga lifestyle based residential treatment
program for addiction in Amritsar in the state of Punjab, India.

Methods
Subject Population
Subjects were derived from a sample of volunteer substance abusers who had responded to
advertising in newspapers in the state of Punjab, India, a state with a high Sikh population. All
subjects were required to complete a medical detoxification program (approximately 3 days)
provided by the Dr. Vidya Sagar Mental Hospital and were required to be accompanied by a
family member during this time. All were interviewed as to interest and appropriateness together
with their family members. Candidates were required to be males aged 18 and older and were

Yoga Program for Addiction Page 3 of 20

screened and excluded for psychosis or a history significant of serious or ongoing violence.
After the initial screening, subjects signed informed consent for the research procedures.
Subjects were then admitted to the program for a 1-3 day trial period, during which initial
outcome measures were administered and during which subjects could be discharged from the
program for physical and mental health or compliance issues. Women were excluded due to a
hospital directive which prohibited a mixed gender population for this project.

Treatment Program
Although the program content evolved over time, the structure was a 90-day residential treatment
program using Kundalini Yoga and Meditation, as taught by Yogi Bhajan, as the primary
therapeutic modality. The residential program was housed in a new dedicated wing of the Dr.
Vidya Sagar Mental Hospital, a state run psychiatric hospital in the city of Amritsar, India. The
hospital facility was basic in nature and typical of Indian medical facilities. Family members
were not permitted into our treatment environment during the first month of treatment. Most of
the program participants slept two to a room. Adjacent to the ward, the program made use of a
patio area, used often to socialize, be out in the open, and for games such as kickball and various
tossing games. Nurses attended the participants on a daily basis for the measurement of vital
signs.
For most of the 90-day period, 3 Kundalini yoga classes were held per day in the morning,
afternoon and late afternoon. Eight certified Kundalini Yoga instructors who were also Sikhs (7
were English-speaking and not of Indian descent) were involved in the program at varying times
throughout the program provided the yoga instruction. About 45 days into the program,
additional staffing allowed an evening class to be added. Also, about 45 days into the program,
clients were taught to teach each other the yoga program as a way to increase a sense of mastery
and to enhance the possibility of the practice continuing beyond the 90 days. During this last
half, clients taught each other classes, with staff supervision, at least once per day. The content
of the classes were standard Kundalini yoga practices and sets incorporating physical postures,
breathing techniques, meditation and mantra. Although the yoga classes were the primary
therapeutic intervention, also of note were the therapeutic relationships and the family
relationships. Therapeutic relationships were developed in individual and group counseling and
in multi-family group sessions (after the first month). In the multi-family group sessions,
meditation techniques were taught as well. Five professional healthcare providers who were also
Sikhs contributed to the treatment program and all had previous experience with psychotherapy
and the drug treatment programs.
Additional program components that played a smaller role in the treatment program were a
mostly vegetarian diet, herbs, vitamins and spices used for cleansing and rebuilding the body
systems (digestion, elimination, respiratory, nervous, glandular, etc.), recreational, music and
dance therapies, spiritual studies and Sikh religious practices, Sat Nam Rasayan (a form of
energy medicine / spiritual healing), acupuncture sessions, videos of lectures on spirituality and
yoga lifestyle, education on addiction and relapse prevention which included training as a teacher
of Kundalini Yoga, aftercare yoga/meditation support groups and some massage therapy
provided by hospital staff. Compliance with the treatment program was enforced in that all
subjects were required to attend all activities of the program unless medically ill.

Outcome Measures
Treatment outcome measures were acquired at baseline, mid-treatment, end-treatment, and at 1,

Yoga Program for Addiction Page 4 of 20

3 and 12-month follow-ups after the treatment phase. The outcome measures below were
evaluated at baseline, mid-treatment, end-treatment and at 1-month followup.
The Perceived Stress Scale (PSS) is a widely used 10-item self-report questionnaire, which
assays the degree to which situations in one’s life are appraised as stressful. Individual questions
address how unpredictable, uncontrollable, and overloaded respondents find their lives and
current levels of experienced stress over the past month. Respondents are asked about the
frequency at which they felt a certain way. It has adequate internal and test-retest reliability
(Cohen, 1988).
The 32-item Behavior and Symptom Identification Scale (BASIS-32) measures the change in
self-reported symptom and problem difficulty over the course of treatment. It identifies a wide
range of symptoms and problems that occur across the diagnostic spectrum. Validated and found
reliable in both inpatient and outpatient settings, it assesses treatment outcomes from the patient
perspective before and after receiving care. The survey measures the degree of difficulty
experienced by the patient during a one-week period on a five-point scale ranging from no
difficulty to extreme difficulty. The survey is scored to provide an overall score with five
subscales for the following domains of psychiatric and substance abuse symptoms and
functioning: Relation to Self and Others, Depression and Anxiety, Daily Living and Role
Functioning, Impulsive and Addictive Behavior, Psychosis (Eisen, Wilcox, Leff, Schaefer, &
Culhane, 1999).
Quality of Recovery Index (QRI, provisional version 7/27/00, the SASSI Institute) is designed
to measure change in behaviors that reflect the extent to which the individual is making the
positive life-changes that often accompany recovery from substance-related disorders. The QRI
consists of 38 items that reflect quality of recovery. Clients are instructed to check the word that
best describes how often they have experienced each of the 38 behaviors during the time period
specified. Items are either positively or negatively phrased and report frequency (e.g., “never” to
“rarely,” “often” to “almost always”). In addition to a global score, there are also scores
available for 4 subscales, Sense of Emotional Well-Being, Active Recovery, Social and Work-
School Performance. The QRI (and its subscales) is provisional and is in a long-term process of
development of empirical indices of its psychometric properties.
Due to the fact that most of the subjects were not fluent in English, the questions on the
questionnaires were translated by a number of hired and volunteer translators and the subjects’
answers recorded. Outcome measures were evaluated statistically for the 4 times points with
one-way repeated measures of variance (RMANOVA) for each scale and subscale, and Tukey's
Honestly Significant Difference (HSD) post-hoc tests evaluated statistical significance between
values at different time points.

Results
A total of 10 subjects formally enrolled and gave written informed consent. One of these
subjects was admitted to the program late, 3 weeks after the start. Another subject was
subsequently disimpaneled for non-compliance with the program. The male subjects were from
a cross-section of the socio-economic spectrum; from the very poor to the very privileged; both
rural and city dwellers; shopkeepers, farmers, businessmen and professionals. Some were of the
Hindu religion and some were of the Sikh faith but they all had experience with or familiar with
the spiritual values imbedded in the program. All were from the state of Punjab in northern India
that has a high Sikh population and had close family ties. All had long histories of abuse with a

Yoga Program for Addiction Page 5 of 20

variety of substances, including alcohol, opiates, and barbiturates.
Questionnaire data was analyzed from the 8 enrolled subjects that completed the baseline
questionnaires. Their ages range from 20 to 57 (average 30.4 years ± 12.2 S.D.). Of these 8
subjects, one did not complete the last 4 weeks of the treatment program due to a limited leave of
absence from his job and did not complete the end-treatment and followup questionnaires, one
did not complete the last 2 weeks of treatment for medical reasons and did not complete the end-
treatment questionnaire, and one left the program temporarily after sustaining a broken leg but
returned later in the program and did not complete mid-treatment and end-treatment
questionnaires, therefore the acquired sample sizes at each of the 4 time points were baseline
(N=8), mid-treatment (N=7), end-treatment (N=5) and followup (N=7).
Average scores on the BASIS-32 total score and for all of the subscales showed clear declines
from the baseline to the followup evaluations (Fig. 1). RMANOVA’s on the total score and
scores for the Relation to Self and Others subscale showed significant main effects for time p <
0.05. Post-hoc tests showed statistically significant improvements between the baseline and
followup measures (p < 0.05) for the total scores, and statistically significant improvement
between the baseline and end-treatment measures (p<0.05) for the Relation to Self and Others
subscale scores. RMANOVAs on the Daily Living and Role Functioning subscales showed
significant main effects for time p < 0.01 and the post-hoc tests showed statistically significant
improvements between the baseline and followup measures (p < 0.01). RMANOVA’s on the
Impulsive and Addictive Behavior, Depression and Psychosis subscales almost showed
significant main effects for time (p=0.06, p=0.07, p=0.07, respectively).
Average scores on the QRI for the total score and for all of the subscales showed clear declines
from the baseline to the followup evaluations. RMANOVAs on the total score and scores for the
Active Recovery and Work-School Performance subscales showed significant main effects for
time p < 0.05 and the post-hoc tests showed statistically significant improvements between the
baseline and followup measures (p < 0.05). However, no significant main effect for time was
found for the Sense of Emotional Well-being subscale (p = 0.14) or Social subscale (p = 0.18).
Average scores on the PSS at baseline were 18.9 ± 9.3 (S.D.), dropped to 16.2 ± 2.1at mid-
treatment and held somewhat steady at 15.4 ± 0.5 at the end-treatment and at 16.9 ± 7.6 at the
followup evaluations. A RMANOVA did not show a significant main effect for time (p = 0.44).
Qualitatively, by the end of the program subjects achieved greater flexibility and physical
strength, their energy level increased, they became brighter and more open in appearance and
had a clearer complexion, they appeared more focused and alert, they were more verbal and
made better eye contact and were more able to ask for appropriate help (as distinct from
medication seeking behavior), they expressed fewer complaints about pain, sleep or physical
discomfort and exhibited less emotional reactivity. The subjects attributed their feeling better as
a result of the yoga and noted that the caring staff was the most important part of the program to
them. They took pride in teaching their peers yoga classes and they also appeared to have
reconnected with their personal spiritual practices and devotion. Compliance to the treatment
program was high due to the required participation, however, compliance with program rules
after hours, when staff was not present, was poor. Despite the enforced nature of the treatment
program, and the language barrier between the subjects and the executive members of the staff,
subjects continued their participation voluntarily and were consistently and universally
enthusiastic about participation in the various program components. By the end of the program
the subjects had developed a high degree of trust and respect for the therapists and instructors.

Yoga Program for Addiction Page 6 of 20

Discussion
The participants benefited substantially from this comprehensive residential, group yoga
lifestyle program. This was confirmed by both qualitative observations and by responses on the
questionnaire instruments. Improvements were most encouraging in the BASIS-32 scores and
the subscales on this questionnaire suggesting that the subjects exhibited improvements in a wide
range of self-reported symptoms, problems and difficulties over the course of treatment. This
was confirmed by the improvements in total score and the Active Recovery and Work-School
Performance subscales of the QRI.
However, scores on the PSS did not appear to improve over the course of treatment, a notable
exception given that yoga and meditation practices are well-known for their capability of
effectively managing stress. A potential explanation for this discrepancy could have been the
fact that some of the subjects could have been under the influence of their substances of abuse at
baseline, and therefore reported lower stress levels.
The Punjab is a region of India undergoing a significant cultural transition due to its vulnerable
geographical location in the “Golden Triangle”, which leaves it highly prone to the prevalence of
substance abuse. Furthermore, the rapid economic development in India is accompanied by the
import of Western cultural influence, which is displacing the traditional cultural value system. It
is likely that the success of this program was due at least in part to the incorporation of spiritual
and religious practices (yoga, meditation, chanting, etc.) respected by the program participants as
nationally popular and inherently valuable. To some degree the rediscovered spiritual practices
on the part of the subjects was likely influenced by the fact that most of the therapists were
Westerners who have adopted spiritual lifestyles (yoga and Sikh practices) endogenous to their
own culture. There was a suggestion that the participants were able to reframe their attitudes and
relationships to their traditional cultural heritage and were inspired by the fact that Westerners
felt strongly enough about the traditional practices to adopt them as a lifestyle.
The addition of spiritual components into addiction treatment programs, including both
religious and non-religious spiritual practices such as meditation, is well known. However, the
potential value of this component as well as its limitations remains to be evaluated (Galanter,
2006; Cook, 2004; Cook, 2004). A recent evaluation of the research literature of addiction
studies incorporating spirituality suggests there are 13 conceptual components of the definitions
and descriptions of spirituality including components known to also be associated with
meditation and yoga such as transcendence, consciousness, wholeness, non-materiality and self-
knowledge (Cook, 2004). It is conceivable that many of these components are therapeutic in
addiction.
There were a number of weaknesses and limitations in this pilot program and its evaluation that
are notable. Foremost is the small group size, which undoubtedly impacted the analyses of
statistical significance of the questionnaire outcome measures. Secondly, compliance with the
questionnaires was uneven across subjects over the different time points, further compromising
the strength of the statistical analyses. Finally, a major unknown is the use of a translator to
interpret the individual items on the questionnaires. The BASIS-32, QRI and PSS are all
designed as self-report questionnaires and the inclusion of a translator may yield different results
due to subtle bias imposed by the translator. Furthermore, the translation itself may have lead to
inaccuracies due to cultural differences in interpretation of individual questionnaire items.
Given our preliminary experience with the pilot program, it seems that if such a program is to
be repeated in India, it should be done with participants who are fluent in English. The

Yoga Program for Addiction Page 7 of 20

complexities associated with language translation issues created problems for both the
implementation of the programs (by English-speaking therapists and instructors) and for the
integrity of the self-report questionnaires that have been developed and validated with patients
fluent in English.
Given the multicomponent nature of the treatment program, it is difficult to determine what
were the most important elements contributing to the clinical improvements. However, based
upon participant responses, it is likely that the yoga-based practice components had significant
impact on the participants. Future programs that might alter the number and/or intensity of
different treatment components will help determine the most effective practices yielding the
greatest benefit to this population.

Acknowledgements
The authors are deeply indebted to Yogi Bhajan, Ph.D., a master of Kundalini Yoga, who
originally taught the techniques employed in this study and originally inspired the 3HO
Foundation SuperHealth program on addictions. The authors acknowledge the invaluable
collaboration of Dr. B.L. Goyal of the Dr. Vidya Sagar Mental Hospital who provided the
clinical residential facility for the program. The authors are also grateful to Sat Sat Nam Kaur
Khalsa who provided consultation on the study design and to the therapists and yoga instructors
Guru Terath Kaur Khalsa, Dr. Ajit Singh, Fateh Singh, Seva Kaur Khalsa, Darshan Kaur Khalsa
who kindly shared their clinical and teaching skills. SSK was supported by research career
award 5K01AT66 from the National Center for Complementary and Alternative Medicine of the
NIH.

Yoga Program for Addiction Page 8 of 20

Figure 1
1.5

1.5 Impulsive and

BASIS-32
Average Score

Overall Average 1.0 Addictive Behavior

1.0

0.5
0.5

0.0 0.0

1.5
Daily Living and Depression and Anxiety
Average Score

2.0
Role Functioning
1.0

1.0
0.5

0.0 0.0

1.5 Relation to Self Psychosis

Average Score

1.0
and Others
1.0

0.5
0.5

0.0 0.0
Baseline Mid-TX End-TX Followup Baseline Mid-TX End-TX Followup

Figure Legend
Average scores on the BASIS-32 questionnaire at baseline, mid-treatment (Mid-TX), end-
treatment (End-TX) and followup for the total overall questionnaire and for each of the 5
subscales.

Yoga Program for Addiction Page 9 of 20

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