IntJYoga.2012JanJun5(1):4247.

PMCID:PMC3276932

doi:10.4103/09736131.91711

Developmentandfeasibilityofneedbasedyogaprogramforfamilycaregiversofin
patientswithschizophreniainIndia
AartiJagannathan,AmeerHamza,JagadishaThirthalli, 1HRNagendra, 2RNagarathna, 3andBNGangadhar1
DepartmentofPsychiatricSocialWork,NationalInstituteofMentalHealthandNeurosciences(NIMHANS),Bangalore,India
1
DepartmentofPsychiatry,NationalInstituteofMentalHealthandNeurosciences(NIMHANS),Bangalore,India
2
Vicechancellor,SwamiVivekanandaYogaAnusandhanaSamasthana(SVYASA),Bangalore,India
3
Dean,DivisionofYogaandLifeSciences,SwamiVivekanandaYogaAnusandhanaSamasthana(SVYASA),Bangalore,India
th
Addressforcorrespondence:Dr.AartiJagannathan,No:10,JAGRATI,5 Cross,MRGardens,VishwanathaNaganahalli,RTNagarPost560
032,India.Email:jaganaarti@gmail.com
Copyright:InternationalJournalofYoga
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Abstract

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ContextandAim:

Yogahasbeenfoundtobeeffectiveinthemanagementofstress.Thispaperdescribesthedevelopmentofayoga
programaimedtoreduceburdenandimprovecopingoffamilycaregiversofinpatientswithschizophreniainIndia.
MaterialsandMethods:

Basedontheassessmentofcaregiverneeds,literaturereview,andexpertopinion,atendaygroupyogaprogram
wasinitiallydevelopedusingthequalitativeinductivemethodofinquiry.Eachday'sprogramincludedwarmup
exercises,yogicasanas,pranayama,andsatsang.Astructuredquestionnaireelicitingcommentsoneachday's
contentswasgivenindependentlytotenexperiencedyogaprofessionalsworkinginthefieldofhealthfor
validation.Thefinalversionoftheprogramwaspilottestedonagroupofsixcaregiversofinpatientswith
schizophreniaadmittedatNIMHANS,Bangalore.
Results:

Onthequestionofwhethertheprogramwouldhelpreducetheburdenofcaregivers,sixofthetenexperts(60%)
gavearankoffouroffive(verymuchuseful).Basedoncommentsoftheexperts,severalchangesweremadeto
theprogram.Inthepilottestingstage,morethan60%ofthecaregiversassignedascoreoffourandabove(ona
fivepointLikertscale,fivebeingextremelyuseful)fortheoverallprogram,handoutsdistributed,andperformance
ofthetrainer.Qualitativefeedbackofthecaregiversfurtherendorsedthefeasibilityandusefulnessoftheprogram.
Conclusion:

Thedevelopedyogaprogramwasfoundtobeacceptabletocaregiversofinpatientswithschizophrenia.
Keywords:Familycaregivers,need,schizophrenia,yoga
INTRODUCTION

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Yogamodelsdescribedbyearlierauthorshaveprovidedtheirownrationalebehindthechoiceofyoga
asanas/program.[13]However,thereisnomentionwhethertheseprogramshavebeenendorsedbyother
specialistsinthefieldthantheresearcherthemselves.Also,thereisnoliteraturewhichdiscussesthedevelopment

ofayogaprogramwhichattemptstomatchtheexpressedneedsoftheparticipants.
Onlytwostudieshavelookedatdevelopmentandfeasibilitytestingofyogaprogramsforcaregiversofpersons
withdisability.Puymbrocketal.[4]testedthefeasibilityofayogaprogramonthephysicalhealthandcopingof
informalcaregiverswhocaredforapersonwithadiseaseordisabilityinUSA.Waeldeetal.[5]conductedapilot
studyofayogaandmeditationinterventioncalledInnerResourcesfordementiacaregiverstressinUSA.
Theabovestudiesfocusmoreonfeasibilitytestingratherthanonthedevelopmentofayogaprogram.Thecultural
applicabilityofthestudiesinanIndiansettingwouldalsorequiretesting.Furthermore,theneedsexpressedbythe
caregiversofpersonswithdementia[69]isdifferentfromthatoftheneedsofcaregiversofpersonswith
schizophrenia.[10]AstherewerenoIndianstudieswhichexploredthedevelopmentandfeasibilitytestingofyoga
programbasedontheneedsofcaregivers,weundertookthesystematicdevelopmentofayogaprogrambasedon
theneedsofcaregiverofpersonssufferingfromschizophrenia.
MATERIALSANDMETHODS

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ThestudywasreviewedandapprovedbytheInstitute'sethicscommittee.Writteninformedconsentofthemental
healthprofessionalswhohelpedinvalidationoftheprogramandfamilycaregiverswhoparticipatedinthepilot
studywasobtained.Asociodemographicsheetelicitinginformationontheirage,occupation,monthlyincome,and
maritalstatuswasfilledupbytheresearcherforboththementalhealthprofessionalsandfamilycaregivers.
Theinductivemethodofinquiry(quintessenceofqualitativeresearch)inwhichgeneralprinciples
(theories/programs)aredevelopedfromspecificobservationswasusedtodevelopandtestthefeasibilityofthe
program.Thedevelopmentoftheyogaprogramwasconductedintwostages.Stageoneinvolveddevelopmentof
thecontentandmethodologyfortheyogaprogram.Stagetwoinvolvedfaceandcontentvalidationoftheprogram.
ThefeasibilityoftheprogramwastestedinStagethreeofthestudywheretheprogramwaspilottestedand
feedbackfromthecaregiverswhoparticipatedintheprogramwaselicited.Theprocessinvolvedineachstageof
thedevelopmentandfeasibilitytestingoftheprogramisdelineatedbelow[Figure1].
Figure1
ProcessofInductivemethodofprogramdevelopment
StageOne:Programdevelopment

Initially,ayogaprogramwasdevelopedbymatchingtheneedsofthecaregivers.[10]Classicaltextssuchas
PatanjaliYogaSutra,[11]Rigveda,[12]GherandaSamhita,[13]Hatharatnavali,[14]andHathayogapradipika[15]
werereviewedtounderstandtheasanas/practicesthatwouldhelpdirectlyorindirectlydealwitheachoftheneeds.
Tohelpwarmupthebodytopracticetheasanasandpranayama,jogging,cycling,andhandsinandoutbreathing
wasincorporatedinthebeginningofeachday'sprogram(Nagendra,2008).
Suryanamaskaraasetofyogicposturesdoneinasequenceofposturesroutinelyfollowedinseveralyogaschools,
helpsinbringingaboutgeneralflexibilityofthebodyandimprovingmentalhealthasapreparationforasanasand
pranayama(SatyanandaSaraswati,2008Yogendra.,1997).Eventheforemostclassicaltext(Rigveda,1st
Mandala,50thSukta)emphasizesthebenefitsofthepracticeindestroyingphysicalillnessesandthediseasesofthe
heart(mind)[udyannadyamitramahaarohannuttaramdivam/Hrdroghammamasuryaharimanamcanasaya//
(1stRucha).Risingthisday,Orichinfriends,ascendingtotheloftierheaven,Suryaremovemyheartsdisease,
takefrommethisyellowhue].
Thegoalofyogapracticesincontextoftheneedsexpressedbythecaregivers(suchasmanagingillnessbehavior,
managingsociooccupationalconcerns,physicalandmentalhealth,andmanagingmaritalandsexualissuesofthe
patient)wastoenablethecaregiverstothinkclearly,haveequanimityinemotions,improvetheirdecisionmaking
aswellastheirresponsetoasituation,andimprovetheirattention.Areviewofclassicalyogatexts(Gheranda
Samhita,Hatharatnavali,Hathapradipika)andcontemporaryyogatextbooks(Yogendra.,1997,Satyananda
Saraswati,2008Nagendra,2008)showedthatasanassuchasPadahastasana,ardhachakrasana,Vajrasana,
Vakrasana,SalabhasanaBhujangasana,Savasana,Nadanusandana,Matsyasana,Nadishuddhi,Bhramhari,and
Kapalabhattihaddirectorindirectbenefitsinimprovingcaregiver'sabilitytothinkclearly,improvetheirdecision

making/responsetoasituation/attention,andequanimityofemotions.
Thesatsangwasusedtoeducatethecaregiversonhowyogacouldhelptackletheirneedsandhelpinrehabilitation
ofthepatient.
Table1depictsthedetailsoftheyogaprogramdevelopedinaccordancewiththeassessedneedsofcaregivers.The
tableenlistspracticesthatareapplicable/notapplicableinfulfillingthesixassessedneedsofthecaregivers.
Table1
Yogaprograminaccordancetoneedsofcaregivers[Practicesapplicable
(A)/notapplicable(NA)]
Theultimateaimoftheyogaprogramwastoreducetheburdenofthecaregiverseitherbyaddressingtheirneedsor
bydevelopingyogaprogramwhichinturnwouldequipthemwiththeabilityandskillstoreducetheirburden
irrespectiveofthefulfillmentofneeds.Asnotallneedscouldbetheoreticallyaddressedbyteachingyoga,we
focusedonthereductionofburden(aimofthestudy),irrespectiveoftheexpressedneeds.
Thus,theframeworkoftheyogaprogramwasbasedonIntegratedYogaTherapy(IAYT)modeldevelopedby
SwamiVivekanandaYogaAnusandhanaSamasthana[3](SVYASA).ThismodelincorporatedtheSelf
ManagementofExcessiveTension(SMET)/Cyclicmeditationapproachwhichreflectednotonlytheaimofthe
currentstudyofreducingburdenandimprovingcopingamongthecaregivers,butalsodirectlyorindirectlydealt
withthesixbroadcategoriesofassessedneedselucidatedinthefirstphaseofthisstudy.[10]
StageTwo:Faceandcontentvalidation

Forthepurposeofcontentvalidationoftheprogram,theresearcherdevelopedastructuredquestionnaireeliciting
dichotomousresponsessuchasYes/Noandqualitativecommentsontheappropriatenessofeachexerciseand
asanaselectedasacomponentoftheentireyogaprogram.Tenexperiencedyogatherapyandresearch
professionals(inandaroundBangalore)wereapproachedindividuallyforthevalidation.Theaveragenumberof
yearsofworkexperience(SD)oftheexpertsaftertheirformaleducationwas14.8(14.1)years.Throughthis
methodologyofcontentvalidation,theresearcheraccumulatedalistofcommentsforincorporatingintoyoga
program.Forfacevalidationoftheprogram,theresearcheraskedeachoftheprofessionalstoratethelikelihoodof
theprogramachievingitsobjectiveofhelpingthecaregiversreducingtheirburdenandstressonafivepoint
Likertscale.
Toarriveataconsensusonthecontentsandmethodologyoftheyogaprogram,threeroundsofiterationwas
conductedamongtheyogaprofessionals,i.e.,theresearchermadechangestotheprogrambasedoncomments
givenbytheprofessionalsandwentback(iteration)tothemfortheirfurtherinputsonthemodifiedprogram,three
timesbeforeallthetenexpertsagreedonthecontentsandmethodology(datasaturation).
Astandardizedscriptofthefinalversionoftheyogaprogramwasdevelopedonincorporatingthecommentsofthe
tenexperts.Thescriptincludedlistofpracticesandasanasalongwiththeirstepwiseprocedureandpictures,
detailednotesoneachsatsangtopic(seventopicsonetopicforeachdaythescriptisavailablefromtheauthors
onrequest).Ahandoutexplainingthecontraindicationofpracticingcertainasanasduringailmentsalongwiththe
orderandlistofyogicpracticesandtheirpictureswasdevelopedinfourlanguages(English,Hindi,Kannada,and
Tamil)fordistributiontotheparticipants.Eachsatsangtopicandnoteswasconvertedintopowerpointslidesinthe
fourlanguagesforeaseofpresentationtotheparticipants.
StageThree:Pilotstudyandfeasibility

Thefinalversionoftheyogaprogramwaspilottestedonagroupofeightinpatientfamilycaregiverswhowere
residingatNationalInstituteofMentalHealthandNeuroSciences(NIMHANS)inBangalore,India(NIMHANS
hasa900bedteachinghospitalwithtrainingandresearchfacilitiesinpsychiatryandotherneurosciences)during
theperiodofthestudy.
Caregiversofpatientswithadiagnosisofschizophreniawereincludedinthestudyiftheyweretocontinueto
providecareforthemfollowingdischarge.Caregiverswithpsychiatricorneurologicaldisordersandthosecaring

foranotherrelativewithpsychiatricillnesswereexcluded.Oftheeightcaregiversrecruitedinthepilotstudy,three
caregiversdroppedoutduringtheintervention.Themeanage(SD)ofthecaregiverswhocompletedtheprogram
was49.6(19.5)years.Theyhadanaverageof10.4(3.8)yearsofeducation.Allofthemwerefemalesandthreeof
thecaregiverswereparents.Theaverage(SD)durationofillnessoftheirpatientswas12.2(8.2)yearsandnoneof
themhadnotreceivedanypriorstructuredtrainingonhowtheyshouldtakecareoftheirpatient.
Participantsweretrainedinperformingyogaasanasundertheguidanceofatrainedyogatherapist(basedonthe
scriptdevelopedtherapisttrainedbySVYASA).Theinterventionincludedsessionsofaboutonehourdailyfora
periodofsevendays.Duringtheentireperiodofthestudy,theillrelativecontinuedtoreceivetheroutinetreatment
prescribedbythedoctorsatNIMHANS.Attheendofthesevendays,thecaregiverswereaskedtofillastructured
feedbackformontheiroverallratingoftheprogram,trainer,andthehandoutsdistributedduringthesessions.
Descriptiveanalysisofthequantitative(Likertratings)feedbackandcontentanalysisofthequalitativefeedback
receivedfromthecaregiverswasconducted.Eachandeverycommentwasgivenimportanceandtheresearcher
triedtoaccommodateallofitintotheyogaprogram.
RESULTS

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Asthemainobjectiveofthestudywastodevelopandtestthefeasibilityofaneedbasedyogaprogramfor
inpatientcaregivers,theresultsreflectthequalitativedataacquiredattwolevels:atthevalidationstageandatthe
pilotstage.
Atvalidationstage

Forcontentvalidation,expertswereaskedfortheirfeedbackonthecomponentsthatshouldbeaddedintheIAYT
model[incorporatingtheSelfManagementofExcessiveTension(SMET)/Cyclicmeditationapproach].The
suggestionsgivenbytheexpertsareelicitedbelow:
Breathingexercises(likeBhujangasanabreathingandSalabhasanabreathing)needtobeincluded.
Chantingeitherwiththebreathingexercisesorseparately(Nadanusandana)shouldbeincludedasitwould
increasetheexhalation:inhalationratioandhence(inallprobability)stimulatetheparasympathetictone,
whichwouldbeusefulinstressreduction.
Emphasisonawarenessofcalmnessandsilencefromwithinduringasanapracticeisofvitalimportance.For
thisreason,explanationsofthepurposeoftheasanasshouldbedoneintheintroductionorduringSatsang
attheend.
Teachthefullroundof13practicesofsuryanamaskarawithinvocationatthebeginningofeachforatleast
sixminutes.
IampersonallyusedtoPadahastasanaattheend,oncethebodyandlegsaresoftened.Itisagood
preparationforfinalSavasana(orQuickRelaxationTechniqueQRT).
PaschimuttanasanaorHalasanacanfeatureinthelistasthesetwo(possiblyincombinationwith
Sarvangasana)areidealforlooseninguptheregionoftheMuladharachakaraandinductingtheshaktito
flowmorestrongly.
Twistposesareexcellentforrefreshingbloodflowtoalltheinnerorgansintheabdomen,fromwhichthe
renewedflowofthevariouspranasinthenadis/meridianstransformhowapersonfeels.Inthiscontext,even
therotatingswingsperformedduringlooseningexercisescouldbeusefulasa1minutepracticeduringthe
warmupperiod.
Sarvangasanaisthebestpositionforbecomingawareoftheinnersilenceandcouldwellbeputatthe
beginning.
Toadddeepbreathing,nadishodhanaandKapalabhattiintheprogramwhichshouldbepracticed
frequently,example:whileattendingsatsang.
Caregiversneedtoconsciouslyfocusonthestretchwhichmaintainseasyandrelaxedbreathingduring
asanaperformance.Thishasthemostpowerfulcalmingandintegratingeffect.
Basedonthecommentsgivenbytheexperts,theyogaprogramwasappropriatelymodifiedanddevelopedfora
sevendayperiodofonehoureach(inclusiveof45minutesofpracticesand15minutesofsatsang).Theprogram
startedwithlooseningexercises,fiveroundsof13stepsuryanamaskaraexcludinginvocation(duetolackof

time),cyclicmeditation,Kapalabhatti,Nadishuddhipranayama,andchanting(Nadanusandana).Emphasiswas
onawarenessofcalmnessandsilencefromwithinduringasanapractice.Forthisreason,explanationsaboutthe
benefitsofeachasanawasgivenduringthepracticeandincludedastopicsfortheSatsangattheendofeach
day'sprogram.Caregiverswereconsciouslytaughttofocusonthestretchwithmaintainingeasyandrelaxed
breathingduringasanaperformance.Paschimuttanasana,Halasana,andSarvangasanawereexcludedfromthe
programastheauthorsfeltthatitwouldbechallengingforthecaregiverstolearnandpracticetheseasanasdueto
theirage.
Forfacevalidation,onaskingwhethertheoverallyogaprogramwouldachieveitsobjectiveofhelpingthe
caregiversreducetheirburdenandstress,sixofthetenexperts(60%)gavearankoffour(verymuchuseful).
Atpilotstage

Ofthefivecaregiverswhounderwentthepilotyogaprogram,fourofthemassignedascoreoffourorfive(ona
fivepointLikertscale,fivebeingextremelyuseful)fortheoverallprogram,handoutsdistributed,andperformance
ofthetrainer.Qualitativefeedbackofthecaregiversfurtherendorsedthefeasibilityandusefulnessoftheprogram
(M:Member):
Theentireprogramwasgoodasittaughtustheimportanceoftakingcareofourownhealth.Ilikedto
attendtheprogram(M1).
Ilikedtheprogramasithelpedtoreducemyphysicalproblem(legpain)andgavemearelaxedfeeling
(M2).
Theprogramhelpedmetounderstandtheproblem(ofmyhealth)andfindawaytogetrelief.Ilikedthe
chantingofslokasthebest.(M3)
Theinstructorandherwayofteachingwereverygood.AlsoIfeelSuryanamskarbenefittedmethemost.
(M5).
DISCUSSION

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Thechallengesfacedbycaregiversindealingwiththeirrelativewhoissufferingfromschizophreniaarevariedand
extensive.Anumberofinterventionsofferedtofamilymemberswithpatientsofschizophreniahavebeen
developingtohelpdealwiththeburdenandstressofcaring.Thecurrentstudyinanattempttodevelopaneed
basedyogaprogramdescribesthestepsinvolvedintheprogramdevelopment,contentandfacevalidation,and
pilottestingoftheprogram.
Thereishardlyanyresearchstudythatdiscussesthedevelopmentandeffectivenessofstandardizedtraining
programsbasedontheassessedneedsofcaregiversofpersonssufferingfromschizophreniainIndia.Thisattempt
todevelopastructuredinterventionprogrambasedontheholisticcoverageofalltheneedsofthefamilycaregivers
viaaparticipatoryapproach(i.e.,thecaregiversthemselvesopinedtheirneedsandareastheyrequiredtrainingin
whichwasincorporatedtodeveloptheprogram)isofsignificantimportance,eventhoughwewereunableto
matchalltheneedsofthecaregiverstothecontentsofyogaprogram(wherethefocuswasmoretoreduceburden
ofthecaregivers).
Theyogaprogramwasdevelopedafteralotofcollectivethoughtandscientificrigor.Thepossibleeffectsofeach
asanaandexerciseonthephysiologyandmentalhealthofthecaregiverwasweighedtoretaintheasana/exercisein
theprogram(whetheritphysiologicallyreducedthestressandmentallyreducedburdenandimprovedcoping).A
numberofrelatedfactorssuchasageandpossiblehealthconditionsofthecaregiverweretakenintoconsideration
beforeincorporatingaparticularasana/exerciseintotheprogram.Expertshadopinedtheimportanceofeducating
thecaregiversaboutthebenefitsoftheasanas/exercisesattheonsetorduringthesatsangincorporationofwhich
helpedcaregivergaingreaterawarenessofthesubtlechangesinthephysicalandmentalstateovertheperiodofthe
program.
Thoughafewexpertswereskepticaloftheeffectsofyogainhelpingcaregiversrelievetheirburdenandstress,
majorityofthemfeltthattheoverallyogaprogramwouldachieveitsobjective.Skepticismcouldbevalid,asboth
conceptsofburdenandstressarecomplex.Variedpracticalissuescouldweighonthecaregiversmindwhen
askedtoratetheirburdenexample,financialburdenandstressincaregiversisaprolongedeffectofenduring

certainunresolvedpracticalproblems.
Anothercritiqueoftheaboveprogramwasthatitwastooshorttoenablethecaregiverstoimbibetheyoga
techniquesintodailypractice.Traditionalyogatherapistswouldarguethatthesevendayprogramcouldbetoo
shorttoperceiveanyeffectsofyoga.However,developmentofanelaborateprograminthecurrentsettingwould
haveitsownlimitations,mainlybeingthatofhighdropoutsandinabilitytoreachouttomajorityofthecaregivers.
Thisismainlybecausetheaverageperiodofstayofapatientandhiscaregiverinanypsychiatricsettingislessthan
oneweek.ThestatisticsatNIMHANSdepicttheaveragestayofinpatientsandtheircaregiversasthreeweeks.
However,asthepatientisusuallyacutelysymptomaticinthefirstweek,itischallengingtoconductany
interventionwiththecaregiveralone,asthereisnooneelsetotakecareofthepatient.Therearemanybarrierslike
convincingpeopletotravellongdistancesfromtheirhomestoacenterforyogatherapy/psychosocial
interventions[16]oncetheyaredischarged.Inthiscontext,webelievethatoursevendayprogramwaspragmatic
initstimelineandachieveditsgoalofreachingouttomaximumcaregiverswhowereadmittedinthewardsalong
withtheirpatientsatNIMHANS,duringthestudyperiod.
Thesociodemographicprofileofthecaregiverswhoparticipatedintheprogramswasconsistentwiththatofearlier
studiesonIndiancaregiversofpersonswithschizophrenia.[17,18]Allcaregiverswerefamilymembers.Mostof
themwereparents,whowereworkingandwereintolateadulthoodoroldage.
Thefeasibilityandusefulnessoftheyogaprogramwasendorsedbythecaregivers.Thefactthatthecaregivers
wereabletoperformalltheasanasproperly,understanditsbenefits,andfeelrelaxedindicatesthattheprogramwas
feasibleandcouldbetestedonalargerpopulation.
CONCLUSION

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Thisstudyisoneofthefirststudiestouseasoundmethodologyofinductiveenquirymodelforthedevelopmentof
aneedbasedyogaprogramforcaregiversofinpatientswithschizophreniainIndia.Thesefindingsarehighly
indicativeandfuturestudiescouldtesttheefficacyoftheprogramwithalargerquantitativesampletoreconfirmits
validity,reliability,andgeneralizability.Theresearchersplantotesttheefficacyofthisvalidatedyogaprogramfor
familycaregiversofinpatientswithschizophreniainIndiainalargerrandomizedcontroltrial,asanoutcomeofthis
study.
ACKNOWLEDGEMENT

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TheteamwouldliketothankDr.HariprasadVR(SeniorResearchFellow,AdvancedCentreforYoga,
NIMHANS)andMeghnaSDeshpande(Yogainstructor)fortheircontributionindesigningtheyogaprogram.
Footnotes

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SourceofSupport:Nil
ConflictofInterest:Nonedeclared.

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