The ancient yogis didn't view yoga as a therapeutic modality. For them, yoga was a path to liberation, an end to suffering. They couldn't have helped but notice, though, that everything from aches and pains to resistance to getting sick improved in those who took on the practice. Since disease was considered an impediment to practice, anything that improved health was a boon to spiritual development.
The first limb of Patanjali's eight-limbed path (ashtanga yoga) is the yamas, the moral injunctions. The first of these, and the foundation of both yoga and yoga therapy, is ahimsa, nonharming. This is equivalent to the Hippocratic maxim to "First, do no harm."
The last thing you want to do as a yoga therapist is to give students practices that end up causing injury or otherwise making them worse. This means you are going to want to be patient, conservative in your recommendations, and well-versed in contraindications to various yoga practices. You would not, for example, recommend inversions to someone who had had a cataract operation last month. You are also going to want to monitor your students closely as they practice during lessons or class to make sure that harm doesn't result from, say, structural misalignments in asana, or nervous system agitation from Pranayama exercises that are beyond their abilities.
Together, the yamas including satya (truth-telling), aparigraha (not being greedy), and brahmacharya (avoiding inappropriate sexual behavior) form the ethical basis of the practice of yoga therapy.
The first three of the niyamas, or personal observances—ashtanga yoga's second limb—are tapas (fire or discipline), svadhyaya (self-study), and ishwara pranidhana. The usual translation of the latter is "devotion to the Lord," but I prefer to think of it as "giving up the illusion that you are in control of what happens." These three niyamas also form what Patanjali calls kriya yoga, yoga of action. Success in yoga therapy is about practice, not theory. The best yoga prescription won't succeed if you can't get your students to do the work.
This is where tapas comes in. You need to cultivate in your students the enthusiasm—and on days when enthusiasm is lacking, the discipline—to get themselves to their sticky mats or meditation cushions. Self-study involves getting clients to look honestly at how their behavior or attitudes could be contributing to their ill health, or how changes might facilitate recovery.
Ishwara pranidhana is about acknowledging that, despite your best efforts, what you hope will happen may not happen. You may not recover from some conditions. In the end, everyone dies, whether they are ready for it or not. Ishwara pranidhana is not about fatalism, though. Letting go of the illusion of being in control is analogous to the advice found in India's beloved Bhagavad Gita: Give your best effort and let go of the results. When you acknowledge to yourself that what happens is ultimately uncontrollable, it can lift a psychological burden—and the stress that goes with it—that can actually interfere with your ability to heal.
Suffering and the Monkey Mind
While modern medicine has a number of effective tools to deal with pain (though they are often not well implemented), it has a much harder time with suffering. Suffering is mental anguish heaped on top of pain, disease, and debility—which can make coping with them so much harder.
Suffering is often fueled by the stories people tell themselves: I'm never going to get better. My life is over. Nobody's going to want me now. In other words, suffering is largely about the mind, and this is precisely the area the ancient yogis studied with such precision. Sages likened the restless mind to that of a drunken monkey. At the very beginning of the Yoga Sutra, Patanjali defines yoga as that which "stills the fluctuations of the mind," the verbal tape loops that lead to so much unhappiness.
Finding Your Dharma
Ironically, it is the diagnosis of a life-threatening illness that gets many people—sometimes for the very first time—to look at their lives to see if they are living they way they really want to. It's not uncommon for people in such circumstances to quit an unfulfilling job, decide to spend more time with loved ones, or revive a treasured hobby, like painting or playing a musical instrument, that they'd given up years earlier because it wasn't "practical."
Yoga tends to build a sense of interconnection, the idea that you are part of something bigger, something that many people would call sacred. By putting your students in better touch with the quiet place inside of them where intuition wells up, yoga also can facilitate the quest for meaning in life. Why are you here? What have you got to contribute to the world? Finding your dharma, as yogis call it—your life purpose—can be a profoundly healing force.
Serious illness can thus be a gateway to explore a spiritual side of life that your students may have previously ignored. It may sound trite, but I can't tell you how many people have told me that getting cancer or an HIV infection is the best thing that ever happened to them. It's not that they think getting sick is good, or that they'd wish it on anyone else. Their illness simply served as a wake-up call and provided the impetus to start living life in a way that better reflects their true selves.
Dr. Timothy McCall is a board-certified internist, Yoga Journal's Medical Editor, and the author of the forthcoming book Yoga as Medicine (Bantam Dell, summer 2007). He can be found on the Web at www.DrMcCall.com.