Perspective The Yamas and Niyamas in Population Health

By Kristine Kaoverii Weber Yoga Morality and Brett Sculthorp The yamas and niyamas can be uti - lized as a lens for biopsychosocialspiritual Consideration of the link between morality decision myaakminags . They promote prosocial on Berwick, former president and and health dates back at least as far as bneiyhamvioars ( ) and personal integration CEO of the Institute for Healthcare Aristotle and the Stoics in the West and ( ), as well as an orientation toward DImprovement, has called for a new Buddhism and the subsequent systemiza - a nonsectarian spirituality. While aspects of the yamas and niyamas can be found in “moral era” in healthcare. He argues that tion of the yamas aenuddneimyaomniaa s in the East. The Greeks linked (“human every major religion, they can be consid - the healthcare industry must change its 5 focus from profit maximization to improv - flourishing”) with virtue, while Patanjali ered trans-religious, beyond the bound - ing quality of care and that healthcare understood the yamas and niyamas as an aries of any particular tradition. According must be practiced with transparency and a antidote to “negative thoughts and actions to Georg Feuerstein, “The foundation of [which] are the causes of unending misery Yoga, as of all authentic spirituality, is a lack of greed. “Without a new moral 6 8 ethos,” wrote Berwick, “there will be no and ignorance,” and the Buddha declared universal ethics.” 1 winners.” that those who abide in morality will receive more “long life, beauty, happiness, While nuances of Patanjali's principles 7 Yoga practices constitute three of the and strength.” The yamas and niyamas, have often been debated in the yoga five most commonly employed comple - as outlined in Patanjali's Yoga Sutra, are world, we propose conceptualizing them mentary and integrative medicine (CIM) descriptions of moral principles and as an Ethics of Empathy (see Sidebar 2). 2 modalities. However, we have observed thatytahme afos undatnioiynaaml pars inciples of yoga— the and —have not been widely researched or systematically inte - grated into the delivery of yoga services. Yet in this discussion about values, ethics, morality, and health, the yamas and niya - mas could make a potent contribution to improving healthcare delivery.

This article will use the yamas and niyamas (see Sidebar 1) as a foundation for discussing a new moral era in health - care at the individual, organizational, and community levels, including exploring the causal relationship between morality and health. We define the yamas and niyamas as “morality” rather than “ethics.” These words are often used interchangeably, but technically, morality refers to beliefs about 3 what is right and wrong while ethics refers to rules of behavior based on those 4 beliefs. Sidebar 1. Yamas and Niyamas meta-ethical elaborations. They are a dual A common-language, non-Sanskritized, Yamas system, best understood in relationship to inclusive version of these two interdepend - Ahimsa Non-harming itself as opposed to linear, discrete princi - ent categories can be used to apply moral - Satya ples, nested in another larger system of ity to healthcare innovation. The first cate - Asteya Honesty Non-stealing practice, the eight limbs of the yogic path. gory is Prosocial Behavior, which would Brahmacarya Buddha and Patanjali do not discuss include empathy/non-harming, honesty, Aparigraha Higher awareness Non-greed “health” per se, but imply that a balanced generosity, holism, and sustainability. The lifestyle is integral to longevity and happi - second is Personal Integration, which Niyamas ness. A holistic definition of health is cen - would include clarity, contentment, Sauca tral to the argument that the yamas and endeavoring, self-awareness, and commit - Santosha Purity Contentment niyamas are integral to the yogic system ment to a higher purpose. Tapas of human thriving and self-actualization. Svadhyaya Sacrifice Ishvarapranidhana Self-study Spirituality

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Sdebar 2. Toward an Ethics of Empathy These levels include looking at morality in Religion and spirituality have been Prosocial Behavior the context of individual behavior, moral shown to positively influence a wide range Ahimsa leadership, community development, and of health measures including wellbeing, Non-harming Satya policy making. The call for morality is a meaning and purpose, depression and Honesty Asteya systemic one that includes bridging the anxiety, alcohol and drug abuse, social Generosity Brahmacarya individual, organizational, and community support, cigarette smoking, heart disease, Higher awareness 17 Aparigraha spheres, from the moral attunement of cancer, and high blood pressure. How- Sustainability individual providers and consumers to the ever, the extent to which the element of Personal Integration behavior of policy makers and leaders in moral behavior has specifically contributed Sauca organizations. to this improved health has not been suffi - Clarity 18 Santosha ciently identified in the research. Tapas Contentment Morality and Individual-Level Health Endeavoring Outcomes Svadhyaya The benefits of one component of Ishvarapranidhana Self-awareness Spirituality, According to the World Health Organiza - morality, prosocial behavior, have been tion, lifestyle factors are the largest con - well studied outside of the contexts of surrender 13 tributor to the global burden of disease. morality or ethics. For example, there is A conscious adherence to moral principles research from the fields of moral cognition that help to moderate behavior is often and moral psychology that looks at how The Call for Morality in Healthcare promoted as useful for individuals looking prosocial behavior reinforces the power of 19 to improve health outcomes. Indeed, the moral self-concept. From the viewpoint of Berwick suggests that the first era of lifestyle advice to eat well; get enough Stephen Porges's polyvagal theory, proso - healthcare was noble or idealistic wherein exercise and sleep; manage stress; wear cial behavior and personal integration can seat belts; and limit harmful foods, risky contribute to overall health and improved medicine was seen as inherently benefi - 20 sexual behavior, and exposure to drugs functioning of the nervous system. From cent and capable of its own self-regula - 14 tion. The second (present) era is an era of and alcohol is pervasive in our culture. a related biological perspective, oxytocin, accountability, scrutiny, measurement, and a hormone associated with bonding and markets in which we value and reimburse There has been little agreement caring, enhances the interpersonal trust performance. Berwick calls for a third era throughout the yoga research community that is essential for prosocial behavior and about the foundational position of the is the foundation of morality in every cul - that would reject the protectionism of the 21 first and the reductionism of the second, yamas and niyamas within the eight limbs ture across the globe. replacing these with honesty, holism, and and whether or not they are a prerequisite values. for “higher” levels of practice, how they However, despite the benefits of should actually be practiced. For example, morality on facilitating prosocial behavior, Berwick's call for a system overhaul there is sparse reference to the yamTahs e which can then lead to better health out - and identifying morality (ethics, in terms of Panridncnipiylaems ansdinPtrhaectniceewopfuYboligcaatiinonHealth comes, placing the moral responsibility of good health solely upon the individual is our definition) as central contributes to Care 15 22 historical calls for social justice, including , and Tim Gard and his team of ineffective. Numerous studies have President Obama's landmark speech in researchers in 2014 found only one study demonstrated that health outcomes are 9 that looked at the effect of the yamas and extremely complex and intricately influ - 2009 on healthcare reform. Others call for 16 10 niyamas on health outcomes. enced by social determinants rather than designing safer systems of care, the 22 development of professional moral solely by individual behavior. In fact, rela - 11 courage, and a recently proposed 12- Beyond the yoga community, there is tively recent research suggests that up to point code of ethics for public health that little research in general on the direct link 70% of the health locus of control is exter - between moral behavior and health. How - nal to the individual and dependent upon includes principles of human rights and 23 distributive justice (a socially just alloca - ever, a substantial amount of research has social determinants of health. According 12 tion of goods). begun to emerge linking spirituality and to Berwick, “Among the great disrupters of health are injustice, inequity, racism, and a failure to regard healthcare as a human According to the World Health Organization, lifestyle right. The commitment to a fair and just factors are the largest contributor to the global burden society, one in which equality is embraced, [is one] in which responsibility for each of disease. A conscious adherence to moral principles 24 that help to moderate behavior is often promoted other is part of the fabric.” as useful for individuals looking to improve health If the yamas and niyamas are founda - outcomes. tional to yoga and are universally applica - ble and morality is beneficial to individual 17 These various calls for morality and religion to health. This research suggests health outcomes, then we need a strategy that those who engage in religion/spiritual- to import this theme into the healthcare ethical behavior in healthcare are notable, 17 but because healthcare is a vast field, ity have improved health outcomes. context. For that to happen, we need to several levels need to be considered. www.iayt.org YogaTherapyToday | Summer 2016 29 Perspective continued

ahimsa demonstrate the link between the yamas dle morality with postures or breathing For esxaatyma ple, do (non-harming) and niyamas and healthcare outcomes. practices. A critical factor will be the evi - and (hsoanuecshtya ) reduce allostatic Embedding these principles within behav - dence base regarding whether the yamas lsovaadd?hyDaoyea s (purity, clarity) and ioral health programs is one possibility; and niyamas are most effective as part of (self-awareness) increaseigshra-y however, providing evidence of their an eight-limb system or as a standalone mvaarattperainidthheanparefrontal cortex? Does effects will be essential. practice. (spirituality, surrender) Scaling Morality to the Organizational Scaling Morality to the Community aimspteryoave heart rate variability? Does Level Level (non-stealing, generosity) facilitate the development of the social engagement Organizational Development (OD), a field Translating morality from an individual part of the nervous system? Does oxy - of practice developed by psychologists in level to a community level requires collab - tocin increbarsaehmtharocuagryha adherence to the 1930s, provides a body of knowledge oration across all sectors, including lead - asteya or (higher aware - for understanding the application of ethics ers in the fields of health, behavioral ness)? at the organizational level. OD uses health, business, education, justice, and research, theory, and practice to optimize others. Developing critical mass in com - In terms of the yoga therapy commu - organizational change and performance munity leaders who share a common ethi - nity, what is the process for accessing and to help organizations learn and adapt cal commitment to change is essential for organizational ethics given the lack of col - to rapidly changing and complex environ - improving the health of the whole commu - laborative focus on the yamas and niya - ments by transforming organizational nity. The yamas and niyamas may provide mas? In a recent SYTAR plenary talk, 25 norms and values. a moral platform from which community Matthew Taylor, PT, PhD, noted that he The Principles and systems can allow creativity and problem- has tried to promulgate the importance of In their chapter in solving capacities to emerge. For instance, risk management in the yoga community Practice of Yoga in Health Care 28 , Alyson strategies like Collective Impact, a prob - but “nobody wants to talk about ahimsa. ” Ross, PhD, RN, and Andreas Michalsen, lem-solving framework that addresses Refining an appropriate social marketing PhD, suggest that the implementation of major social issues with an integrated strategy that will help the yoga therapy yoga lifestyle could best be effected in community approach across domains, community improve the image of yoga as 15 schools and workplaces. This could could utilize an adapted version of the a healthcare system may increase interest in yoga's other limbs, including the yamas and niyamas. Until more research is Relatively recent research suggests that up to 70% undertaken, we will continue unwittingly of the health locus of control is external to the perpetuating the reductive misconception individual and dependent upon social determinants of yoga as asana, which minimizes the of health. potential benefit of yoga on health. Another area of focus could be deep - involve using organizational policies and yamas and niyamas, like our proposed ening the alignment of the yoga therapy procedures to reward culture change, as Ethics of Empathy, to provide an accessi - profession with the integrative medicine well as prosocial behavior and personal ble language of morality to test the deci - community, which has already been integration choices. Organizations like sions and actions of these community- adopted into the conventional medical 26 Google and Whole Foods have been focused organizations. "Accountable system. Yoga therapy could gain more developing values-oriented systems, and Care Organizations" or "Accountable acceptance by collaborating and integrat - 27 many schools promote ethics and values Health Communities" may be a context ing with this, our most important profes - as foundational to their function and for aligning organizational values and sional alliance, which currently has better purpose. ethics but, again, the credibility of a yoga- connections with the larger healthcare based ethical system must start with community. Because yoga practices con - In order for healthcare to change, a research. tain the most commonly used CIMs, yoga broader healthcare leadership committed Areas of Focused Action for the therapists are uniquely skilled at providing to a process of deepening personal and Yoga Therapy Community techniques, practices, and a worldview professional morality will need to emerge that can be seamlessly merged into the and collaborate. The yamas and niyamas delivery of truly integrative care. How can could be used as a central reference for If the yoga therapy community acknowl - the yoga therapy community better align quality management decision makers. As edges the yamas and niyamas as founda - with the integrative medicine community to with the individual level, a solid evidence tional, then they should likewise be specifi - offer the practices and philosophy of yoga base for its effectiveness at the organiza - cally acknowledged as central to the pro - to the benefit of the models, philosophy, tional level will be required. Workplace fessional code of conduct. While there has and implementation of integrative medi - wellness and leadership development pro - been a significant effort to bring asanas, cine? One way is through user leadership grams could be used as a vehicle, particu - pranayama, and meditation into healthcare development programs to propagate ethi - larly if coupled with other aspects of the and to back up their effectiveness with cal conduct within their communities of yoga system. Understanding the yamas empirical data, there is also a need to practice. In this way, both the yoga thera - and niyamas as part of a system will be study yoga's first two limbs. An important py profession and the integrative medical important for some, although others may goal is to research how adherence to, or community will greatly benefit. feel more comfortable not having to bun - practice of, specific principles affect health. (continued on page 50)

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Spirituality & health research: pists, we are now also equipped with the Morality, ethics, and health are 1M7e.thKoodesn,igm, eHa.sGur.e(m20e1n1t,).statistics, and resources. vocabulary that will allow us to directly com - tangibly linked. If yoga therapy is to West Conshohocken, PA: Templeton Press municate with Quinn's doctor. move beyond the studio, then morality 18. H.G. Koenig (personal communication, June 15, 5. Assess needs to be a part of this expansion. 2016) As a community, we have an opportuni - 19. Young, L., Chakroff, A., & Tom, J. (2012). Doing ty to expand our definitions and make Good Leads to More Good: The Reinforcing Power of a assess Moral Self-Concept. Retrieved April 16, 2016, from The fifth and final step is to . This step the yamas and niyamas an integral part http://moralitylab.bc.edu/wp-con - evaluates the effects of the treatment plan we YofToT ur understanding of yoga therapy. tent/uploads/2011/10/3YoungChakroffTom2.pdf applied in our approach. 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An eight- A. (2016). Health Services Delivery and Ethical Health Education Center. Brett Sculthorp, week yoga intervention is associated with improvements in Implications. Xlibris. LCSWA, LCASA, CSAPC, is a therapist pain, psychological functioning and mindfulness, and 13. 2.1 The Global Burden of Chronic Disease. at Family Preservation Services and the changes in cortisol levels in women with fibromyalgia. Journal of Pain Research (4) (n.d.). Retrieved May 30, 2016, from co-director of Subtle Health, LLC. They , 189-201. http://www.who.int/nutrition/topics/2_background/en/ live in Asheville, North Carolina, with 14. Ornish Lifestyle Medicine | the proven program. their son. www.subtleyoga.com Pamela E. Jeter, PhD, is (n.d.). Retrieved May 30, 2016, from a yoga researcher and https://www.ornish.com/proven-pro - educator trained in cogni - gram#section_lifestyle 15. Ross, A., & Michalsen, A. (2016). Yoga for pre - tive science and clinical vention and Wellness. In S. BT.hSe.pKrihnaclispale, sL.aCndohen, investigation. She is the pT.raMcctiCcealol,f&yoSg.aTienllehsea(Elthdsc.a) re. founder of Yoga Therapy East Lothian: Hand - for the Blind, co-founder of The Science spring Publishing, Ltd. 16. Gard, T., Noggle, J. J., Park, C. L., Vago, D. R., Sutras, and faculty at the Maryland University & Wilson, A. (September 30, 2014). Potential self- of Integrative Health. Pam can be reached at regulatoFrryomnteiecrhsainisHmusmoafnyNogeaurfoosrcpiesnyceh,o8logical [email protected]. health. , 8.)

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