Kundalini yoga as mutual recovery: a feasibility study including children in care and their carers

Introduction

Children are looked after by local authorities for various reasons, including abuse, neglect, challenging behaviour, breakdown of family relationships, homelessness and disability (Department for Education (DfE), 2012). Corporate care is far from perfect, with cumulative evidence showing that children in care (CIC) are still among the most vulnerable children in society. Within the UK, outcomes following local authority care have improved in the last ten years but are still poor and research has shown that CIC still have higher physical and mental health needs than their not-in-care counterparts (Department for Education (DfE), 2014) and in comparison with children who are in other forms of care such as family foster care (Lee et al., 2011). CIC are more likely to have special educational needs (SEN; 66 per cent have a statement of SEN), poor educational performance, more contact with the criminal justice system, poorer health and greater vulnerability to homelessness and unemployment (DfE, 2014; National Audit Office, 2014). Only half of CIC have emotional and behavioural health that is considered “normal” when using statistical terms (DfE, 2014). Moreover, CIC are substantially overrepresented as both victims and perpetrators of crime (Department for Education and National Care Advisory Services, 2013; Department for Education (DfE), 2013; Centre for Social Justice, 2014). It is difficult to determine, however, the extent to which these outcomes are as a result of experiences prior to entering care or experiences once in the system (Rodrigues, 2004).

One of the contributory factors to this disadvantage may be workforce skills. A report produced by the Expert Group (DfE, 2012) on the quality of children’s homes highlighted the main issues facing the workforce as: insufficient levels of qualification, specialist knowledge and skills; inadequate career pathways and progression routes; a lack of reward and recognition; and a lack of identity or shared core professional standards. A recent research report commissioned by the Department for Education (DfE) (2015) and co-produced with a series of stakeholders, including CIC and children’s home staff, has explored the qualifications, skills and training required to meet the needs of CIC. This, together with the latest OFSTED (2014) report, have highlighted a series of recommendations to improve the quality of care and staff (i.e. youth practitioners) working in children’s residential care. These recommendations include training on techniques for improving practice and new methods for working with children and young people as well as procedures for working in a children’s home.

Another factor affecting outcomes for CIC is the problems children have with forming relationships. Children’s responses to staff may well be influenced by previously damaging interactions with adults. This is known to have an impact on both initial attachment and the ability to form trusting relationships over time (Golding et al., 2006; Hughes, 2004; Thomas and Johnson, 2008). This may partially explain why some forms of therapy are not as readily accepted or engaged with, particularly those which rely on relationships of trust to be effective, which include most psychological interventions. A review of the literature pertinent to looked after children’s views of mental health services (Davies and Wright, 2008) identified ambivalence towards professional intervention, noting that children “felt wary of professionals and uncared for”; and ambivalence towards talking. The review concludes that “research suggests that the therapy type (e.g. cognitive-behavioural therapy, family systemic therapy) is less important, rather the experience of being heard and understood could be the foundation for a good match between a child’s need for action and therapeutic responsiveness” and that “eliciting looked-after children’s views of their mental health service should be standard practice: both in individual treatment and in service development discussions”.

This is consistent with policy and practice developments that have put greater emphasis on services user involvement in mental health services. This remains an important part of government policy, with the 2010 White Paper, “Equity and excellence: liberating the NHS” (Department of Health, 2010), making the explicit statement “no decision about me without me”, which is adapted from a phrase widely used in the disability movement and one used in patient and public involvement in England for over ten years (Gilbert, 2003). Service user involvement is widespread across health and social care services in the UK (Simpson and House, 2003) but it is clear that this is less widespread in service for CIC (Davies and Wright, 2008).

Local authorities usually explore different alternatives (e.g. foster care) before placing children in residential care, which is often perceived as “last resort” and there has been a steady decline in the use of children’s homes since the 1970s. In 1978, 32 per cent of CIC were living in a children’s home, secure unit or hostel (Berridge et al., 2012) compared to 9 per cent in March 2012 (DfE, 2013). In addition, children’s home have, for the most part, become small group settings. This can be characterised as a move from dependence to independence, and reflects developments in all areas of social care in the UK. Although the move from dependence to independence has been widely (in fact, almost universally) welcomed, it is not without its problems. In particular, the focus on the individual and their condition or diagnosis remains on people’s illness, impairment or, put bluntly, deficit. We have started to consider independence as a necessary, but temporary, stepping stone towards interdependence. Interdependence recognises the reality that, though we may be individuals, we all rely to a greater or lesser extent on one other. We have noted above that for support for CIC to be effective, the condition of the relationships between people is as important as the condition of the individual (Davies and Wright, 2008). This narrative moves our thinking from people lumped together as a single problem to people as a collection of individual problems and as a whole community that can provide both problems and solutions (Crepaz-Keay et al., 2015).

In order to address the inequalities and high levels of mental health needs of CIC, it is, therefore important to deal with a number of key factors including improving workforce skills, giving a stronger voice to CIC, building positive relationships between staff and CIC and improving trust relationships through creative approaches to therapeutic interventions. In short, a more mutual, reflective and collaborative approach may be productive. This includes promoting reflective practice in the workplace, for example, thinking critically about one’s contribution, to enhance personal professional development and improvement (Jasper and Rosser, 2013). Several models for reflective practice have been proposed to facilitate staff engaging in a process of continuous learning (Paterson and Chapman, 2013). A key component involves taking a conscious and mindful look at emotions, thoughts, actions and responses, and using that information to reach higher levels of understanding about the personal professional experiences of staff.

We contend that the desirable personal attributes that both CIC and staff identified as core qualities important among those working in residential child care. These qualities included: being caring, physically agile (i.e. active and sporty), calm, patient, non-judgemental (in-tune with young people), positive and cheerful. These specific qualities are central for the promotion of human health and well-being and are the focus of a study of the nascent discipline of Health Humanities (Crawford et al., 2015) which provides a robust framework for bringing more creative practices to current health and care settings.

Creative practice as mutual recovery

This feasibility study was framed under the notion of creative practice as mutual recovery, the idea that shared creativity, collective experience and mutual benefit can promote resilience in mental health and well-being among communities that traditionally have been divided (e.g. children’s home staff and CIC). Mutual recovery (Crawford et al., 2013) has its roots in the increasingly influential notion of “recovery” in mental healthcare, and refers to the possibility of achieving a meaningful and more resilient life irrespective of mental health “symptoms” or disabilities. Mutual recovery is, by definition, a reciprocal relationship in which all members – service users, residents, professionals, clinicians and everyone else involved – benefit together. Traditionally, recovery-based interventions tend to focus almost exclusively on treating service users, failing to address the high levels of “burnout” and work-related stress among informal carers, and health practitioners (Arber and Venn, 2011; Veage et al., 2014). Mutual recovery challenges the traditional recovery model as an individualised and unidirectional process by promoting spaces where interventions are experienced together. Enacting togetherness is an important relational concept within mutual recovery (Nyman et al., 2012). By engaging in creative practices with someone else, we are expecting the participants to gain access to, and become part of an unfolding enacted narrative that could improve the relationships that form in residential children homes.

Taking into consideration the personal attributes and core qualities that CIC identified as important among residential staff (i.e. physically active, positive, calm), the systematic poor outcomes reported within CIC populations and the high levels of stress experienced by residential staff and management working in children’s home, we proposed a creative practice – Kundalini yoga – for bringing together a diversity of people, including management, youth practitioners and CIC, to establish and connect communities in a mutual or reciprocal fashion to enhance mental health, well-being and social inclusion among all stakeholders.

One of the benefits of yoga over other physical exercise or creative therapies is that it gives a sense of connectedness to the self and others, facilitating healthier relationships and a sense of togetherness which is a need expressed by the caring staff of these homes.

What is yoga?

In the Sutras (Bryant, 2009), Patanjali describes yoga as “calming the fluctuations of the mind stuff”. That is to say that the goal of yoga is to calm the mind and affect the way we not only think, but also how we interact with the world. Through asana (yoga postures) and pranayama (control of the breath) we can positively affect our lives and interactions with others.

What is Kundalini yoga?

Yoga means union. Originally designed as a preparation for the body for meditation, it has become, in modern times, well recognised for the ability to de-stress, and improve many mental and physical conditions. Yoga is a non-pharmacological intervention with few if any adverse effects (Cramer et al., 2013) and can be practised both in groups and individually. Yoga is highly versatile and offers a valuable self-help tool that can be adjusted and tailored to individual needs (Vorkapic and Range, 2014). Cumulative evidence documenting the therapeutic benefits of yoga has grown considerably in the past few years with more healthcare practitioners drawing attention to these more contemplative Eastern practices, including tai-chi and meditation. For example, the British National Health Services recommends the practice of mindfulness to treat stress, anxiety and depression. Not only has the quantity of studies increased but the quality of the research has improved exponentially, now including controlled trials and active control groups (Khalsa, 2004). The positive benefits of yoga have been reported in studies tackling several mental health issues such as depression, sleep disorders, anxiety and panic disorder (Balasubramaniam et al., 2012; Khalsa, 2013; Varambally and Gangadhar, 2012; Deepak, 2013). The study of yoga as a complementary therapeutic intervention has also been proven successful in the treatment of insomnia (e.g. Larouche et al., 2015) as well as a main therapeutic intervention in effectively reducing stress (Smith et al., 2007; Michalsen et al., 2005; Malathi and Damodaran, 1999; Esch et al., 2003), anxiety (Sahasi et al., 1989; Vahia et al., 1973; Sharma et al., 1991; Broota and Sanghvi, 1994; Oken et al., 2006; Kjellgren et al., 2007; Javnbakht et al., 2009), depression (Oken et al., 2006; Michalsen et al., 2005), and stress-related symptoms such as hypertension and insomnia (Smith et al., 2007). Relevant for this study is the work of Conboy et al. (2013) showing that amongst a group of high school students there were many reported benefits of the regular practice of yoga, such as improved self-image, posttraumatic stress disorder symptoms and the propagation of optimism about life challenges (Clark et al., 2014; Rhodes, 2015).

Kundalini is a more dynamic type of yoga with a special focus on breath and movement that works predominantly on the glands and nervous system. It differs from other more classical styles of yoga where quiet still postures are predominant. Called by practitioners, “the yoga of awareness”, Kundalini yoga includes repetitive vocalisations (i.e. chanting), breathing exercises (i.e. pranayama and breath of fire), yoga postures (i.e. asana) and meditation to facilitate a calmed and relaxed state of mind and body. This approach is much more suitable for those who have high levels of anxiety or trauma as it gives “hooks” for the mind, keeping the practitioner occupied with following the rhythms of the practice. When the nervous system is over taxed due to stress, coming to a quiet still place requires a physical release provided by combining challenging physical fitness with dynamic meditations. When practiced in a secular way, Kundalini merges traditional mantras with uplifting fun music whilst stimulating the “feel good” brain chemistry. This combination improves relationships (e.g. sense of connection to others and self), promoting compassionate thinking, and attentional focus. Practised regularly over an extended period of time, these changes in perception have the potential to affect the approach to life of participants in positive and profound ways (Castro, 2015).

This study assesses the feasibility of whether a more dynamic, fun and physical type of yoga can improve well-being, mental health and relationship outcomes on children living in a residential home. We hypothesise that this type of embodied practice will be more appealing than conventional therapy or other forms of treatment that may lack the physicality and dynamism present in Kundalini yoga. Although there have been non-controlled studies of the effects of yoga in children’s homes, we reasoned that this type of yoga could have beneficial effects in a setting where psychological functioning is often low and the frequency of impulsive behaviour high. The idea that you are affected by your environment and the people around you informs the approach of “mutual recovery” and the need to include formal/informal carers in the recovery process, who also experience high levels of stress while caring for traumatised individuals. Children’s homes bring an unprecedented opportunity to re-think responses to mental health distress and well-being through the arts and humanities, specifically under the framework of “creative practices as mutual recovery”.

Methodology

The feasibility of a mixed methods study was evaluated according to the following: recruitment and retention rates, self-report questionnaires and semi-structured interviews. The study was conducted from November 2013 to July 2014 and participants were recruited from a private residential provider comprising three children’s homes situated within the East Midlands region of the UK. The three children’s homes were rated by the national inspectorate, OFSTED, in 2013 as adequate, good and outstanding, respectively.

Recruitment was considered at three initial meetings with management to inform them about the study, followed by two more meetings to inform youth practitioners and CIC. The research was verbally explained to all stakeholders and recruitment packs were distributed containing a letter for prospective participants, a study information sheet, a consent forms and a demographic questionnaire. Ethical approval and oversight was undertaken by the School of Medicine at The University of Nottingham (UK). The only inclusion criterion was the willingness to participate in the research protocol and yoga sessions. There was no exclusion criterion.

The style of yoga was based on a secular version of Kundalini yoga. The programme was delivered via a 20-lesson-plan and included postures, breathing exercises, chanting, dancing and meditation techniques. Each 44-60 min session was generally structured to include warming up, one or two periods of meditation or rest combined with physical movements ranging from warm ups to a peak session of dancing, running, shaking and squats, combined with some static postures, cooling down, 10 min of relaxation, and ending with 3-5 min of meditation. In some aspects it resembles the newly popular interval/intensity training (Buchheit and Laursen, 2013) in that there are short bursts of intense activity, but this is combined with the benefits of mindfulness and meditation which balance the elevating effect of exercise.

Certificates of attendance (see Appendix 1) were offered to all CIC, a £10 gift voucher was offered to the two CIC with best attendance rates.

Immediately before and after the 20-week yoga programme (see Table I), a trained researcher administered the children versions of self-report questionnaires designed to assess well-being with the Warwick-Edinburgh Mental Health Well-being Scale (WEMBWS; Appendix 2) and social inclusion (Appendix 3) to CIC and the adult versions of those same questionnaires, plus the General Health Questionnaire (GHQ-12, Appendix 4 designed to assess mental health to staff). Completion of questionnaires took 15 min while completion of the recruitment pack took an average of 20 min.

The qualitative semi-structured interviews were adapted from Conboy et al. (2013; see Appendix 5). The interviews were conducted within one to three weeks after the administration of the post-yoga session questionnaires. A representative sample of participants (n=9) was selected to participate in interviews via stratified randomisation; strata were gender, status (resident/staff) and children’s home (n=3). One interviewer familiar with yoga and meditation was trained to conduct the interviews one-to-one over the phone. When appropriate, interviewers probed participants to retrieve explanations and experiences related to the yoga sessions. Each interview was audio-recorded with participants’ permission and took an average of 15-20 min. A thematic analysis was applied. The audio transcripts were first read at least twice and then double coded for themes independently by two of the authors (E.P.V. and M.B.) and any disagreements in coding were addressed in discussion. Coding consisted of searching for sought themes and emergent themes in each transcript, as well as condensing responses to each topic across the sample. We used NVivo v10 and Microsoft Word Office 2010.

Results

Discussion

Little is known about the use of Kundalini yoga in children’s homes. This mixed methods feasibility study explores the experiences of CIC, youth practitioners and management staff participating together in the treatment arm of a 20-week yoga programme. We asked participants about the practice of yoga, its perceived benefits and their experiences participating in the study. They reported individual benefits (such as stress reduction and better sleep), social benefits (such as feeling more positive and open to others), suggestions to improve the design of future programmes (such as more foregrounded co-construction and stakeholder involvement) and ways of improving the design of the research with this population (such as reducing the amount of the paperwork).

Due to the low engagement rates, participants were asked to offer suggestions for improving the feasibility of the intervention in this context. During the 20-week programme, participants were invited to provide feedback regarding retention rates and suggestions included bringing food for sharing after yoga when the sessions took place outside the children homes (e.g. church hall) or cooking a meal in the children’s home and dining together, so promoting the community spirit and also taking advantage of the calm and pleasant feelings experienced right after the Kundalini yoga practice. This suggestion was put into practice and was well accepted, creating a feeling of togetherness and the opportunity to share food with others.

By engaging in the yoga practice with others, residents and staff gained access to the experiences of others and responses to actions which created spaces for interpretation and empathy. Spontaneous vocalisations (e.g. loud sighs) enhanced the social togetherness and a sense of proximity to others. The yoga sessions were designed as a social activity, as something to be done together. The more dynamic aspects of the yoga practice (e.g. jumping), in combination with the more relaxing parts (e.g. lying down), enhanced the positive effects on physical and mental health while promoting a sense of connectedness to the self and others.

Some of the CIC brought their favourite music tunes to be played during the yoga sessions, promoting ownership and participation. All participants reported liking the yoga programme, not willing to change any aspect of it and a wiliness to continue it.

Importantly, the self-report questionnaires did not capture any statistical change due to high rate of attrition but they did show alarming levels of self-reported clinical depression among the staff. This result emphasises the need to promote mutual recovery in terms of well-being and mental health in children’s homes among CIC as well as the staff and confirms the importance of self-care practices, as well as, raising the profile, status and pay of those who work in children’s residential care. It is self-evident that staff in children’s homes are working with some of the most vulnerable members of society, yet their pay and status leaves them feeling very undervalued.

Taking into account that positive, good quality interactions between carers and children are key to the success or failure of a residential placement – as they determine whether the environment is one of care or stress (Holden, 2009) – we would postulate that improvements in the well-being of carers as well as children allow for a mutual and reciprocal improvement in well-being. We argue that if residential staff were better equipped emotionally, then the outcomes for children would be enhanced. One route to enhancing well-being is the shared practice of Kundalini yoga, especially when taking into account interviewee statements indicating that they felt more tolerant, less stressed, more patient, open, positive and receptive to CIC – all attributes perceived as highly desirable by CIC.

To our knowledge, there is only one published study by Kennedy et al. (2013) involving front-line staff alongside the children and this was undertaken in the psychiatric department of a large children’s hospital. The study reported in this paper shows that yoga sessions (alongside other arts therapies) improved self-esteem, taught coping skills and provided relaxation among other benefits. Participants reported personal and professional benefits as well as being able to perceive the benefits the patients were getting from the therapy. We must be careful not to generalise the results of this study too widely as it is not possible to isolate the individual impact of the yoga itself as it was part of a wider range of therapeutic activities (music, art, dance/movement); it was also conducted using a sample of children who all suffered from diagnosable mental health disorders, so the outcomes may be different when compared with those of children without a formal diagnosis. The benefits of this mutual recovery approach, where children and staff in residential homes took part in an activity together, is one of the aspects that was explored by our study.

Conclusions and recommendations

The general conclusion that residential care for children is not ideal, expensive and has few long-term benefits – particularly those who stay for a long time – is supported by many studies and reports (e.g. De Swart et al., 2012; Frensch and Cameron, 2002; Hair, 2005). However, this provision is the “last resort” for approximately 5,000 children in England (DfE, 2014). Viewing recovery as reciprocal opens up new possibilities for examining how recovery for mental health and well-being in children’s homes could be enhanced through shared practice between CIC and residential staff – and through outreach beyond children’s homes including education personnel and local community groups – and how creative practice may contribute to this. The perspective of “mutual recovery” challenges current individualised and divided conceptions of recovery within social and health care services and policy, instead seeing it as an interactional, holistic and mutual process where all players are present enacting togetherness, so instigating a more comprehensive and meaningful understanding of the recovery process. Indeed, the study has provided qualitative evidence to suggest that the goal of yoga (i.e. union) has been achieved for the participants of this study as most mentioned feeling more open to others and nearly all of them described the practice as calming and relaxing.

We found evidence that creative practice as mutual recovery (i.e. the practice of Kundalini yoga in children’s home when participation involves both CIC and staff) is a plausible intervention that can lead to individual and social benefits, even when such gains are not directly prescribed by the yoga programme or captured on the self-report questionnaires. This is an exciting finding for it suggests that yoga practice, in children’s homes, especially when participation is high, has the potential to enact togetherness and mutuality and improve health and psychological outcomes for CIC as well as for the workforce. Consequently, when yoga is practiced in a group, it has the potential to minimise the negative consequences associated to poor outcomes (e.g. higher risk of poor mental health and increased likelihood of being a victim or perpetrator of crime) by promoting emotional and social togetherness.

In order to maximise retention rates, participation and, therefore, potential benefits, a series of suggestions and recommendations can be made. The study has shown that both CIC and youth practitioners were unsure of whether attendance was prescribed or voluntary, possibly resulting from what participants considered heavy agreement and consent documentation or a presiding top-down decision making within these often challenging environments. Future interventions should promote a horizontal structure (instead of a vertical top-down approach) where equal partnership within CIC, staff, yoga teachers and researchers is celebrated. Working with stakeholders as equal partners is important to guarantee an active and balanced involvement in the designing process and decision making, enhancing participation and ownership. It is essential to co-design strategies and guidelines to maximise the success of any intervention even though this may require more time for planning the intervention. We suggest the creation of a reference group that will include a representative sample of those directly and indirectly involved in the project that should meet several times before any decision is taken to build rapport, trust and leadership. This reference group will discuss potential solutions to known barriers and also participate in a series of workshops to discuss relevant evidence related to the project to improve understanding of the “why” and “what”. Implementation strategies should be co-produced with stakeholders to ensure that these are sensitive to cultural differences and relevant to a specific point in time. In this way, interventions co-produced with specific communities will differ from other programmes developed for similar communities as each context is treated as unique.

We also suggest minimising paperwork and providing information verbally to participants, if considered ethically acceptable, and using passive consent and opt-out procedure instead of explicit consent.

Further research should be designed to overcome the methodological limitations of the current study including the relative small number of participants and total number of sessions completed in the intervention, as well as the absence of a comparison or control group (e.g. other group activity). A larger and more representative sample involving several children home providers could allow a better understanding of the numerical findings from the questionnaire measures and a greater focus on mutuality (i.e. the social benefits linked to enacting togetherness). The above recommendations for maximising participation (e.g. creation of a reference groups) will feed the design of a larger pilot study that it is expected to produce a more powerful approach to quantitative data as well as a greater focus on the concept of “mutuality”.