6 yoga in addicted people – critical problem of compliance ======================================================== karel nespor, m. d

6
Yoga in addicted people – critical problem of compliance
========================================================
Karel Nespor, M. D., Ph.D.
Executive member of the Czech Addiction Society
Department for the Treatment of Addictions – Males (Head), Psychiatric
Hospital Praha
Institute for Postgraduate Education Praha
Address: Psychiatricka lecebna, Ustavni 91, 181 00 Praha 8, Czech
Republic
[email protected], www.plbohnice.cz/nespor
J. Res. Educ. Indian Med. 2007; 13(1):17-26.
Summary
-------
Yoga is a useful part of the complex treatment of addictive diseases
for several reasons such as stress management, better coping with
emotions and pain or increased self-awareness. The problem is
compliance with long-term regular practice. We distributed an original
questionnaire among 53 former and 103 current inpatients treated for
addictive diseases. Among them 70.2 % felt that the joint yoga
sessions, during in-patient treatment, improved their mental state.
Despite this, only 55.0 % of current in-patients intended to practice
yoga once a week or more at home. 29.5% of former in-patients reported
that they practiced yoga at home once a week or more. The main
obstacles included 'laziness', other interests, problems with privacy
and housing, lack of time, problems related to family members and
friends, health limitations, lack of information and lack of interest.
Ways to overcome these obstacles are discussed.
Key Words: Yoga – Spirituality – Addictive Diseases – Compliance –
Treatment – Obstacles
Introduction
------------
Yoga and psychotherapy
Yoga is compatible with other approaches and can be combined with
them, as described e.g. by Lohman (1999). The principles of modern
psychotherapy and traditional Indian medicine (Ayurveda) overlap. In
fact Satvavajaya or psychotherapy is one of three principal categories
of treatment approaches as described in Ayurvedic classics (Nespor and
Singh 1986). The classical Satvavajaya is based on three principles:
1. Replacement of emotions (an undesirable emotion can be replaced or
neutralized by other incompatible emotion), 2. Assurances, 3.
Psychological shock. The author had an opportunity to observe an
experienced professor of ayurveda performing an exemplary
psychotherapeutic sessions in English with his patients. He used
empathy and unconditional positive regard, as many Western
psychotherapists would. The replacement of emotions took place by
gently switching emotions e.g. from the mother-in-law (anger) to
children (love). He also used reframing (a negative event was
presented in a more positive way), and employed various stories and
metaphors that directly or indirectly related to patients’ problems
and possible solutions. Such an approach was used e.g. by M. H.
Erickson in the West.
Advantages of Yoga
There are many relevant reasons why addicted people should practice
yoga.
*
Stress, anxiety and depression relieving effects of yoga (e. g.
Michalsen et al. 2005, Pilkingtona et al. 2005).
*
Safer social network. According to the author’s experience
yoga-minded people are less prone to addictive behaviour.
*
Yoga enables safe management of some psychosomatic problems such
as insomnia, headaches, and some painful problems. It may be
possible in this way to avoid addictive analgesic or sedative
drugs (Goyeche 1979).
*
In the author’s experience, yoga and relaxation, as the part of a
complex treatment programme, can counterbalance less pleasant
aspects of treatment, strengthen therapeutic relationship, and
decrease the number of patients leaving the programme prematurely
(Nespor and Frouzova 1985).
*
Yoga and meditation develop and emphasize self-awareness, which is
important in many ways. It is a common experience that sufficient
self-awareness is required e.g. for early identification of
internal or external clues triggering craving for alcohol or
drugs.
*
Yoga compensates for long sitting during psychotherapy.
In-patients are frequently obliged to sit during psychotherapeutic
activities for up to 4.5 hours. This can prove tiring and
uncomfortable. Yogic practices, especially those with the spine in
the horizontal posture such as “cat" or marjariasana variations
are useful to counterbalance this.
*
The author presumes that yoga also enhances spirituality. The term
spirituality, however esoteric it may look, has become the serious
topic of medical research. In September 2006 the Database of
American National Library of Medicine contained 2496 references to
the search word “spirituality”. Lower occurrence of daily smoking
in spiritually minded people has been identified in the Czech
population (17.6 % in those believing in God and 28.6 % in those
not believing) (Sovinova et al. 2006). Among substance-dependent
individuals, higher levels of religious faith and spirituality is
associated with a more optimistic life orientation, greater
perceived social support, higher resilience to stress, and lower
levels of anxiety (Pardini et al.. 2003).
Some problems with yoga
When the author was 26 years old he visited a noted Czech professor to
whom he suggested that all his addicted patients could be cured by
means of yoga. Having been offered the opportunity to test the claims
the author found that it was not quite so easy; and that there were
some problems, such as:
*
Long-term compliance of patients (the enthusiasm for yoga of most
patients was much less than the author expected).
*
Systemic (domestic) interactions (e.g. lack of understanding of
yoga by family members).
*
Practical problems (for some patients it was difficult to find
time and place to practice).
*
The trainees were competitive and not patient enough.
*
The need of a qualified teacher to modify the practice according
to the needs of an individual. As somebody said: “An individual
should not adapt to yoga, not yoga should adapt to him.” It is
especially important in physically or mentally challenged people.
Despite these problems, the author still believes that yoga is useful
for this patient population. The aim of this paper is to investigate
the above mentioned problems in more detail.
Formal sessions of yoga
The yoga protocol has been described in a previous paper (Nespor
2000). The structure of two typical 30 to 45 minute sessions is
outlined below. Regardless of the duration, the lesson is usually
divided into three roughly equal thirds. This scheme is not rigid and
can be modified according to the situation.
*
1st third: Physical exercises of Yoga
*
2nd third: Full yoga breath and/or some simple pranayama and some
short story symbolically related to common patients’ problems.
*
3rd third: Relaxation with sankalpa (resolve)
Most of the following practices are described according to Satyananda
(1996).
An example of a yoga session (30 minutes)
Marjariasana (Cat stretch pose): Instructions: Place the hands flat on
the floor beneath the shoulders with the fingers facing forward.
Inhale while raising the head and lowering the spine and create a
hollow between your shoulder blades. Exhale while lowering the head
and stretching the spine upward. The trainees may be instructed to
emphasize the movement of the thoracic spine while inhaling, and the
lumbar spine while exhaling.
Vyaghrasana (Tiger’s stretch): This usually commences from the
marjariasana (cat’s pose) which is for trainees easy enough.
Instructions: While inhaling straighten the right leg , stretching it
up and back. Bend the right knee and point the toes toward the head.
Look up and try to touch the toes to the back of the head. Hold the
breath for a few seconds in this position. While exhaling, straighten
the right leg, bend the knee and swing the leg under the hips. At the
same time arch the back up and bend the head down. The right foot
should not touch the floor. Press the knee against the chest and, if
possible, touch the nose to the knee. Fix the eyes on the knee for few
seconds while holding the breath out. With the next inhalation start
to repeat these movements 5 times or so. Then repeat it with the left
leg.
Shashankasana (Hare pose): This is also started from marjariasana.
Instructions : While exhaling move downward and back so that the head
and the arms rest on the floor in front of the knees. If you want to
relax, just observe your natural nasal breath As you breathe deeply be
aware of your abdomen. After a while return back to marjariasana.
Sphinx asana and its variations: Instructions : Lie on the stomach.
Bend the arms and place the forearms on the floor with the palms
facing downward. The upper arms are vertical. Raise the head but relax
all the muscles which are not necessary to maintain correct pose. The
possible variations include hitting one’s buttocks with the heels,
gentle rotations of the head and spine. Backward bending should be
increased during inhalation and relaxed during exhalation.
Jyestikasana: Instructions : Lie down on your belly with the legs
straight and the forehead resting on the fingers, with both hands
interlocked, palms facing up. Be aware of your body and let it relax.
Then observe your breath.
Supta udarakarshanasana (sleeping abdominal stretch pose or supine
rotation with the knee bend): Lie on your back, bend the knees and
place soles flat on the ground in front of the buttocks. Keep the
knees and feet together. Interlock the fingers of both hands and place
the palms under the back of the head. While breathing out slowly lower
the legs to the right. The knees move down to the floor. At the same
time move the head in the opposite direction. Hold the breath in final
position for few seconds. While breathing in move the legs back to the
upright position. Repeat to the opposite direction. Repeat 5 times.
Spontaneous abdominal breathing: I usually let the trainees to be
aware of their spontaneous abdominal breathing on the back with the
legs bent. Only after that we practice deep abdominal breathing, as
something based on spontaneous abdominal breathing. Eventually we also
add thoracic and clavicular breathing.
Full yoga breath
Stories symbolically related to common patients’ problems. An example
of a story: Swami Satyananda often received visitors who sought his
advice in spiritual or personal matters. Some visitors were satisfied
with his advice but some were not. They objected “Yes, but it can be
done so and so.”
“It is also good,” replied usually Swami Satyananda.
A disciple once asked Swamiji doubtfully: “Is it really also good?”
“Of course,” replied Swamiji. “Karma of some people does not allow
them to accept good advice. They have to commit mistakes, to suffer
and to learn through their painful experiences. That is why it is also
good.”
This story is liberating. It shows that even our mistakes can be
instrumental to our ultimate awakening. In the same time it shows that
it is better to avoid these mistakes and related suffering.
Brief yoga nidra or yogic relaxation. During yoga nidra, I tend to
offer to the trainees three sets of images they can choose from.
Images for vata types (air and ether prevail; these people need
grounding, stability, the feeling of safety): You are looking at the
quiet surface of a lake. Its firm reliable banks are full of flowers
whose fragrance is sweet. Somebody at the bank is singing a calming,
sweet song. Images for pitta types (fire and water prevails; they need
calmness and detachment): You are in rocky maintains at night. You see
a pine, rooted firmly in the stony soil. There is plenty of free space
around. Far away above your head Moon and stars spill their silver
light all around. You feel pleasant breeze bringing to you cool
fragrance of jasmine from some distant valley. Somebody is playing
there a flute and its melody is detached and calm. Images for kapha
types (earth and water prevails; these people need stimulation): You
are looking at Sun high at sky. It shines brightly and colours the
clouds by its orange and yellow light. The clouds move to the horizon.
You smell sharp fragrance of eucalypt. Somebody is playing fast and
skilfully a drum far away. Alternative symbolic imagery for everybody:
You see a quiet surface of a lake reflecting nature around it.
Similarly your mind, calm and sober, perceives things as they are. Now
see a river, mighty and moving on and on. Similarly you are able to
overcome every obstacle if pursuing good and appropriate goals.
Finally you see a strong, healthy pine tree with strong roots in the
soil and its branches open to the sky. This tree is resistant against
storms and winds. Similarly you are grounded in reality and in the
same time open to positive spiritual influences. You are able to cope
with all challenges in this way.
Namaste: Beforehand I usually explain that this mean „I bow to the
highest in you which is the same as the highest in me.“ I found this
simple practice very useful. Our patients need very much to learn to
respect themselves and others. They like this practice.
An example of a yoga session (45 minutes)
Marjariasana (Cat) on forearms. This variant diverts blood from pelvic
area which is useful after long sitting.
Vyaghrasana (Tiger’s stretch)
Shashankasana (Hare pose):
Sarpasana (snake): Lie on the stomach, interlock the fingers and place
them on top of the buttocks. Raise the head, neck and chest from the
floor. Push the hands back and up. Squeeze the shoulder blades
together and look forward. Hold for as long as comfortable. Then
return to the starting position and relax the whole body.
Tiryaka Bhunjangasana (twisting cobra).
Ardha shalabhasana (a variant of half locust pose): Lie on the
stomach, legs are together and the forehead touches the floor. Stretch
the arms above the head and place them and the chin on the floor.
Simultaneously raise the stretched left leg, the head and right arm.
Hold for as long as comfortable. Then lower the leg, head and arm.
Repeat the same movement with the right leg and left arm.
Jyestikasana: Lie down on your stomach with the legs straight and the
forehead resting on the fingers of both hands interlocked and palms
facing up. Be aware of your body and let it relax. Then observe your
breath for a while.
Supta udarakarshanasana.
Spontaneous abdominal breathing and full yoga breath.
Seetkari. Cooling pranayamas seetkari and sheetali, according to
Satyananda (1996) cool the body and the mind as well and decrease
thirst. They are recommended in ayurveda especially for pitta (fire)
personalities. Maybe they can also help to cope with craving for
alcohol. The advantage of Seetkari compared with sheetali is, that
seetkari can be performed in its mild form, inconspicuously, even
during daily activities. Seetkari is practiced as follows: Hold the
teeth lightly together and separate the lips. The tongue is passive in
khechari mudra. Breathe slowly and deeply through the teeth. At the
end of inhalation close the lips and keep the tongue where it is and
breathe out slowly through the nose. Inconspicuous variant: Lips are
separated very little and breathing is not as deep as during the
normal practice of seetkari.
A story, yoga nidra and namaste.
Yoga outside formal sessions
Beside formal practice of yoga, I frequently use the elements of yoga
during other activities. E.g. we may practice a little at the end of
psychotherapy workshops. It is especially useful after long sitting or
when we have dealt with some difficult and heavy psychological
material. This “miniyoga” is also helpful to deal with tiredness and
boredom. It works not only in addicts. Once I gave a lecture to
business people. When I arrived, I found them tired and bored. We
exercised a little bit and their mood instantly changed. When these
people gave their feedback to the organizers of the workshop, my
lecture was considered the best. I suspect that it was because of what
we did, and not because of what I said.
Some examples of “miniyoga“
Heavenly stretch or dynamic Tadasana
For our purposes I call it “Delights of abstinent life”. Begin in
standing position with the feet slightly apart. The weight of the body
is equally distributed on both feet. Raise the arms over the head.
Interlock the fingers and turn the palm upwards. Place the hands on
the top of the head. Fix your eyes at the point on the wall slightly
above the level of your head. Inhale and stretch the arms, shoulders
and chest upward. Raise the heels coming up onto the toes. Stretch the
body from the bottom. Hold the breath and the position for a few
seconds. Lower the heels while breathing out and bring the hands to
the top of the head. Practise 5 to 10 times.
Chopping the wood or Kashtha takshanasana
For our purposes I call it “Hammering the pillars of abstinence”. The
only difference from the practice as it is described in Satyananda
(1996) is that I do not practise in squatting position but in standing
posture and bend the knees slightly while moving the hands down and
exhaling. The full posture would be too difficult for most of my
patients.
Wings
Begin in standing position with the feet slightly apart. Lift the arms
sideways to the level of shoulders. While inhaling move the hands
stretched backwards, and let the chest expand. While exhaling the
stretched hands move to the front of the body so that the palms and
fingers touch each and the head bow with the chin touching the chest
at the end of exhalation. Practise 5 times or so. I usually add to
this practice that the patients leave behind them all the problems
which alcohol or drug abuse caused in the past, and move on to the
better future.
Bow and arrow (Akarna dhanurasana)
We practice as described in Satyananda (1996). Usually I ask the
patients to target a positive aim in the external world when the right
hand is pulling the bow-string, and an aim in the internal world when
the left hand is pulling.
I am
Begin in standing position with the feet apart on distance of the
width of the shoulders. During inhalation move stretched arms
sideways. At the end of exhalation the palms are on the level of the
head. During exhalation beat your chest gently with the fists and
pronounce long “I“. Repeat this once more and during next exhalation
repeat in the same way “am“. A variation: Instead of “I am“, we laugh
at all drug dealers and alcohol or gambling industry because they will
get nothing from us in the future.
Hero
Step with the right foot askew forward a slight bend the right knee.
Arch the back, expand the chest and push it forward. Clasp the hands
and stay for a while breathing naturally. Repeat this with the other
side. Those who try to overcome addiction are heroes. The first
bravery is to acknowledge one’s addiction; the second one is to cope
with it and the third one to persist.
Tadasana (static)
Sometimes I use it instead of relaxation, if it is - not possible to
lie down. At the end I often suggest: “You are standing in a firm,
steady and relaxed manner now and you can stand so in your life as
well.”
Adding colour to aura
It is not a yogic practice. With the legs widely apart we pick up
balls of colour energy from the well on the floor and improve with
them our auras (yellow is intellect, green health, blue calmness and
detachment, violet spirituality and abstinence, pink youthfulness,
orange independence and rainbow gives beauty and strengthens immunity.
The problem of compliance
As mentioned earlier, the main challenge when using yoga in substance
dependent patients is the long-term regular practice outside the
hospital. The aim of this paper is to identify possible barriers which
hinder regular unsupervised practice and to consider the ways how
these problems can be overcome.
Material and methods
--------------------
A questionnaire
I prepared an original questionnaire which was administered to
in-patients and former in-patients. They were asked to answer a set of
simple questions such as:
*
How do your feel after yoga session?
*
Do you intend to practice yoga outside the hospital?
*
Are there any possible hindrances in regular yoga practice at
home?
*
If so, how these hindrances can be overcome?
Subjects
The subjects were:
1. The group 53 current male in-patients treated for addictive
diseases and 50 current female in-patients treated for the same
problems. Their age was on the average 38.2 years (SD=11.8).
2. The group of 44 former male in-patients treated for addictive
diseases and 9 female former in-patients treated for the same problem.
Their age was on the average 43.1 years (SD=12.7).
Results
-------
Most patients felt after yoga session better or much better. That is
why it is surprising that most of them do no intend to practice yoga
regularly.
Former and current in-patients: Feelings after the yoga session during
in-patient treatment (n=156, missing answers: 5)
*
Much better: 47 (31.1 % of relevant answers)
*
Better: 59 (39.1 %. of relevant answers)
*
The same: 37 (24.5 % of relevant answers)
*
Worse: 3 (2.0 % of relevant answers)
*
Much worse: 2 (1.3 % of relevant answers)
How often in-patients intend to practice yoga at home (n=103, missing
answers: 3)
*
Not at all: 23 (23 %)
*
Less than once a week: 19 (19 %)
*
Once a week: 24 (24 %)
*
2 – 4 - times a week: 19 (9 %)
*
5- 6 - times a week: 5 (5 %)
*
Daily: 7 (7 %)
How often former in-patients practice yoga at home (n=53, missing
answers: 0)
*
Not at all: 32 (64 %)
*
Less than once a week: 5 (9.4 %)
*
Once a week: 11 (20.1 %)
*
2 - 4x times a week: 3 (5.7 %)
*
5- 6x times a week: 0 (0%)
*
Daily: 2 (3.7 %)
The obstacles
The main obstacles included laziness (29), other interests and sports
(14), lack of time (12), problems with privacy and housing (11),
health limitations and age (9), problems related to family members and
friends (8), lack of information (6), lack of interest (3) and that it
is difficult to practice alone (3).
The obstacles in practicing yoga are summarized in table 1.
Discussion
----------
The feeling after a yoga session predictably improved in most
patients. It is in accordance with our previous paper written many
years ago (Nespor and Frouzova 1985). It is surprising that many
patients, even if they feel better, do not intend to practice every
day and they do not practice. I believe that the above mentioned
obstacles are not specific to the people with addictive diseases. Many
of these obstacles are relevant also to the general population of yoga
trainees.
Regularity: Most patients like yoga and did not mention any obstacles
to regular practice. Despite this, they do not intend to practice
regularly in the future. Maybe it should be repeated more often that
regular practice is one of the crucial factors of successful use of
yoga in health management.
Laziness and indolence: This most common obstacle it not easy to
overcome. It may be useful if trainees are able to motivate
themselves, e.g. to remind themselves that after investing some effort
and inconvenience (such as getting up early) in yoga they will be
rewarded by pleasant feelings afterwards.
Other interests, sports: Our aim is not to replace healthy and useful
interests by yoga. But most of our patients have unhelpful hobbies
which should be substituted. It may help to contemplate ways how their
healthy interests can be accommodated with yoga or sometimes even
integrated with yoga (e.g. mantra repetition during walking).
Lack of time: Time can be organized better. For example, yoga can be
practiced instead of unnecessarily long sleep or even better instead
of watching TV. A 2004 report estimates that young Americans aged
13-24 years watch nearly 14 hours of television a week (Brier 2004).
73.4% of Czech population watched TV daily in 2005. The problem of
lack of time has more specific context. Some addicted people want to
pay their debts (both financial and moral) as soon as possible.
Because of that they become exhausted. Their self-control
deteriorates. Such life-style increases the risk of relapse. It is
absolutely necessary for them to maintain balance between duties and
rest. Yoga fits well into this. It is also possible to emphasize, that
regular practice of yoga can increase productivity.
Family members, friends: It may be difficult to explain to relatives
why one practices yoga, and a trainee may feel ashamed. This obstacle
is mentioned frequently and may be also serious. The relatives, if
possible, should be informed about yoga by a therapist. The aims of
yoga in addicted people should be explained. Alternatively trainees
should be encouraged to explain the reasons why they practice to their
relatives themselves.
Privacy, housing: This may be a serious problem. It was much more
often mentioned by current in-patients than the former in-patients.
This can be explained by the excessive anxieties of in-patients
regarding their future. Such apprehension decreased with continuing
abstinence outside the hospital; beside this, the social situation of
the people who abstain from alcohol usually radically improves.
Possible solutions to the problems of privacy may be to practice
silently early in the morning when other people sleep, information
about yoga, its meaning and usefulness to family members may also
help. There are also many practices which can be used inconspicuously
(e.g. mantra) or outside home in parks, etc. It is also possible to
include yoga practices into normal daily activities (relaxation during
waiting, mantra or full yoga breath during walking etc.) sometimes.
Health problems, pain: Assurances can be given that carefully selected
yoga practices are safe and helpful. Even very old or physically
challenged people can benefit form suitable yogic practices.
Lack of information: To assure that basic principles and practices are
simple. To give the trainee addresses of yoga classes outside
hospital. Trainees should be recommended practical books about yoga.
It is difficult alone: Patients should be supplied with contact
details of yoga classes or clubs that are willing to accept them. They
may also attend our yoga class after their dismissal, but it may be
rather complicated for them because these classes do not take place in
the evenings.
Religion: It is possible to argue that yoga is compatible with any
religion and that yoga is practiced by people of different confessions
both in India and all over the world. This problem seemed to be
negligible for most patients. Yoga may deepen the individual's
religious and spiritual life.
Unpleasant feelings: This objection appeared rarely. Yoga is usually
perceived as pleasant. The reasons somebody may feel pain includes
overstretching and competitiveness, lack of experience or lack of
mental and physical flexibility.
It is not interesting: This objection was rare. I try to include
interesting elements and colourful stories in the lessons.
Commuting: This obstacle was mentioned only once. Perhaps emphasizing
that the practice in private is most important and to enhance it by
retreats etc. from time to time.
Acknowledgements
Author is grateful to Bihar School of Yoga where he received his
training in yoga. The linguistic assistance of Ms. Helen Greatorex is
gratefully appreciated.
References
----------
Goyeche, J.R.: Yoga as therapy in psychosomatic medicine. Psychother
Psychosom. Vol, 31, 373-381 (1979).
Lohman, R.: Yoga techniques applicable with drug and alcohol
rehabilitation programmes. Therapeutic Communities. Vol. 20, 1, 61-72
(1999).
Michalsen, A., Grossman, P., Acil, A., Langhorst, J., Ludtke, R.,
Esch, T., Stefano, G.B., Dobos, G.J,: Rapid stress reduction and
anxiolysis among distressed women as a consequence of a three-month
intensive yoga program. Med Sci Monit. Vol 11, 555-561 (2005).
Nespor, K.: Yoga in addictive diseases - practical experience.
Alcologia. Vol. 13, 21-25 (2001). Available at www.plbohnice.cz/nespor
Nespor, K., Frouzova, M.: Changes of psychological state after
relaxation in patient treated at alcohol treatment unit.
Ceskoslovenska psychiatrie. Vol. 81, 313-319 (1985).
Nespor, K., Singh, R.H.: Experience with ayurvedic psychotherapy.
International Journal of Psychosomatics. Vol. 33, 29-30 (1986).
Pilkingtona, K., Kirkwooda, G., Rampesc, H., Richardsona, J.: Yoga for
depression: The research evidence. Journal of Affective Disorders.
Vol. 89, 13-24 (2005).
Pardini, D.A., Planteb, T.G., Shermanc, A., Jamie, E., Stumpd, J.E.:
Religious faith and spirituality in substance abuse recovery.
Determining the mental health benefits. Psychology of Addictive
Behaviors. Vol. 17, s159-162 (2003).
Satyananda Swami Saraswati: Asana pranayama, mudra, bandha. Bihar Yoga
Bharati, Munger, India (1996).
Sovinova, H., Sadilek, P., Csemy, L.: The trends in smoking in Czech
adult population. Research report (2006).
Table 1. The obstacles in practicing yoga.
Current in-patients
Former in‑patients
All patients
Laziness, indolence
13
16
29
Other interests or sports
8
6
14
Lack of time
8
4
12
Privacy, housing
9
2
11
Health problems, age
5
4
9
Family members, friends
4
4
8
Lack of information
2
4
6
It is not interesting
3
0
3
It is difficult alone
1
2
3
Unpleasant feeling
1
0
1
Commuting
1
0
1
Other
1
0
1

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