26 Feb A Brief Overview of Pañcakarma (Ayurvedic Detoxification Treatment) For Patients, Places To Get It, & How To Make the Most of the Experience
In the last few years, the momentum of my attention has shifted from my professional life to more interior journeys and focus. Sometimes dramatically, sometimes fascinatingly, sometimes excruciatingly clerically, but in very tangible, as well as energetic and visceral ways.
While I don’t plan to disappear from my professional life and endeavors, I am committed to cooperate with and support this shift of attention. In mid-November, many, many professional and familial obligations I had were (at least temporarily) wrapped up and I felt hunger for solitude, retreat and isolation –to allow emptiness its say and to mark entry into the third of the four āśrama (stages) of life— “vānaprastha” or, “forest dweller”—the stage where we begin to withdraw from the professional arenas of life and spend increasingly more time on internal pursuits. I feel right on schedule.
Literally the day after many things wrapped up, I boarded a plane for Northern India. I had booked this trip to mark entrance into this third stage of life. I thought it would help make an impression on my being that might be a tad more beneficial than slipping into a Friends reruns stupor. Not that I haven’t been there and received benefit from such a stupor before, but this required different medicine.
While I’ve returned to India many times since I lived there in my late teens and early 20s, I hadn’t set out on my own, following my nose there since. While I spent the second half or so of my five-week trip on a pilgrimage of sorts, I spent the first half in retreat physically, mentally and spiritually preparing for the pilgrimage (which I suppose is part of a pilgrimage in itself). I spent this time at avs punarnava Ayurveda hospital (that, as of June 2020 has unfortunately closed–at least temporarily) in the foothills of the Himalayas.
In April 2019, avs punarnava opened its doors under new management. It so happens that the new management are the folks and friends that brought us and manage the Ayurveda eco-village in South India, vaidyagrāma, about which I have previously written. (And which, thankfully, IS still functioning and thriving).
I continue to deeply love and respect vaidyagrāma, so I was curious how their new facility would compare for pañcakarma and, being a Northern girl, I am appreciative of cooler weather (at least certain times of year) than the South offers. I was also interested if it would be a good resource for others—either for pañcakarma or to continue an education in Ayurveda. (I address this at the end of this article).
So, I underwent close to three weeks of pañcakarma at avs punarnava. In order to contextualize how I found the experience, and also to hopefully support yours should you find yourself there –or somewhere else for pañcakarma sometime, it may be helpful to give an overview of pañcakarma. If you are already familiar, feel free to skip this part.
[Note: I expect I will update, revise, refine and add to the following material as time goes by, so check back every once in a while if you’re so inclined, to see the changes].
“Pañcakarma”: What, Why & How
In Ayurveda, we understand that over years we humans tend to build up some toxicity—Ayurveda calls, “āma” in our systems. Āma is produced or accumulates from any number of the following reasons off the top of my head, plus probably some others that aren’t at the top of my head at the moment:
- Eating and drinking wholesome food and drinks, but either consuming too much of them or consuming them while we are nervous, anxious, depressed, sick, overworked, too lethargic or otherwise physically, emotionally or mentally stressed—a situation that causes our digestive systems to function sub-optimally, thereby resulting in poorly digested food.
- Consuming highly processed or packaged foods and drinks. This would be things like packaged cookies, crackers, chips, desserts, condiments, frozen or canned meals etc. many of which contain additives, preservatives and other ingredients that most of us don’t know and find difficult to pronounce.
- Eating too much leftover, canned or frozen food.
- Eating food that is not appropriate for the season, condition and age in which we find ourselves. Like eating ice cream on a cold evening in the middle of winter.
- Exposure to environmental toxins in our air, food or water.
- Consumption of alcohol, cigarettes, certain hormones or other mind or body altering substances or medications. Some of these things may be important to ingest for a specific reason, but also wind up contributing to production of āma.
(If you are unclear on what or how to eat to support proper digestion, there are many good books that address this and perhaps it is best to work with a personal health care practitioner well-versed in Ayurveda).
Once either āma or increased doṣa (difficult term to quickly translate but also troublesome) has accumulated, it circulates throughout our blood, lymph and other bodily fluids, irrigates our tissues and organs and, if not expelled, lodges in vulnerable spots. Our tissues and organs that receive healthy prāṇa and blood flow, are well nourished and doṣic waste or āma is trucked away and disposed of. If prāṇa or blood flow is minimal or compromised, āma or doṣa is able to tuck in and lay dormant. It accumulates in vulnerable joints, organs or—sometimes deep –tissues. What are deep tissues? They are tissues that lay deep to circulating fluids. This can be likened to a river, where over time debris builds up between rocks, or is weighted under the floor of the river.
Śamana (palliative treatment) is that which does not expel the (increased doṣas (out of the body), does not excite (increase) the normal (doṣa) but makes the abnormal (doṣas) normal. It is of seven kinds- pācana (digestive carminatives), dīpana (hunger producing, stomachic), kṣut (fasting, avoidance of food), tṛṣṇa (withstanding thirst/avoidance of water drinking), vyāyāma (physical activity or exercise), ātapa (sunbathing) and maruta (wind bathing). Aṣṭāṅga Hṛdayam: Sūtrasthāna:XIV:13-14
Ayurveda prescribes two major categories of therapeutic measures to either reduce or remove āma or doṣa from our systems: 1. śamana therapies, that reduce or process āma or doṣa within the body and, 2. śodhana therapies, that forcibly expel āma or doṣa from the body, while the body is concurrently supported to withstand this treatment. Many practitioners of Ayurveda safely and effectively employ śamana therapies. Śodhana therapies require extra training, supervision and expertise to carry out safely and effectively. They often require a residential stay during treatment.
What is often referred to simply as, “pañcakarma” is a protocol within the śodhana category of treatment.
I have found it ideal, and would advise my patients in general, to follow five basic tenets of health for at least three months before undergoing pañcakarma. At least not to undergo pañcakarma until one has at least for the most part forsaken all processed foods, alcohol, cigarettes, refined sugar or mind altering substances for at least three months, and to consume only whole, freshly cooked foods, and not to overeat. Doing so generally increases the odds that a patient will maximize the benefit of pañcakarma—something that can be costly and challenging to undergo so we want to make the most of the experience. If patients do not do this before undergoing pañcakarma, it may make the process significantly more uncomfortable and the presiding physicians may even decide, once the patient arrives for treatment, that pañcakarma is either not advised or will need to be significantly modified. For example, in part because more and more patients are eating more and more processed foods than ever before in the history of man, more patients are arriving at facilities for pañcakarma with more and more āma. While one of the purposes of pañcakarma is to rid the body of it, if the patient is too saturated to begin with, they may not be strong enough to withstand the treatment or to tolerate the various preparatory practices involving oil—oil being contraindicated if there is too much āma. My friend and colleague, Dr. Ramanandan of vaidyagrāma, one of the places I recommend for pañcakarma, recently told me that this is happening more now than ever before, in his experience. In such cases, instead of the relatively pleasant massage with warm oil, he will prescribe no oil at all in the treatment—instead opting for treatments where warm herbal decoctions are poured on the patients. In these cases, the patients sometimes complain that they are not receiving the more pleasant oil massage treatments or full pañcakarma protocol, but to do so would be dangerous for them. So…why not reduce the āma load on the system for a few months before undergoing treatment, so that the time can be more effectively spent achieving a deeper level of health and to increase the chances that we can have the more pleasant treatments?
If possible, I believe it is good to work with a qualified personal Ayurveda health care practitioner for at least three months leading up to pañcakarma, to develop a relationship that will be in place for you to rely on possibly during and –certainly for at least three months after —pañcakarma is over, and hopefully well into the future. We also offer free, live, “Good Company Meetings” that are open to all, to support the practice of basic tenets of health before and after pañcakarma.
When you are ready for pañcakarma, wherever you go for this experience, you will—or at least probably should—experience some measure of, and guidance for, the following three stages of treatment. While it is well beyond the scope of this article to provide full education about each of these stages, and all the various ways physicians might implement them, it may be helpful to have at least a little understanding of each stage, to allow us to more easily trust and surrender to the process.
Pūrvakarma: preparing for pañcakarma:
Even the dry pieces of wood bend after proper application of oil and heat; then what is to be said about the living human beings?” Caraka Saṃhitā: Sūtrasthāna:XIV:3-5
Pūrva literally means, “before” and, “karma” simply means, “action.” So before getting into the thick of the detoxification action, one needs to prepare for it.
The internal and external use of oil or oily substances holds a unique place in Ayurveda, as compared with any other traditional (or non-traditional, for that matter) medical paradigm to which I’ve been exposed, and is often employed at this stage.
Hence, if you do not have any contraindications to do so, you may well be advised to do a daily warm oil self-massage, called abhyaṅga, which you can read about in this article. This is actually something you may have already been doing, if you have consulted with an Ayurvedic health care practitioner or read about it.
Once you get closer to the main treatment—pañcakarma—whether you do this part at home, under guidance of a practitioner, or in residence at facility, if you do not have contraindications and the Ayurveda physician deems it appropriate, you may also be advised to consume some form of plain or medicated ghee (clarified butter) or some other oily substance, often (but not always) in increasing amounts over a number of days.
During pūrvakarma, the use of both internal and external oil is intended to serve a few purposes. Here are a few main ones:
- The purpose of regular use of oil, often with the addition of heat—even if it is simply heated oil for your massage—is to soften the stubborn tissues of the body, allowing them to give up whatever āma they have been harboring.
- to lubricate the digestive system, facilitating, eventually, easier removal of waste.
- Flow reversal: The third important reason requires a bit of explaining: In daily life, we can think of the nutritive flow in our bodies to be rather centrifugal; meaning it moves from our digestive tract, outward towards our extremities so that nourishment can reach our bodily tissues and extremities. In preparation for pañcakarma we aim to reverse that flow, so that the direction is centripetal, so that dislodged (from the heated oil massage) doṣa and āma moves from the periphery of the body, towards the center—the (now lubricated) digestive tract, including the stomach, small intestines and large intestines, from where it is ready to be expelled. During this time, the appetite is likely to drop off considerably, as the agni, or digestive fire and capacity, has enough of a job digesting the incoming āma, doṣa and whatever herbal preparations have been prescribed. It is important during this time to consume a very simple diet that is very easy to digest.
Your regimen during this time will favor rest, reflection, and meditation. You may be advised not to exercise at all. When we exercise, we encourage the normal centrifugal direction of nutritive flow, from the digestive system to the muscles and extremities. Since we are working to reverse that flow, we do not want to strain the organs, muscles, and other tissues, increasing their demand for nutrition.
Śodhana “that which expels the doṣas out of the body forcibly, it is of five kinds, viz nirūha, (decoction enema), vamana (emesis), kaya reka (purgation for the body [virecana]) siro reka (purgation for the head [nasya]) and asra-visruti (blood-letting)” Aṣṭāṅga Hṛdayam: Sūtrasthāna:XIV:5
Pradhāna means, “main”, “chief” or, “primary. So pradhānakarma is the main part of the treatment in this protocol and indicates the pañcakarma or, “five actions” that are undertaken at this point in the treatment. Now that pūrvakarma has delivered at least a good passel of āma and doṣa to the digestive tract—the stomach, small intestines or large intestine, action is required to remove it from the system. There are five actions from which the physician will choose: vamana—or vomiting, virecana or purgation, nirūha or anuvāsana basti—two kinds of medicated enemas, nasya—cleansing of the nasal passages, and raktamokṣa —bloodletting. While the term, “bloodletting” may conjure dark and scary images of patients being drained of pints of blood to the point of death, that is not the practice in Ayurveda. Bloodletting in Ayurveda is usually performed with leeches—though I have seen lancets used—to let small amounts of blood in specific locations. This is the most rarely employed of the five actions.
For any given patient, it would be rare to use all five actions. I have not seen an occasion where that has happened. In the majority of cases one or two of the actions may be employed, depending upon where āma or doṣa has ended up by the end of pūrvakarma. If has ended up predominantly in the stomach, usually vamana is indicated; if in the small intestines, virecana; if in the large intestines, basti; if in certain localized areas near the surface of the skin or vessels, creating stagnation or poor circulation, raktamokṣa; and if in the nasal passages, nasya.
All five of these actions should be taken only when there are signs that pūrvakarma is complete, and they should be carefully monitored and adjusted, based on the patient’s condition. Once completed, the patient moves into the third stage of treatment.
Paścātkarma: re-integrating after pañcakarma
Paścāt literally means, “after.” This is the final stage of the protocol. After pradhānakarma is complete, the system needs support to return to normal. There are at least a couple main things that need to happen for this stage to be successful:
- reverse the nutritive flow back to normal. Whereas in the pūrvakarma stage, the normal centrifugal flow was reversed to a centripetal flow, now we need again to reverse the flow, back to the normal centrifugal direction, where nutrients flow from the digestive tract to nourish the extremities and the deeper tissues.
- Restore agni –the digestive fire needs to return to normal strength.
Accomplishing these goals is a gradual process, facilitated by certain remedies and regimens. The patient gradually follows the appetite back into a normal diet. As the appetite and agni increases, slowly the patient is able to safely consume and digest more complicated and varied foods. This process may begin at the treatment facility but is almost always continued in the patient’s daily life at home and may last for three months or so. It is often only when this stage is complete that the patient is able to experience the full benefit of the protocol we have come to call pañcakarma. At this point the patient should feel increased energy, ease upon waking in the morning, improved digestive and cognitive capacity and other benefits.
During this stage it is very important that the patient return only slowly to a normal diet and that the, “normal” diet be one of whole foods, well suited to one’s constitution and season. Because someone’s health can be damaged by not following this stage carefully, it may require consultation with, and support from, the patient’s Ayurveda health counselor. It is because of the importance of this that I find it best, as I mentioned above, to undergo pañcakarma only after one has at least for the most part forsaken all processed foods, alcohol, cigarettes, refined sugar or mind altering substances for at least three months, and to have consumed only whole, freshly cooked foods. In part this was to maximize the benefits of the treatment protocol, but it is also very important when it comes to this stage. It can be too great a learning curve to try to work that out after finishing pañcakarma, when it is crucial to have an appropriate, healthy diet in order to avoid damaging our systems. As mentioned before, it is probably advisable to have access to your regular, personal Ayurveda practitioner during this time, as the physicians that oversee your treatment at a facility are not likely to have the time to follow up personally with all the patients they see, as well as attend to those currently undergoing pañcakarma. And follow up is important to receive maximum benefit.
Similar to following our digestive capacity gradually back to normal food, we gradually return to our normal, healthy exercise routine, supporting the return to the normal nutritive flow in the body from the digestive tract to the tissues.
Education and Trust
Depending upon the treatment facility, the attending physicians, and the particular condition and needs of the patient, the three stages, and how their goals are achieved may be altered slightly or dramatically. To support this process and receive the maximum beneficial results, it is very helpful to trust the practitioner and the space. It may be good to research the place, the physicians and the general theory and practice of pañcakarma before embarking on this process, to the point that one feels sufficiently comfortable with the process that one is able to surrender and quiet the mind.
The relationship between sufficient education and trust in the process may be different for different individuals. While some education can be useful to assist us to surrender and allow the mind to rest, we can also become obsessed with the particulars of the experience and want more education than will facilitate ease in the process. The practitioners that are facilitating this process should be well educated and it is not generally any more possible for patients to fully understand the process and why certain steps are being taken at any given time, than it is for a patient to fully understand why a surgeon is taking every step they are taking. But it is also important for us to use our discrimination so that we choose a facility and program that is run by experienced and well-educated practitioners. If we are confused or concerned about our treatments or the treatment strategy, I find it good to be forthright about my questions with the attending physician. I find sometimes women in general, and certainly sometimes specifically I, do not want to appear to be troublesome, so we may keep our concerns to ourselves. However, if our concerns are not addressed, it can be more difficult to trust the process. I find it helpful to be honest with myself and consider what are valid, basic concerns that I need to address in order to trust, and what constitutes obsession with detail and requires me to put that part of my brain for a time out. It may be helpful to keep a journal where we write these sorts of things for later consideration.
Related tips for a successful stay at a pañcakarma facility:
During the process of pañcakarma, it is normal to feel quite vulnerable or sensitive. I have found there is not always—but often—a cultural difference between India and many Western communities, where the Indian doctors, nurses, technicians or staff may not discuss emotions, feelings or treatment protocols as much as Westerners may expect, want or need. This may not mean the Indian people do not care, or are not competent to deliver high quality treatment. It is often simply a cultural difference. Because of these possibilities I have found it, or feel it would be helpful to:
- Directly request friends & families not to convey any news during this time –especially during pradhānakarma –that could be disturbing, unless it is an emergency that I truly need to be informed of, and of which I can and need to do something about.
- Designate a comfortable friend from, “home” that is great at listening; who will agree to be available to chat about emotional things that come up in a sensitive, not alarmist manner if something comes up about which I don’t feel comfortable talking with the attending physician or staff.
- Have your regular Ayurveda personal health practitioner be available—at least for one appointment– by phone or Skype during your stay and certainly afterwards, to help explain things you may be unclear about, in the event that language, cultural or gender issues mean you are not receiving the educational support you might need or want about what is going on while you are undergoing treatment.
- Once I have a general idea of the treatment strategies, why they are being employed, and I trust the place and the doctors, I find it helpful to turn off my brain; not to use this time for intellectual education (I can always go back over the treatment strategies and treatments later), but rather as a time to surrender what has been buried, and gently follow my attention inwards.
Is pañcakarma appropriate for me?
In my experience it is best to consider this question with your experienced personal Ayurveda health care counselor, practitioner or physician as well as with the facility in which you are considering undergoing it.
One thing worth considering is if you feel you can tolerate a very simple, bland diet for the duration of the treatment. If you feel you simply cannot tolerate that, and you feel too great a need or craving for more complex food than the facility will recommend during the pañcakarma process, perhaps now is not a good time for pañcakarma. Perhaps you can work out a modified protocol where you can enjoy foods that you find tastier along with some supportive, limited treatments or therapies. This is nothing to feel shame around. It may be the perfect balance of treatment and nourishment for the current time. That can be the best medicine for the moment. I have chosen this option many times with good results. More, or more extreme, is not always better or appropriate.
What should I bring with me?
This depends in part on the climate and place. I would ask the specific facility but I would consider, if going to a cool place, bringing warm layers, including a hat. It is important to stay warm during this process. Also, wherever we go for this, if oil massage will be involved, it may be useful to bring clothes you don’t mind being ruined by oil. Bringing inspirational reading material, a journal, a shawl for chilly mornings, all can come in handy.
Where should I go for pañcakarma?
I find it useful to research a place and its physicians when considering it for pañcakarma; to do the intellectual reasoning up front—until we are confident the physicians and place are trustworthy. When researching, it can also be helpful to research what the temperature and weather are likely to be at the time you are considering receiving pañcakarma. It is best if either the weather is very comfortable temperature–neither too hot nor too cold, or that it is reasonably certain that the facility will be able to keep the treatment and accommodation rooms at a comfortable temperature.
I find it useful also to consider what other conditions are likely to be stressors. For example, if you live in the US, the travel to India and the acclimation to its climate, food and environment may be too stressful on your body to warrant that choice.
Finally, the pañcakarma process in India is generally more complicated than the process in the facilities that I recommend in the US. Sometimes the protocols in these places in the US are criticized for being too simple. However, in the same way that in Ayurveda we usually treat conditions with their opposite qualities—for example we treat cold conditions with heat, heavy conditions with lightening qualities, etc.—it can be useful to treat complicated conditions or lives with simple treatment strategies. I personally have received every bit as much benefit –sometimes more– from the, “simple” protocols employed by the US facilities in which I have received pañcakarma, as from the more extended or complicated protocols I have received in various places in India.
We are unable to recommend anyplace all the time for everybody, since quality of administration, therapists or environments can change at any time for any place and not everybody will do well in every climate or country. However, I have either personally experienced or heard good things from people with whom I have enjoyed a long, trusting association, about the following:
- vaidyagrāma about an hour outside of Coimbatore in Southern India, is a facility and community with which I have been associated since its inception. As mentioned above, I have written about vaidyagrāma in this article and I continue to hold it in the highest regard. One of the things I greatly respect about it is that its doctors and founders continuously respect feedback they receive and are always striving to improve the quality and experience. They continue to aim to prioritize quality over quantity.
- KARE outside of Pune. This is a place that may be especially good for a modified pañcakarma experience or a place to eat some tasty food, do some yoga and experience some Ayurveda treatments.
- Vasanta Institute of Ayurveda in Pune. Perhaps surprisingly, I have neither undergone treatment here, nor visited it. However, it is run by Dr. Vasant Lad, one of the foremost Ayurveda clinicians and educators in the West.
In the US:
- The Ayurveda Center of Vermont. I have received pañcakarma here several times, had excellent results, and have high regard for it and for the staff here. Allison Morse, who currently is the chief practitioner, is highly experienced and educated.
- The Ayurvedic Institute in New Mexico, run by Dr. Vasant Lad, one of the foremost Ayurveda clinicians and educators in the West.
Finally, everyone, it’s one of those times of year that we start seeing lots of promotion for Ayurveda detox cleanses—many of them part of an online program. For a discussion on the safety and efficacy of these and further discussion on each of the components of pañcakarma and how they relate to Ayurveda home cleanses, you can listen to this conversation between Dr. Welch & Dr. Scott Blossom in 2012.
If you are curious about places to study-or continue your studies in–Ayurveda, there are loads of places. One option is to take our online Foundations of Ayurveda Part I and Part II; Women’s Health & Hormones Part I and Part II, and then to go either to vaidyagrama, or one of our other affiliated schools in other parts of the world. You can contact us for that list and current options.
Phew. If you’ve reached this point, you deserve some kind of a prize.
Thank you for being here.
copyright Feb 26, 2020 Dr. Claudia Welch
[Note: I expect I will update, revise, refine and add to this article as time goes by, so check back every once in a while if you’re so inclined, to see the changes].