The Principles of Yoga and How They Apply to Eating Disorders Recovery
By Lisa Diers, RDN, LD, E-RYT & Dianne Neumark-Sztainer, PhD, MPH, RD, RYT-500
Having an eating disorder can serve as a distraction from unwanted feelings, experiences, and stressors. Eating disorders create a disconnect, or severely interrupted connection, between body and mind. When one is struggling with an eating disorder, the needs of the body are often ignored to an extreme degree, and the disconnect from uncomfortable sensations can occur through a variety of maladaptive coping mechanisms. These coping mechanisms can be dangerous to body and mind. In order to live life in a recovery-minded way, one needs to learn how to cope with the patterns of the mind, stressors in life, and unwanted feelings, experiences, and memories in a healthful manner. Paramount to recovery is a greater understanding of the patterns of one’s mind, the language of one’s body, the mechanisms developed to cope, and an increased awareness of eating disorder thoughts, urges, or dysregulation in one’s system. This internal awareness can be very useful in using more positive coping skills when faced with life challenges and delaying, reducing, or even preventing eating disorder symptoms or behaviors.
There is no “one way” to recover from an eating disorder. Eating disorders are multifaceted, nonlinear, and complicated, and can evolve over time from one condition to another. Many approaches may be tried to build momentum and sustain recovery. A multidisciplinary approach (psychotherapy, nutrition therapy, medical monitoring) is highly recommended, but even all of these components in combination may not always be enough. Getting into one’s body and truly feeling what is going on in the body may also be helpful, even necessary. Enter: therapeutic yoga and yoga therapy.
The Authors’ Experience with Yoga and Eating Disorders
It is perhaps useful to understand a bit about the authors’ relevant perspectives and experiences, particularly with yoga, prior to delving into a discussion of yoga as it relates to eating disorders. Lisa Diers is a registered dietitian who has specialized in eating disorder treatment for 15 years. More than 10 of those years have been as both a registered yoga teacher and dietitian in an eating disorder treatment setting, instructing clients at multiple stages in the recovery process and multiple levels of care (residential through outpatient). She was also instrumental in successfully incorporating yoga into an eating disorder treatment program, which, as of 2017, held 115 weekly yoga classes across four states. To date, Lisa has completed more than two of four years training as a Viniyoga therapist in the lineage of Sri Krishnamacharya and T.K.V. Desikachar. She has developed yoga interventions for research study designs seeking to learn yoga’s potential benefit for treating eating disorders, and has instructed thousands of therapeutic yoga classes, hundreds of individual sessions, and multiple trainings for those struggling with an eating disorder or wanting to learn how to help others. Her current role is continuing this work, integrating yoga and nutrition therapy into recovery, conduction trainings, writing, and research in private practice (Diers, 2016a, 2016b; Klein & Diers, 2018; Pacanowski, Diers, Crosby, & Neumark-Sztainer, 2017).
Dianne Neumark-Sztainer is also trained as a dietitian and a yoga teacher. Her current primary role is as a researcher in the area of eating and weight-related problems in young people, with a focus on understanding and addressing risk and protective factors across the life course to prevent these problems. Through her own practice, she recognized yoga’s potential for coming inward into one’s body in a positive manner, establishing a greater connection to oneself, and emotion regulation. These observations, in addition to various comments made by her yoga teachers, made her curious about the potential for yoga to help in the area of eating disorders, particularly prevention. She began to read more about yoga, practiced more regularly, got trained as a yoga teacher (500-hour certification), taught yoga within an eating disorder treatment facility (with Lisa), and embarked on a program of research exploring connections between yoga and body image, eating disorders, eating behaviors, physical activity, and weight status (Neumark-Sztainer, 2014; Neumark-Sztainer, Eisenberg, Wall, & Loth, 2011; Neumark-Sztainer et al., 2017; Neumark-Sztainer, MacLehose, Watts, Pacanowski, & Eisenberg, 2018; Pacanowski et al., 2017; Watts, Rydell, Eisenberg, Laska, & Neumark-Sztainer, 2018).
Yoga: An Overview
The practice of yoga provides an opportunity to learn how one’s mind, body, and breath react to a variety of life experiences, thus creating awareness of behavioral and emotional patterns that many people who struggle with eating disorders follow automatically (Kraftsow, 2002). When yoga is practiced in a manner that truly links one’s body, breath, mind, and emotions together, something magical can happen within oneself. Yoga is the practice of noticing actions and thoughts that cause pain and suffering, and creating new and more positive patterns to replace unhelpful ones. With the practice of yoga, it is possible to begin to see situations in life more clearly, strengthen the ability to act instead of “react,” and have greater awareness of self and one’s surroundings. Regular practice can also create the ability to develop more helpful patterns, make wiser choices, and eventually decrease the potential for pain and suffering (Desikachar, 1980).
The principles of yoga include a commitment to a regular practice of moving from one point to a higher point. Whether this happens in the mind, in the body, or in both, it is yoga if it brings one insight into one’s own truth. Although the pendulum seems to be swinging slightly back to balance, yoga is often thought of in the West as solely a physical practice with very little awareness of the holistic and multidimensional qualities it holds. In fact, it identifies five dimensions of the human system and approaches to balancing each, which in turn help to balance the others and, as a result, the entire person. The book Yoga for Transformation by Gary Kraftsow (2002) gives a digestible description of these five dimensions and how yoga affects them: the physical body, the vital body, the intellectual mind, the personality, and the heart. Another way yoga’s potential in eating disorder recovery can be more fully understood is how yoga “asks” someone to study and understand one’s patterns of attitudes and behaviors and the impact they have on one’s life. The practice of yoga postures (asanas) and breath techniques (pranayama) increases one’s awareness of perception, bringing about clarity and self-realization. With practice, yoga has the potential to change attitudes toward self and others (Desikachar, 1999). In order to truly be considered yoga, a practice of postures must have the inclusion and stability of breath, along with the focus of mind (dharana).Yoga is an internal experience that requires our whole being. It is a science that when properly applied, can help one find peace of mind and body and reach one’s highest self (Desikachar, 1999). We believe that the physical and breath components are very important, particularly for addressing eating disorders, since the physical practice and the breath techniques allow for a greater connection with one’s body, an increased ability to self-regulate and “act instead of react,” and a greater sense of embodiment.
A yoga teacher or yoga therapist’s experience and approach can vary widely based on the focus of training, duration of one’s training program, and on-the-job training or experience. In general, yoga teachers focus on teaching a variety of yoga methods in a correct and appropriate way. While there are many similarities across yoga teachers, there are also many differences based on the teacher’s training, philosophy, and personal style. Many yoga teachers working to help individuals with eating disorders engage their clients in therapeutic yoga, even if not trained specifically as a yoga therapist, although training as a yoga therapist is desirable. Yoga therapy fundamentally focuses on the client’s unique needs, using tools learned in yoga therapy training and ongoing mentoring to design a plan that brings the client toward balance and alleviation of symptoms. Similar to other professions within eating disorder treatment, the yoga therapist conducts a thorough review of the client’s current situation, along with what present conditions and patterns may be contributing to the current state, in order to determine a course plan (yoga sequence, breath practice, meditation approach, and lifestyle recommendations) that will best meet the needs of the client. The yoga therapist is also trained to work collaboratively and regularly with other members of the client’s care team, to provide optimal care and support. When a client is seeking out a yoga therapist or a therapeutic group, it is usually to achieve relief from a specific symptom or health condition (Kepner et al., 2014).
Yoga and Eating Disorders
If eating disorders create a disturbed connection between body and mind, yoga aims to repair the connection. Repairing the connection between body and mind can aid in the development of a nonreactive stance in the face of harmful thoughts, emotions, and behaviors (Dittmann & Freedman, 2009). Eating disorders are multifaceted and complicated. Yoga, especially when practiced wholly, works on all levels of the human system simultaneously. Like in a web, what one experiences in yoga affects every other aspect of one’s being (Bossart, 2007; McCall, 2007). Because of these qualities, yoga, when skillfully applied, may be a useful tool for this complex and multifaceted illness.
Given the potential for yoga to repair the connection between the body and mind, and help with eating disorders, it may be offered as part of more comprehensive eating disorder treatment. The number of eating disorder treatment programs that include yoga as part of their scheduled programming seems to be on the rise. So is the need to better our understanding of if and how yoga could be helpful in treatment. While the underlying tenets of yoga suggest that it could be helpful, and the scientific literature leans toward being positive, there is a dearth of studies. Studies tend to be small scale with limited study designs, and findings are not consistent.
For example, based on a review of the scientific literature on yoga and eating disorders, Klein and Cook-Cottone concluded that better controlled studies are needed to understand if and how the type, amount, and frequency, along with other variables, determine how yoga may be influencing eating disorder symptoms (Klein & Cook-Cottone, 2013). Similarly, another review, conducted by the second author of this article, concluded that more research with stronger study designs is needed to assess yoga’s effectiveness in preventing and treating eating disorders (Neumark-Sztainer, 2014). Based upon the first author’s experience with yoga and premeal anxiety among clients receiving eating disorder treatment, Pacanowski and colleagues (2017) implemented a small randomized, controlled trial to assess the impact of yoga prior to dinner within a residential eating disorder treatment facility. Findings indicated that clients randomized to yoga before dinner exhibited a premeal reduction in negative affect compared with the control condition; however, the effect was attenuated post-meal. Prior to concluding if and how yoga can be effective in the prevention and treatment of eating disorders, more research is clearly needed.
Clinical Application of Yoga to the Treatment of Eating Disorders
When considering incorporating yoga into the recovery process, one must consider the state of the recipient. Just as there is no “one way to recover,” there is no “one way” to approach yoga that fits all people. Yoga, by nature, should be adapted to the recipient. It is critical that the student or client is directed toward a yoga teacher or yoga therapist who is educated and experienced within the field of eating disorders and that the client is receiving guidance and mentoring from an experienced yoga therapist. It is equally as important that those teaching yoga within eating disorder treatment facilities have processes in place to screen their students for trauma, emotional barriers, physical needs, and medical stability so they can effectively instruct the therapeutic group session. In addition, registered yoga teachers and yoga therapists teaching yoga to clients should be considered important members of the client care team, attending multidisciplinary case consult groups, collaborating with staff, and receiving regular mentoring, support, and supervision.
When properly applied, yoga has the potential to provide great relief and resolve in many challenging areas in the recovery process. While further research is needed to confirm the benefits of yoga within eating disorder treatment, based on the first author’s clinical observations, some benefits of incorporating yoga into the recovery process include: improved digestion, decreased anxiety and depression symptoms, increased awareness of hunger and fullness cues, improved sleep, trauma reprocessing support and post-traumatic stress disorder symptom alleviation, decreased physical pain, and increased self-acceptance and confidence. Yoga, in the typical way it is viewed (i.e., as purely or primarily a physical practice), can be contraindicated for some. However, authentic yoga is completely adapted to the person’s current state. So, truly, yoga has no contraindications unless it is applied inappropriately.
With this in mind, if one is uncertain about incorporating yoga into recovery, here are some considerations (Diers, 2016b):
- Are you (your client) in a state of mind to trust and be open to yoga as a treatment modality?
- Is the yoga teacher or yoga therapist well-equipped to determine appropriate approaches and applications of yoga?
- Is the yoga therapist or teacher capable of asking questions that help determine the client’s needs in the moment and in the overall treatment plan?
- Is the yoga teacher a collaborator in the care process, asking good questions in order to provide quality care?
- If trauma recovery support is needed, does the yoga teacher or yoga therapist have experience, training, and success in these areas?
- What type of training has the yoga teacher or yoga therapist received?
- Is the style or lineage of yoga appropriate for the client’s current state and needs?
In summary, the underlying tenets of yoga suggest its potential for preventing, treating, and recovering from eating disorders. The authors’ clinical experience has found that clients with eating disorders can find the practice of yoga to be a way to have a greater connection with their bodies and relief from suffering. Further sharing of clinical experiences and more rigorous research is needed to determine if and how yoga can be most effective.
About the authors:
Lisa Diers, RDN, LD, E-RYT, Yoga Therapist is owner and president of Lisa Diers Yoga and Nutrition Consulting, LLC, where she provides nutrition and yoga therapy to individuals and groups. She also provides consultation, trainings, and presentations in the areas of yoga and nutrition therapy, program development, and designs yoga interventions for research studies. Lisa also loves to write regarding the topics of nutrition, yoga therapy, body image and general health and wellness, in addition to hosting her inspirational podcast, Wise of Heart©. Lisa has extensive experience within the eating disorder treatment, mental health, and clinical yoga and nutrition fields. She is currently enrolled in a 1,200-hour yoga therapy program in the lineage of Krishnamacharya and TKV Desikachar.
Dianne Neumark-Sztainer, PhD, MPH, RD is Mayo Professor and Division Head in the Division of Epidemiology and Community Health, School of Public Health, University of Minnesota. She leads an active program of research, primarily funded by the National Institutes of Health. Her research focuses on a broad spectrum of eating and weight-related outcomes including eating disorders, unhealthy weight control behaviors, body image, dietary intake, weight stigmatization, and obesity. She has published over 500 articles in peer-reviewed journals and is the author of the book, “I’m, Like, SO, Fat! Helping your teen make healthy eating and exercise choices in a weight-obsessed world.” In the past few years, she has begun to explore the potential for using yoga as a tool for addressing weight-related problems and is currently engaged in various research studies on this topic.
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