Yoga, Mindfulness, and Eating Disorder Recovery

Yoga, Mindfulness, and Eating Disorder Recovery

By Karen Samuels, PhDKaren Samuels

In the words of yoga master B.K.S. Iyengar, “Yoga, an ancient but perfect science, deals with the evolution of humanity. This evolution includes all aspects of one’s being, from bodily health to self-realization.”

Yoga and mindfulness-based practices as components of eating disorder recovery treatment have increased from a few treatment programs to mainstream, front and center. Having begun my own yoga practice in 1970, it has been fascinating to witness the West’s growing engagement with the study and practice of yoga. All things yoga, from classes and teacher trainings to the wardrobe and industry of yoga clothes, jewelry, and props, have mushroomed in recent years. Many celebrities, “yogalebrities,” and many in recovery reference their yoga practice as central to finding the mind-body connection, increased self-awareness, and “making peace with their bodies,” along with a return to health. The questions remain: What are some consistent benefits, and what are the prevailing trends?

Yoga has been a mind-body model of restoring health and calming the mind for centuries. The meaning of the word yoga is union, to join or yoke physical, mental, and spiritual disciplines. The study of yoga teaches poses (asanas) accompanied with breathing exercises (pranayama) and focused attention, or meditation (dhyana). The student learns physical movements performed in a consistent, prescribed way, combined with focused attention to breathing, which results in increased attention to internal/interoceptive feedback and tolerance for discomfort. Yoga classes typically end with savasana, a deep-relaxation exercise. The regular practice of yoga increases the capacity to understand and manage physical and, potentially, emotional states.

Research suggests regular yoga can improve depressed mood and immune function, as well as reduce stress symptoms and lower blood pressure (van der Kolk et al., 2014; Korb, 2015). Yoga may help one connect with his or her body in a more accepting, self-soothing way. Additional studies indicate that certain areas of the brain are enlarged through consistent hours of yoga practice over many years.

Indeed, yoga’s potential neuroprotective effects, across age, experience, and frequency, indicated increased age-related gray matter (GM), mostly in the left hemisphere, toward a parasympathetic mode, with benefits to affective states. Yogis reveal larger brain volume in the somatosensory cortex, the superior parietal cortex (in directing attention), and the visual cortex (visualization). Yogis may also have enlarged hippocampi, perhaps dampening stress, and the posterior cingulate cortex, which helps with the concept of the self. Results suggest regular yoga practice, including postures, breathing exercises, and meditation, predicted GM volume differences benefiting body representation, attention, self-relevant processing, visualization, and stress regulation (Villemure, Ceko, Cotton, & Bushnell, 2015). My doctoral research noted improved state/trait anxiety, body image, and self-efficacy in first-time pregnant women participating in consistent prenatal yoga training (Samuels, 1987). Additional research utilizing yoga as an adjunctive treatment for post-traumatic stress disorder (PTSD) indicates significant improvements that appear to be maintained and comparable to psychotherapeutic and psychopharmacologic methodologies (van der Kolk et al., 2014).

The history of yoga is rather spotty because many early writings were lost. The beginnings of yoga in northern India can be traced back more than 5,000 years. The word yoga was first mentioned in the oldest sacred texts, the Rig Veda, a collection of songs, mantras, and rituals used by the Brahmans, the Vedic priests. Starting in the late 1800s and early 1900s, yoga masters began to travel to the West and attracted followers who attended lectures and demonstrations.

Krishnamacharya opened the first hatha yoga school in Mysore, India, in 1924. He is widely considered the most influential yoga teacher of the 20th century and credited with the birth of hatha yoga in the West. Krishnamacharya produced four students who would continue his legacy and increase the popularity of hatha yoga: B.K.S. Iyengar (Iyengar-style), T.K.V. Desikachar, Pattabhi Jois (Raja or Ashtanga-style), and Indra Devi, who opened her yoga studio in Hollywood, California, in 1947. Thus, the birth of the “yoga studio” in the U.S. (Goldberg, 2015).

Hatha yoga now has many different schools or styles and emphasizes a wide range of practice applications and study. Since the turn of the century, the popularity of yoga practice has risen dramatically to more than 36.7 million people in 2016 from 4 million in 2001. Upwards of 15 percent of U.S. adults regularly practiced yoga in 2016, according to the Yoga in America Study, conducted by Yoga Journal and Yoga Alliance. These numbers are on the rise as our patients, colleagues, friends, and family embrace these ancient rituals and routines. Spending on yoga classes, clothing, equipment, and accessories rose to $16 billion, up from $10 billion four years ago. In a world that triggers enormous anxiety and increased symptoms of distress, ancient yoga practices appeal to many seeking accessible self-soothing and self-care skills.

The top reported reasons for starting and continuing yoga are: “stress relief,” “flexibility and balance,” “improved health,” “mental health,” and “physical fitness.” Some 80 million Americans, or 34 percent of the population, intend to practice yoga, or are “very likely to,” in the next 12 months (Yoga in America Study, 2016).

What do we currently know about whether yoga practice helps with eating disorders and body disturbance? This perplexing question persists. Centuries of the practice and study of yoga have suggested numerous health benefits related to chronic low-back pain, high blood pressure, glaucoma, sciatica, possibly forms of arthritis, multiple sclerosis, PTSD, and menopausal symptoms (NCCIH, NIH, U.S. DHHS, 2013). Many of the yogis who brought “modern” yoga from India to the West describe their own physical maladies as factors that contributed to the development of specific schools of yoga. The goal was to restore health.

What are we beginning to understand and why may it be a cornerstone of eating disorder recovery?

Dianne Neumark-Sztainer, PhD, noted researcher and certified yoga teacher, has written: “Yoga and eating disorders: Is there a place for yoga in the prevention and treatment of eating disorders and disordered eating behaviors?” (Neumark-Sztainer, 2014). She concludes that “promising findings point to a need for randomized, controlled trials that would allow for the determination of whether involvement in a regular yoga practice leads to a decrease in risk factors and an increase in protective factors for eating disorders.” She also determines that students in yoga classes are at equal or greater risk for having disordered eating behaviors than the general population. Yoga classes, with well-trained instructors, can be a nurturing environment to learn better tools for self-care, how to pay more attention to their bodies’ needs, and, potentially, less disordered eating symptoms. Neumark-Sztainer suggests that “high levels of yoga practice may be helpful in promoting body awareness, responsiveness, and appreciation.” She also emphasizes that yoga studios bear a responsibility to employ teachers of all ages, shapes, and sizes; to offer mirror-free studios; and to provide varied classes for all levels of ability. Carei et al. (2010) conducted a randomized, controlled study and reported that the group receiving yoga had significantly lower global scores on the Eating Disorder Examination at follow-up (four weeks following intervention) compared with the standard treatment group. Less food preoccupation after their yoga practice was also noted. Thus, this study and others have begun to produce promising findings that indicate yoga interventions result in a reduction in eating disorder symptom severity. More rigorous studies are needed.

Another example, the Emily Program, based in Minnesota with locations in Ohio, Pennsylvania, and Washington, has a number of yoga classes now incorporated in all levels of eating disorder care—from outpatient to 24/7 residential treatment at its many facilities. It has also begun instruction in specific yoga teacher training, Body Image Sensitive Yoga Training, for the treatment of eating disorders (Diers, personal communication, September 2015).

Noted authors Carolyn Costin and Joe Kelly published Yoga for Eating Disorders: Ancient Healing for Modern Illness in May 2016. This compilation from expert contributors is intended to be a guide for both mental-health providers and yoga practitioners and teachers. Yoga and Body Image, edited by Melanie Klein and Anna Guest-Jelley (2014), describes 25 personal stories of how yoga both informed and provided a path for healing body image disturbances. Books, articles, research, and profiles are being gathered about the benefits of yoga in the treatment of eating disorders. While certainly in its nascence, the effectiveness of yoga in the prevention and treatment of eating disorders and negative body image is encouraging. Personal reports describe yoga as beneficial for self-esteem, stress relief, decreased symptoms of anxiety and depressed mood, and improved body acceptance (Diers, TEP). In the words of a health care professional in her late 50s: “I have hated my body my entire life, and struggled with an eating disorder in my 20s. I don’t know where I’d be if I hadn’t found yoga. My body doesn’t torment me now; I love being surprised by my body as I’m getting older.”

Yoga, in its current explosion of popularity, can either exacerbate or be reparative for eating disorders. Increasingly, individuals are sharing their stories of healing, offering hope, along with their books, workshops, and classes. Social media efforts promote body and size acceptance—for example, The Yoga and Body Image Coalition has promoted the “This is what a yogi looks like” campaign, presenting images across the life span of varied abilities, figures, proportions, and ethnicities. Its mission challenges the stereotype of the thin ideal yogi perpetuated by the beauty and fashion industry with models scantily clad in formfitting yoga gear and performing advanced inverted poses in idyllic settings, often photo-enhanced and misleading. Yoga instructors, similarly, may be unaware that they may represent harmful, triggering role models for their vulnerable students living with disordered eating, as well as body image disturbance.

These idealized images, combined with yoga teachers instructing gymnastic or intense cardio workout styles of yoga, can be triggering and damaging. Similarly, caution is needed for overcrowded classes with minimal instruction and “hot yoga,” which may be particularly harmful for students with unstable health. The hot rooms appear to enable greater flexibility and intense perspiration, which in turn encourages overexertion and may result in injury and medical crisis. The current appeal of “30-Day Challenges,” popular at yoga studios, is also a potential health hazard. These challenges emphasize a competitive atmosphere instead of encouraging students to recognize the need to respect and be aware of their own physical limitations. A local chiropractor described how his practice balloons every time the local yoga studio offers a 30-day challenge, with student injuries skyrocketing. Certainly, yoga classes may serve as another form of exercise compulsion, prompting orthorexia symptoms and other aspects of perfectionism. To summarize, a competitive environment is antithetical to the roots and underpinnings of yoga.

Thankfully, also growing in popularity are gentle, beginner’s yoga, chair yoga, restorative yoga, yin yoga (slow, deliberate movements often held for several minutes with numerous props to support the body’s physical limitations), partner yoga, yoga for seniors, yoga nidra (deep relaxation), and yoga therapy. It is crucial for students to match their study of yoga with knowledgeable, adequately trained instructors who create a safe atmosphere. While many teachers advise to “go at your own pace,” students often attempt to mimic the teacher or more experienced classmates and risk injury. Finding a safe space, in which the risks for students are acknowledged and the yoga teachers and studios become “havens for positive attitudes and behavior” is crucial. The yoga therapist or instructor can also be included in the eating disorder treatment team. Hopefully, the yoga student will inform the teacher and modify yoga postures to preserve his or her progress toward remission. Including curriculum about the potential risk factors for their students, how to speak to their students in a non-body-shaming manner, and when to make referrals to eating disorder health care specialists in yoga teacher training would greatly benefit the growing yoga community.

The popular Yoga Journal magazine published “The truth about yoga and eating disorders,” by Chelsea Roff on September 8, 2014. A key question was posed: If yoga can both help and hurt vulnerable students, the question remains: What aspects are positive and which are harmful, and how can the yoga community protect students from the risks?” Roff founded Eat Breathe Thrive, a nonprofit foundation supported by the Give Back Yoga Foundation, whose mission is to assist people to fully recover from disordered eating and negative body image through yoga and community support.

Some men and women absolutely embrace the idea of learning to self-regulate breathing, disturbing thoughts, and proprioceptive and interceptive information, while others are quite uncomfortable with being asked to be still, listen to their breath, and quiet the chatter of thoughts. As a lifelong yogi, it is commonplace in my clinical practice, groups, lectures, and community events to offer exercises bringing awareness to the breath, to physical positioning, to observe the flow of thoughts and feeling states, and to note discomfort. Often, an audience is invited to move in their seats, stand, or do a simple posture to increase physical awareness, focused attention, and breath integration. You may feel inclined to do something as a result of reading this. Please do! Yoga does not require special attire or equipment. Awareness and attention to the union of your breath, body, and mind is the practice of yoga.

Namaste.

About the author:

Karen Samuels, Ph.D, is a psychologist in Ormond Beach, FL. Karen is the Founder/Director of COPE: Community Outreach to Prevent Eating Disorders. She serves as a consultant to the Family Residency Program, Halifax Medical Center & affiliates and to the Jean Baker Miller Training Institute, Wellesley Centers for Women. A lifelong practicing yogi, she is a guide and psychologist at www.OneOeight.com serving to provide education, outreach, and guidance in seeking treatment for the continuum of disordered eating, body image disturbance and utilizing yoga as an adjunct for treatment. She developed middle school outreach media literacy programs, trains physicians on interprofessional Eating Disorder teams, and conducts Eating Disorder group therapy with midlife women. She has published, speaks, blogs, tweets, and posts as a specialist in the field of Eating Disorders. Dr. Samuels received the 2014 NEDA Westin Family Award for Activism and Advocacy.

References:

Carei, T.R., Fyfe-Johnson, A.L., Breuner, C.C., & Brown, M.A. (2010). Randomized controlled clinical trial of yoga in the treatment of eating disorders. Journal of Adolescent Health, 46(4), 346-351.

Costin, C., & Kelly, J. (Eds.). (2016). Yoga for Eating Disorders: Ancient Healing for Modern Illness. New York: Routledge.

Goldberg, M. (2015). The Goddess Pose: The Audacious Life of Indra Devi, the Woman Who Helped Bring Yoga to the West. New York: Vintage Books.

Klein, M., & Guest-Jelley, A. (Eds.). (2014). Yoga and Body Image: 25 Personal Stories About Beauty, Bravery & Loving Your Body. Woodbury, MN: Llewellyn Worldwide Ltd.

Korb, A. (2015). The Upward Spiral: Using Neuroscience to Reverse the Course of Depression, One Small Change at a Time. Oakland, CA.: New Harbinger Publications, Inc.

Neumark-Sztainer, D. (2014). Yoga and eating disorders: Is there a place for yoga in the prevention and treatment of eating disorders and disordered eating behaviors? Advances in Eating Disorders: Theory, Research and Practice, 2(2), 136-145.

Samuels, K.L.  (1987).   An Examination of Childbirth Training:  Changes in Self-Efficacy, Anxiety, and Body Image (Unpublished Doctoral Dissertation). California School of Professional Psychology, Los Angeles, CA.

 

Sutherland, S. (2014). How yoga changes the brain: The ancient practice promotes growth in brain regions for self-awareness. Scientific American, March 1, 2014.

Van der Kolk, B.A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak, M., & Spinazzola, J. (2014). Yoga as an adjunctive treatment for posttraumatic stress disorder: A randomized controlled trial. Journal of Clinical Psychiatry, 75(6), e559-e565. doi: 10.4088/JCP.13m08561.

Villemure, C., Ceko, M., Cotton, V.A., & Bushnell, M.C. (2015). Neuroprotective effects of yoga practice: Age-, experience-, and frequency-dependent plasticity. Frontiers in Human Neuroscience, (12)9, 281.

Yoga in America Study. (2016). Yoga Journal and Yoga Alliance, in association with Ipsos Public Affairs, January 13, 2016.

 

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