Robin Boudette, Ph.D.
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YOGA IN THE TREATMENT OF DISORDERED EATING AND BODY IMAGE DISTURBANCE Reprinted from the Journal for Treatment and Prevention of Eating Disorders, 14:1-4, 2006 The ancient Indian practice of yoga has enjoyed a surge of popularity in the last several years, supported by an increasing awareness of the indisputable link between a person’s overall physical and mental health and the inner peace and wellbeing that yoga is designed to achieve. About six years ago I experienced a back injury and turned to yoga for rehabilitation. After experiencing profound physical and psychological benefits within myself and seeing them in other students, I began studying yoga and eventually went on to become a yoga instructor. Then I began to wonder about integrating yoga into the treatment of eating disorders, which has been my area of specialization for the past ten years. I started by teaching a yoga class in an eating disorders program and by referring my outpatients to yoga classes. While using this integrative approach, I have found that yoga contributes to the recovery process in a wide variety of ways. Yoga introduces many patients to a new sensation: relaxation. Patients often report that the combination of yoga postures (asanas) followed by relaxation (savasana) creates a deep sense of peace and freedom they have never before experienced. In one class, for example, the patient was a woman in her twenties struggling with addiction and bulimia. She passively moved through the beginning postures with a distinct lack of enthusiasm. When our eyes met, she asked to leave. I suggested that she at least stay until the end of the postures, and then if she still wanted to leave she could discreetly do so. I gave her little further direct encouragement as the class went on, hoping to downplay her negativity and keep the rest of the class energized and focused. When it came time for the deep relaxation portion of the class, she continued participating. Afterward when I asked for feedback, she said, “That was better than a cigarette,” and went on to describe her surprise with the feelings of peacefulness she experienced. Yoga also enables patients to experience their bodies in a new way. Living in a society that values how you look more than how you feel, eating disorder patients often relate to the body as an ornament; they suffer from a disconnection from the body, feelings, appetites, and inner experience. In an authentic yoga class, you will find no mirrors. Rather than having all the senses focused on the external, awareness is tuned to internal sensations. “Where am I open? Where am I tight? Where do I hold tension? How is my breathing? How does it change when I take this posture?” Many patients become much more aware of the body for how it feels, rather than how it looks – which opens a window into a new experience of the body off the yoga mat. I also worked with a woman struggling with compulsive overeating, first in a treatment setting and then in community yoga classes. After decades of boycotting exercise, she bought a yoga mat and began practicing at home. She even requested a private yoga session to develop a routine that would be consistent with her personal physical and emotional needs. When we met she told me that she consciously wanted to use yoga to develop body acceptance. We developed a series of poses that helped her experience positive association with her body as well as poses that presented emotional and physical challenges. Over time, the transformation in her sense of self and body image was made clear by a change in her clothes. When she first started yoga, she wore sweat pants and baggy T-shirts that served to cover and hide the form of her body. After many months, she began wearing yoga tights and form-fitting tops displaying her new found confidence. Yoga frequently invites in a new way of looking at things. One patient reported a marked change in her perception while managing her day-to-day life. She said that before taking up yoga she felt her mind worked like the zoom lens on a camera, magnifying the most minor issues into angst-ridden, crisis situations. But after several months of weekly classes, she said her perception began to change; she began seeing things more through a wide-angle lens. The little things, she said, no longer seemed so big and could more easily be put into proper perspective. While yoga offers many benefits to people struggling with eating disorders, referrals to yoga classes must be done thoughtfully and cautiously. In my practice, I first assess how yoga could be helpful to a patient. For some, it may not be appropriate. A patient who has used exercise destructively in the past or patients who are extremely resistant to exercise may not yet be at a stage where yoga should be introduced as an adjunct to treatment. When I determine that yoga is an appropriate intervention, I educate the patient about how yoga may be a part of their recovery process. It is important to make clear that the purpose of going to yoga is not to put your foot behind your head, but to find a way for the yoga to support and enhance the recovery process. This will be different for each patient. I help identify goals in recovery that may transfer to taking a yoga class, such as: cultivating self-acceptance, respecting personal boundaries, challenging resistance, or tolerating discomfort. If patients are receptive, I refer them to a class that I know will support their goals. Matching patients to the right type of class is critical. Yoga classes and their instructors can vary widely in terms of emphasis on the physical versus the spiritual. Some yoga classes could reinforce the very self-destructive beliefs and cultural values that we are trying to extinguish. A competitive, perfectionistic patient does not need a class where she would be vulnerable to pushing too hard, ignoring personal limits and becoming overly focused on physical results, creating the risk of injury. This type of patient needs a class with less emphasis on the physical and more on the meditative aspects of yoga. A patient with a depressive quality and a need to increase energy would need a class with movement and flow, but also with an emphasis on self-pacing and acceptance. Above all, the goal is to send patients to classes that help them to promote balance, rather then imbalance, toward which they might naturally gravitate, and to break old, destructive tendencies. Referrals to yoga are not always successful. Another patient of mine is a high school student who is suffering from anorexia as well as severe anxiety and refuses medication. Several years ago she was hospitalized. Since then she has been able to avoid re-admission and made some progress but her weight is still below menstrual threshold and her anxiety level quite high. Her primary means for managing with her fear and her sense of lack of control is to exercise and restrict her food intake. I recently referred her to a relaxation-based yoga class. Her response was initially positive. She liked the class and felt relaxed. Over time, however, she did not continue. The pressure to stay busy and be productive enough to get into an Ivy League college became overbearing. Unfortunately, there are often too many rewards for compulsive over-activity. We are exploring her resistance to allowing herself to slow down, relax, be calm. Teaching yoga to patients recovering from eating disorders has provided a unique experience for me. I have been able to blend my knowledge of the recovery process and eating disorder patients with yoga practice. I often begin a class by encouraging patients to set a goal that joins their yoga practice with a challenge, physical or emotional, that they face in life. This helps to set the stage for focusing on process rather than product. Being in the moment, letting go of judgment, accepting personal limits are some suggestions. Tolerating the discomfort of a yoga pose is akin to tolerating the discomfort that comes with tolerating fullness from the re-feeding process experienced in recovering from anorexia. At the same time, refusing a posture that causes pain or emotional distress maybe likened to learning be more assertive. Throughout the class, I provide many modifications to fit the needs of the individual patients. Some experience panic or dissociation if they lie down with their eyes closed. I encourage them to do only what is comfortable, taking this as an opportunity to use their internal sense of what they need to set limits and find safety. I have had several eating disorder patients with a history of trauma who wanted to renounce yoga altogether due to the aspects that may trigger uncomfortable feelings. I typically suggest that, rather then deny themselves something that could be enjoyable, pleasurable, and helpful, they use creative problem-solving to find a way to participate that feels safe and right for them. This is similar to the way that I might encourage them to challenge a fear and try something new in their daily lives, such as trying a fear food. In this way, yoga can serve as a metaphor for life. There are many opportunities to tune-in to automatic and unconscious responses. New poses and balancing poses often stimulate negative anticipation: “I’m not good at this. I’ll never be able to do that.” I ask patients to reflect on how many times a day they say this to themselves and what kind of effect it may have on them. Does it help or hinder the recovery process? Does it build or impede self-esteem? They are able to see, right in the moment, their negative self-talk. Yoga becomes an experimental laboratory for seeing and then changing habitual patterns. In conclusion, with some eating disorder patients, words are not enough. Yoga offers a non-verbal, experiential adjunct to talking therapy that provides an opportunity for connection with the physical body and the inner experience. The process of practicing stretching and strength-building positions with relaxation, meditation and breathing techniques provides opportunities for self-awareness, reflection and change while at the same time creating inner peace. Both the practice and the result can help to heal disordered eating. REFERENCES Bennett, B. (2002). Emotional Yoga: How the Body Can Heal the Mind. New York, NY: Fireside. Farhi, D. (2003). Bringing Yoga to Life. New York, NY: HarperCollins. Sell, C. (2003). Yoga From the Inside Out: Making Peace With Your Body. Prescott, AZ: Hohm Press.
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