Yoga Therapy for Mental Health
Eating Disorders
By: L Paige Lichens
July 2020
I decided to write about eating disorders (‘ED’s’) for this assignment and according to the National Association of Anorexia Nervosa and Associated Disorders (ANAD) more than 20 million people in the US alone suffer from ED’s and account for a high mortality rate among mental illness. ANAD defines eating disorders from the publication of “Diagnostic and Statistical Manual, Fifth Edition (May 2013) of The American Psychiatric Association” as:
Anorexia Nervosa: Not getting enough calories which may lead to low body weight. The person shows intense fear of gaining weight. The person also has a difficult time recognizing the seriousness of their weight or unable to see how they appear currently.
Body Dysmorphic Disorder: An obsession with their physical appearance and responds to slight blemishes as if they were extreme. In some cases they may even imagine a defect.
Bulimia Nervosa: Defined as recurrent episodes of binge eating along with compensatory behavior. An episode may involve over eating in large quantities and lack the ability to stop. Then the person tries to make up for the eating by fasting, excessive exercise, use of laxatives, purging or other items such as digesting food that is known to cause the body to eliminate.
Binge Eating Disorder: Defined as eating large amounts of food, larger than the amount most would eat, and have a sense of lack of control or ability to stop. They may even eat faster than normal and/or eat past the point of feeling full. They may feel a sense of guilt and prefer to eat alone.
Avoidant/Restrictive Food Intake Disorder: Eating disturbance where a person is unable to meet their nutritional or energy needs.
PICA: Eating substances that have no nutritional value and for a long period. ie eating cotton.
Rumination Disorder: Repeated regurgitation of food and may include re-chewing, re-swallowing or spitting out food.
Other Specified Feeding or Eating Disorder or OSFED: Combining many of the items above but also including things like night eating syndrome or purging disorder (purges without bingeing).
Unspecified Feeding or Eating Disorder: disorders that don’t meet the criteria of the above but still cause emotional upset in daily life.
Obviously there are many ways to define an eating disorder but there may be may other mental illnesses issues going on as well; such as anxiety or depression. Of course know one knows for sure how the brain specifically developed the disorder and areas effected may be unique but a more important issue is how to restore brain patterns. There may be reasons that the client developed this mental illness that also need to be explored with a therapist; abuse or addiction may have been the trigger or it could have been the way the client managed. The client may have experienced a trauma, conditioned into behavior, felt a sense of control, or lacked a sense of worthiness. I teach yoga at a residential treatment house for eating disorders, where the ED clients live onsite; either coming from a hospital or they are admitted because they didn’t require a hospital but out-patient care wasn’t safe for them. Often the decision on treatment is made by doctors and insurance plans, and they are referred to a treatment center. Unfortunately this doesn’t mean that the client receives the proper treatment or care but instead was the one they could afford or allowed.
The residential sites separate adults and adolescents to different locations and I teach at both nearby Alexandria and Fairfax. I also teach yoga at the outpatient clinic for both groups in Alexandria. For over two years I have listened and learned a lot from the clients and staff. First of all, this mental illness is much more than society leads us to believe. From my personal experience clients have explained using their mind as a way to control and avoid harm. For example they couldn’t control some past event, so this was their way of feeling safe. Others define it as not feeling worthy or good enough, so they inflict harm on themselves; which is why I will see some with cutting marks on their body or why they felt the need to control their intake of food. This is also why they are often provided structure and rules to help them develop the cognitive function, compassion and self-care. They may be victims of a crime and show little care for themselves but with the help of a therapist, they start to figure out what they do care about, for example a dog, cat or loved one. With this they may start to see that if they don’t take care of themselves they can’t take care of their animal or loved one.
What we do know about brain development is that a person develops signals that are triggered within the neurons of the brain. These are transmitted to the neurotransmitters that are then relayed to other parts of the brain and body; the neurons may have sensed a threat happening and the body responds to this. Next the brain will perceive a threat and decide if something needs to be approached or avoided. Then the occipital cortex sends images of the threat to the hippocampus, for evaluation, and to the PFC and other parts of the brain for more processing and time consuming analysis. The experience is then deemed pleasant, unpleasant or neutral. That aspect of the experience is called the “feeling tone” and “is produced mainly by your amygdala (LeDoux 1995) and then broadcast widely”. (Hanson, R. p 36).
Additionally human beings have neurochemicals inside your brain that affect neural activity. Hanson refers to these on page 36 and some are:
GABA: inhibits receiving neurons
Serotonin: regulates mood, sleep and digestion
Dopamine: involved with rewards and attention; promotes approach behaviors
Norepinephrine: alerts and arouses
Acetylcholine: promotes wakefulness and learning
Cortisol: released by the adrenal glands during the stress response; stimulates the amygdala and inhibits the hippocampus
Human beings often use the brain for avoiding and safety vs. approaching, but it may also be for goals, such as rewards and actions. Therefore human nature tends to focus more on negative impacts to avoid suffering. This may be why mindfulness helps mental development past the concept of the felt sense. For example with the early stages of an ED the person may start out controlling to avoid suffering; it may be a parent making fun of the person eating. The development of the brain was set into motion, to reward the action, then reinforced by receiving praise and avoid feeling shamed. Over time though this reveals much more harmful suffering and life threatening situations based over long term behavior; the decision to override natural responses manifests and shows up in the body. “You feel it in your body, and it proceeds through bodily mechanisms. Suffering cascades through your body vis the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenal axis (HPAA) of the endocrine (hormonal) system.” (Hanson, R p 51).
By understanding the functions of the brain a yoga therapist can better understand ways to help a client with this disorder. Each part of the brain does many things and the plan of care can take this into consideration as I will describe later. According to Hanson on page 53 some of the major brain areas are:
Prefrontal cortex (PFC): sets goals, makes plans, directs acton; shapes emotions and sometimes guiding the limbic system.
Anterior (frontal) cingulate cortex (ACC): steadies attention and monitors plans; integrate thinking and feeling
Insula: senses the internal state of the body; including gut feelings
Thalamus: major relay station for sensory information
Brain Stem: sends neuromodulators such as serotonin and dopamine to the rest of the brain
Hippocampus: forms new memories and detects threats
Amygdala: a response to emotionally charged or negative stimuli
Hypothalamus: regulates primal drives such as hunger and sex; activates the pituitary gland
Pituitary gland: makes endorphins; triggers stress hormones and releases
Therefore learned behaviors draw on the anterior cortex (ACC), insula and we can take steps to activate the prefrontal cortex (PFC) in yoga therapy to help us to process situations, build empathy, self-care and loving-kindness. Psychotherapy works this way as well, as the treatment believes that thoughts and feelings are directly related to behavior. This is why psychotherapy is often used in treatment for ED as it concentrates on patterns of abnormal thinking and distorted beliefs. There are stages the therapist will work on with the client; starting with identifying problematic beliefs. Then they will work with them to develop new skills and how to practice and apply them, and then toward implementing. According to West, M. (p132) “It has been suggested that mindfulness training can enhance therapists qualities related to common factors of effective treatment, such as affect tolerance, acceptance, empathy, equanimity, paying attention and accepting.” As a yoga therapist we want to enhance what other medical professionals are doing with clients and develop a plan of care with similar stages in mind.
The treatment for ED can vary and obviously the hospital is for severe life threatening cases. Some decide on living at a rehab or residential treatment center (RTC) that offers 24 hour care along with programs that help them with cognitive behavior, psychotherapy, nutrition education, yoga therapy (YT), relapse prevention skills and programs that can be up to six hours a day. The length of stay is often a month but may be longer; again the choice is from the client, insurance and the doctor, but they don’t always agree. My personal experience has been at the ‘Center For Discovery’ that has sites all over the US and been around over 20 years. The groups are small and there are many treatments and services. Many have to learn to measure their food, work with a nutritionist, be given instruction on how much movement they are allowed to take, and can’t go to the bathroom alone. They are encouraged to do artistic things and take time away from their life so they don’t have a computer or phone. They often have to learn how to take care of themselves as well; to clean, make the bed, shower and be with others in group activities. The clients also receive levels for their treatment; they refer to it as ‘stepping down’ as their level of progress changes; the lower the number the more the client is moving to next stages and eventually leaving the program. Vitals are taken regularly, prescriptions may be issued by the doctor on-site or at hospital. Family is often involved to come and visit, but many also chose the site to get further away from their home. When clients step down from the residential treatment they may go for intensive outpatient programs (IOP) or decide to return to their home and see a private therapist. Some clients attend the IOP part of the time and go to a hospital for other programs; called a partial hospitalization. These off site programs still provide structure for the client but also allow many to return to work or school. At all the sites the clients prepare meals and eat together, attend group and single therapy sessions, write, draw, attend yoga, play games and vitals are taken regularly by staff.
Unfortunately clients often repeat care and may be shifted up or down to different treatments. Also someone may start out in the outpatient but decisions are made to move to a residential site. Watching first hand the conditions and treatments, I feel we have a long way in helping clients with the disorder. Something like eating food is challenging for someone with an ED and can’t be cured with logic. I have witnessed many breakdowns, fear and panic attacks from clients being asked to finish food or drink more water. Some build up barriers and learn to get by in programs but unfortunately they haven’t changed the mental illness behavior and are still battling with the disorder.
Additionally the community has a lot to learn about mental illness and especially ED; it is often stereotyped. I watch young men who were encouraged to meet demands of their sport and that the event mattered more than the needs of their body; in-fact this behavior is often rewarded and accepted regardless of the harm. Some shared with me stories about their coaches, instructors and family members; being made to feel ashamed for who they were. I once heard a client describe that a weight-in was taken regularly before her dance class and then compared to the rest of the group; the one that was deemed the highest weight was judged and ridiculed. We still have a way to go in understanding that ED is not about being thin; it stems from a mental illness that developed and is causing harm to the person. If you examine the definitions on page one you may be able to see that someones body type may be large but still anorexic. Furthermore I wish family was more involved in treatment and in many cases encouraged to seek therapy as well. Taking these views into account, the estimated numbers of ED sufferers in the US (from the ANAD) might be higher.
I also feel the community still has a lot to learn about Yoga Therapy (YT). Even mental health centers don’t fully understand how Yoga is not the same as YT. Prior to working at the ED Center, I worked at an addiction center for three years and as a yoga contractor I provide notes into their software so they have information for insurance documents. Still though I am not provided detail on the clients treatments, triggers or feedback (unless it is urgent).
At the ED center I have learned to modify much of my yoga language as well. I use anatomic words to describe the physical area; words like abdomen vs belly. Each time I arrive there it can be different, for example I won’t be aware of their sleep issues till class starts. The clients may walk in full of energy or they are all balled up in a blanket and unresponsive. Often I have a group of those new to the center and those who have been there. Sometimes I am offering gentle movement, yin practices but most times it is restorative. For the adolescent group I do movement and instruction that needs to change a bit faster so I do something I call the TikTok movement (since they love the application). I decide on the first movement and then we have another client pick the next. Then we repeat the first movement and add on the second and keep building that way around the entire group. I do this as it builds mental resilience and shifts the mood (dopamine). Often we only do this for about ten minutes and then they are ready to restore and rest (serotonin levels are more balanced).
There are many ways to develop a plan of care but I like to follow the pancamaya or Kosha Model especially for clients that have experienced trauma. This model has us focus on ‘layers’ or sheaths of the self; from the outside-in. For example, if I just started working with a client I will keep the focus on the outside layer primarily at the Annamaya Kosha (physical sheath). I may add a small focus to the Pranamaya Kosha (breath sheath). Later, as I work with them more, I will develop the care to include the Manomaya Kosha (intellect sheath) and then Vijnanamaya kosha (perception sheath) and have ways to guide them safely to experience anandamaya (emotion sheath).
Additionally there is a book called “8 Keys to Recovery from an Eating Disorder” and it was written by a therapists and former ED’s Costin, C. and Grabb, G.. The book lists effective strategies from a therapeutic practice and has many first hand experiences with ED. The Center likes to have the staff, clients and family read it. The book discusses the ‘self’ and that many won’t know how or want to be themselves; that they only know themselves as the person with ED. In fact clients are disconnected, so the book discusses that first they have to understand there are steps to healing, they won’t be easy, and that they have to also believe that someday they will be healed. For treatment they often start off having clients identify the ‘ED Self’ and the ‘healthy self’. I have heard many use the phrase “I will not be defined by my eating disorder” as their way of learning about themselves. Therefore I can see the correlation to the pancamaya model as we often feel defined from the outside (Annamaya Kosah) but we can learn to develop awareness of ourselves that is deeper and more profound.
There will be sensitivities, precautions, and contraindications to consider when working with the mental health population. As a yoga therapist I want to know about the conditions, brain and body connections to develop a plan of care around the practice. Also I want to be able to identify the triggers and communicate to the client as well as the professional medical field. As previously discussed we may be dealing with high sensitivity, anxiety, depression, and delusion. Also the client may be experiencing higher dopamine levels and needs help regulating the serotonin and cortisol levels as well. They will be working with a medical doctor and possibly taking prescriptions but I can also build the practice around function of the brain and body as well.
I like to design the yoga practice various ways; starting with an assessment as well as identifying the energy or “Gunas” state I observe the client in. The Guna’s, according to traditional ancient text, are present in all things. The three Guna’s are Sattva (goodness, harmonious), Rajas (active, confused) and Tamas (darkness, destructive and chaotic). Also I may be looking to develop more cognitive awareness and assessing what they are aware of during the practice and asking them what else they can notice. I may also have them experience mindfulness; in movement or stillness. “Our attempts to avoid anxiety can actually trap us in it. Trying to avoid difficult emotions can also contribute to depression.” (Siegel, R. p159). He continues to point out that, “most of us learn to hide negative moods from a very young age.” So I will be aware that for the client much of what I am instructing may not feel normal, but help them develop safe skills so they can ease into feeling which may also shift or change their belief or understanding. Finally they may be experiencing sleeping disorders and I want to know the best ways to cause a shift in the neurons to stimulate rest.
In developing a yoga therapy plan it will always vary on the person but I will offer a brief example based on much of the information gathered above. Lets assume the client has just started in-house treatment, has been instructed not to stand but can sit up for a brief period, is having sleep issues, is feeling depressed and in a new place so geting used to the other clients, house and rules. To me this is a time to help the client feel safe, grounded and centered. I’m thinking about the psychotherapy steps discussed above; I am looking to help them develop an awareness to acknowledge their beliefs. I could start them in constructive rest but at the same time if someone is depressed I often find it better to start them off sitting up; even if this is sitting up at an angle or leaning back.
The gentle somatic yoga practice is really good as the positions are kept simple and allow for mindful movement without it being a trigger or comparison to past yoga practices. The interoception of this movement also helps develop a deeper sense of awareness and mental behavior. To start, I will have the client seated and either looking down at the ground or closing the eyes. I will offer some guided observation of their breath; just natural breath. Then seeing if they feel comfortable with this and maybe adding soft pranayama awareness in one part of the body; taking deeper breath out to activate the parasympathetic nervous system. Then with hands in the lap I will have them discover a neutral position and then round the back, drop the head and return to neutral; repeating several times. Then switch to arching the spine, lift the head and then return back to neutral; repeating several times. Finally we do all three motions together; round, neutral to arch. If they are ready for more, I will add eye direction to the movement; eyes move in the opposite direction of the head. Then we will shift to seated twists very slow. Placing hands at chest and then slowly turning to one side and back to neutral; repeat in the same direction a few times and I can add eye movement to this as well. Each time we pause, listen and notice. Still seated I will also have them move from the side waist; lowering the hand beside the seat as if you were reaching down for something; then back to neutral. Asking them to notice and inquire more. At first it takes time for clients to stop looking for the right answer but I like to reassure them that there is no right or wrong, good or bad. Instead the practice is there to learn more about ourselves. This doesn’t mean the client is guaranteed to see what I see but it is important to allow them to share their experience without a feeling of shame.
I will then have the client lay down and could continue with Somatic movement on the side or back. However I can also have them move into a supportive bridge pose with a blanket on the back and let them feel their body in a position that feels safe and supported.
From here the client is often ready to rest so I will have them set up in constructive rest position in a way they like to sleep. Many prefer to lay on their side but they roll up and pull on their neck. So I will suggest ways to consider laying on their side but supporting their body more using blankets and pillows; like restorative yoga poses. Then I will ask the client if what we just did made this better or worse and let then decide; their ability to be asked this and make their own choice also helps them. Then I will guide them into the Yoga Nidra practice, that I am certified in, and sometimes offer with sound bowl. Yoga Nidra is instructing following the pattern of the Koshas. With a new client I will simply start with a lot of focus on the physical and breath sheath for the first few lessons. At the close of the practice I will ask the client to describe any experiences they were aware of and anything else they wanted to share. Simply let them talk and see if they can expand on that thought. They will be uncertain and looking for me to tell them what to feel, but I want them to be encouraged to search for those answers within.
To finish their practice I will listen to their experience and then offer them practices they may do until next time; however the house may have restrictions on this because the client may be doing movement as part of their disorder. Therefore I try to keep the focus on things they can do to sleep or rest better. Over time I hope to see more resilience and strength but again that isn’t my overall goal for someone with ED. Someone at this stage is going to have many ups and downs and thinking that yoga therapy or treatment had to be on an upward moving scale is wrong. I believe we are conditioned into ‘fixing’ ourselves with yoga poses and really missing that yoga was about being present; not to find fault with ourselves which is our conditioned behavior.
In conclusion ‘belief’ and ‘self’ seem to be important words to notice with an ED. What makes an eating disorder difficult to treat is that one believes one thing but the ‘self’ is distorted. Even if the client is shown facts or images, they still ‘believe’ they aren’t that way. A client with ED has a goal that isn’t satisfied; never thin or good enough. Also they feel safe within their disorder and although rehabs may offer structure and temporary change, the client often returns back to old patterns and habits and this could have a fatal consequence. The difficulty in treatment of ED is that the person often returns back to their life, family, friends and patterns. Unfortunately most of the harm comes from the family; passing down their beliefs, blame and judgement. As a society we need to observe our communication that may seem harmless, but is sending messages that we aren’t good enough; ie commercials or marketing. I want to keep studying this mental illness, especially with other kinds of addictions, to see how the medical field and yoga therapy can learn more and be useful to brain development and recovery.
References
Association of Anorexia Nervosa and Associated Disorders Website: https://anad.org/education-and-awareness/about-eating-disorders/eating-disorder-types-and-symptoms/
Costin, C. and Grabb, G. (2012). 8 Keys to Recovery from an Eating Disorder, W.W. Norton & Company.
Hanson, R., (2009). Buddha’s Brain Happiness, love and wisdom, New Harbinger Publications, Inc.
Siegal, R. (2010). The MIndfulness Solution, Everyday Practices for Everyday Problems, The Guilford Press.
West, M (2016). The Psychology of Meditation, Oxford University Press.