An exploration of the possible links between eating disorder recovery and yoga
I have decided to share the full-length version of the paper I wrote years ago on yoga and eating disorder recovery. The thing is: I wrote this before studying to become a coach, before further studying yoga in various forms and practices, before doing more therapy, before learning oh so many lessons.
And I could, theoretically, review the whole text to add nuances here and there, adapt my personal commentary as my understanding sometimes changed, and supplement this paper with all the parts that I had to cut through because there was a maximum length to be respected (and I was already bending the rules when it came to the total word count).
But I won’t.
Because… this is good enough. And I am trying to choose ease when I can, this year.
Oh and the paper was meant to be read by other yogis - so apologies in advance if I use unclear terminology. Please don't hesitate to write a comment or send an email if you have a question!
So anyway. Here’s a piece from my past. And the bridge that led me to recovery coaching.
I first discovered yoga as a fresh university student by trying out a new fitness class at my local gym. Unlike my other go-to choices at the time, however, it was a much slower, gentler and less competitive practice. And for an unidentified reason at the time, I was drawn back to class week after week.
Fast forward a few years and I am a young graduate working at a big financial services firm, with the “right” diploma in hand and the “right” job to start an ambitious career.
And I am slowly losing my mind and sense of self.
It took well over two years to admit that I was having a hard time (read: suffering from an eating disorder (“ED”)) and another one to seek (proper) help. At which point I had to meet myself again. Intuition was an unknown. I did not know what I could possibly want to do, who I was or wanted to be. No hobby. No interests. No fire burning in my seemingly inexistent soul.
As part of my therapy, I planned activities just for the sake of doing them in order to try to identify which ones would arouse any feeling or emotion, which ones I could enjoy (or not).
I rediscovered my creative side and took on watercolour painting (and wasn’t half bad at it).
And I rediscovered yoga.
Yoga, as a movement modality with no machine screaming the number of calories burned at me. A practice that put me back in touch with what and how I felt. I realized that not feeling anything and being incapable of identifying feelings was making my recovery tremendously difficult. And diving in was scary and painful (spoiler alert: it still is). But yoga somehow seemed to help open the doors to the world inside of me, reconnecting my mind with my body, thus opening a door to recovery.
This essay is my attempt at understanding how and why yoga seems to have played such a significant role in my own recovery. It goes from linking EDs to the world of yoga, in theoretical, philosophical and then therapeutic terms, to a review of modern-day research and studies*, which discusses whether and how yoga is shown (or theorized) to help with EDs.
Is it theoretically possible to link EDs and yoga?
In theoretical and very broad terms, someone suffers from an ED when they become unhealthily preoccupied with eating and exercise, basing their self-worth largely upon their shape and weight, and the ability to control them (8). There are several types of eating disorders but some behaviours and thought patterns are shared amongst most, such as any form of restriction, of binge eating, of compensatory behaviours and body-image avoidance (9). In more concrete terms (and definitely tainted by my own experience): everything becomes linked to the amount and/or specific qualities of the foods ingested, how to burn the food through exercise, or get rid of it in any other purging way, allowing your mind to only focus on these aspects of your life, making you believe that the rest (of the problems you are not facing) will come into place once you are a certain weight or shape, as you are currently not deserving of anything nice (and would probably ruin it anyways). The ED voice in your head convinces you that if you are in control of “just this one thing” first, then everything else will either be fine or is unimportant anyways (another spoiler alert: it does not work). This process not only sabotages your relationship with yourself but also others, as your life ends up solely focused on (ridiculous) rules your mind (the ED voice) has edited for you.
Before trying to understand how yoga could have helped my recovery, I figured it would be helpful to understand if EDs could even fit, conceptually speaking, in the realm of yoga.
Change, habits, inappropriate self-esteem and inappropriate eating habits are all mentioned as possible causes for suffering (dukha) in the Yoga Sutras (2.3-2.9)(1)(7) and are all, in one way or another, referenced in ED literature (and my own experience – cfr above). The Yoga Sutras (1.31) also explain how suffering expresses itself in different ways: in our emotional state, negative mental attitudes, physiological changes and breathing patterns (1)(7). As EDs are a mental health diagnosis, it is here, again, rather straightforward to draw parallels with all but the last expression of suffering.
Furthermore, the Yoga Sutras (2.20) suggest that the quality of the mind is of utmost importance (7). Indeed, the understanding of perception and cognition, in yogic terms, is one of a greater consciousness (purusa) which requires a medium, to function. This medium can be the body, the mind (citta) or senses, and their quality thus matters greatly (1)(7). This also means that one cannot work directly on purusa, but one can reach it through one of its tools: the mind, which itself becomes more transparent through yoga (7). This brings me to make the following connection: yoga saying to “work on citta to make it of greater quality/bring clarity, to reach the state of yoga” is the yogic definition of psychotherapy: work on your mental processes to allow your brain to work how it is meant to, in order to mitigate problematic behaviours, beliefs, compulsions or thoughts.
In fact, drawing this parallel also works with the goal of yoga as defined by Desikachar and Mohan. Desikachar proposes that the goal of yoga is to reduce the film of avidya (incorrect comprehension) in order to act correctly and reduce dukhaarising from it (7). If avidya is the mind itself, it is to work on the mind, whose quality (as we already learned above) is of great importance. Thus yoga can be understood as acting on the mind and reducing its veil (avidya, i.e., in our context, quieting the ED voice), and providing clarity. Mohan states that the aim of yoga is reintegration: the process of bringing us back to a state where our minds perceive things clearly (2). Not only is this in line with Desikachar’s view but it introduces the concept of reintegration, of connecting back elements that were not (ourselves with our own purusa) because any disconnect would be an imbalance that can draw our attention outward, with our mind distracted and attaching itself to pain (definition of vyadhi in yoga therapy (1)). The lack of connection between mind, body, sensations and feelings being hallmarks of EDs (11) (as well as something I personally experienced), this concept of reintegration is all the more relevant.
EDs thus seem to be understandable in yogic terms and possible “subjects” to a yoga practice and/or yoga therapy. But is there more in the world of yoga philosophy or therapy that can help us understand how yoga could be beneficial in an ED-context?
Yes. Maybe too much, actually. So much that I chose to develop the most referred to and accessible themes, whether because they are base tenants of yoga philosophy or ones that any practitioner, in the West, can get in touch with.
Patanjali’s Yoga Sutras, with their yamas, niyamas, as well as the plethora of notions developed in foundational texts of yoga philosophy, provide a wealth of ethical principles and guidelines which can be linked to some that one might develop in therapy.
Yoga, for example, encourages people to self-examine and tune in to their body and mind (svadhyaya, one of the niyamasand steps of kriya yoga), practice self-compassion (ahimsa, also understood as non-violence and one of the yamas) for where they are at now, whilst embracing the concept of constant change (parinmavada)(7)(8). And even though it is encouraged to work on change through tapas (another niyama and step of kriya yoga), which can be hard as dukha is the “lot of those who seek” and can also “arise out of our efforts to progress” (7), the other two steps of the kriya yoga (Yoga Sutra 2.1) ladder are as important: svadhyaya, which we already introduced, and isvarapranidhana which is usually interpreted as “love of God” but also refers to the quality of the actions (not motivated by their outcome)(7), or, as Kaminoff presents it, the “non-negotiable”, as in “what one surrenders to” (10). In other terms: you are welcome for who you already are, you are encouraged to work on yourself (although it will admittedly, sometimes, be hard – as is (psycho)therapy), but you are not meant to “do it all/fix it all”. You can also simply “be” (here and now). There is no need for perfection, for control over everything, and no need for “pain to gain”, which are common themes in Western “health” culture and fuel disordered habits and thoughts (“pain is normal and necessary to become better/more”, “you have to push yourself to get somewhere”, “control food/weight and you will control the rest of life”,…). Yoga, in this very way, thus also promotes self-acceptance to reach contentment (samtosa, another niyama) rather than happiness (7), which is important and at odds with the Instagram-perfect-and-always-positive-thinking-happiness-aiming attitude to life, as it reminds us that we are human beings, not human “doings”, with space to breathe at the satisfaction of being “enough”.
Coming back to tapas, and aiming at keeping the body fit, it is commonly understood to be the combination of practising asanas and pranayama, as well as feeding oneself properly to ensure a fully functioning body (2)(7). Of course “move, breathe, eat well” sound like obvious and familiar guidelines for good health (or just remaining alive). But in an ED-context, moving and eating both present challenges (too much and/or too little) and reasoning does not work in a setting where the mind is overtaken by a (mistakenly) wired inner logic. Movement, in yoga, however, can be understood as a door to the mind.
Indeed, yoga is a holistic approach: it considers all dimensions of the human system as an entity and what happens to one dimension can thus impact the others (1)(2)(8). So even though yoga has a special emphasis on the mind, this holistic approach means that asanas, whose concern is not the poses’ outward form but their function, can become a starting point to connect with the subtler dimensions; including the mind and emotions (1). This indirect approach to healing is called samana in yoga therapy: the aim being to stabilize, not directly address the root of a problem (1). Which, to circle back to EDs, is the acceptance of not always being able to identify and fix the cause in a focused and immediate way (as, if it were the case, EDs would not be said to be so complex and multifaceted making them immensely difficult to treat (8)(9)), but, rather, to start creating a pathway or opening cracks in the door to our mind, thoughts and emotions, through (psycho)therapy…
…And yoga? Is this actually possible or does this remain only theoretical?
Research has shown (quite literally through brain-imaging) that combining (mindful) body-based movement and sensory experience in conjunction with psychotherapy facilitates the “neurological convergence of the mind, brain and body” (3).
In other words, movement that includes mindful attention and intention (i.e. not “just” working out) can help with the “reintegration of the experience of one’s self (body and mind)” (3). Let’s rephrase that: yoga (mindful movement) has the potential to help your brain to reconnect with your sensations, feelings and emotions, which is in line with the holistic understanding of the “yoga body” and with Mohan’s similar choice of wording (“reintegration”) when discussing the goal of yoga. If we accept that emotions are indeed body phenomena and that the body experiences emotions and thoughts prior (or in conjunction with) mental awareness of those feelings (3), then it explains why body movement (asanas) could help with mental health. ED sufferers (past-me included) are cut-out from body and senses: feeling at a physical level is prohibited (because you have to forget the pain, the hunger, the light-headedness,…) thus is feeling at an emotional level also made inaccessible, which in turn (and as mentioned earlier) makes recovery quite hard as therapy requires to dive into oneself. Recovery, in Western-therapeutic terms, requires learning to feel (identifying “physiological activation” of emotions or thoughts) in order to identify the link between emotions and unhealthy coping mechanisms: going from automatic reaction to conscious observation. And yoga, according to the authors of a series of studies (see further below), can be a step or tool in doing so by starting at the level of the body itself.
How does “neurological convergence” translate in the context of EDs?
Poor body and emotional awareness are common symptoms and risk factors for EDs (6)(9). Several studies highlight how yoga can help mind and body cohesiveness through mindful movement, awareness of breath and body first, by challenging the beliefs that an ED sufferer might have about their body’s limits (4)(11)(13). By discovering and sharpening perceptual faculties, yoga can also help bring awareness to the non-physical layers of feeling (i.e. emotions)(11). Moreover, yoga has been found to lead to less body dissatisfaction, reduced weight control behaviours/drive for thinness and less self-objectification (5)(6)(8)(9)(13). The latter, implying the perception of self as a person rather than the object of someone else’s gaze is actually a common target for ED intervention in therapy (6). In practice, the aforementioned benefits mean that asanas are a possible door to the reconnection with one’s own body, thus also the ability to feel sensations such as hunger and satiety (5)**… and maybe reach the next level of feeling with emotions, through this newfound connection to the present moment.
Present moment awareness is indeed another challenge for ED sufferers who spend a lot of time in their own heads, with obsessive thoughts (the ED voice takes up a lot of mental space to control how you behave). Studies have shown that yoga helps practitioners to let go (of critical thoughts) by being present (8)(9). It is important to note that this does not translate into an absence of thoughts, but rather the experience of noticing what happens in the body and the mind (cfr above), in a non-judgmental way (ahimsa, with self-compassion), leading to a sense of clarity and being grounded (9). It is not freedom from thoughts but of the judgment of those thoughts (i.e. freedom from the overly critical ED voice) prompting both a better understanding and separation of own thoughts vs the ED voice, thus giving the practitioner literal time away from the ED (and the first taste of what recovery can be like)(9). This newfound power on the mat is theorized to slowly become available outside of the practice, partly because breath plays an important role in the process of reconnection to our bodies and selves on the mat (“follow your own breath”) and remains with us in the outside world, thus becoming a tool for mindfulness there too (9). Additionally, mindfulness therapies/present moment awareness through yoga have been observed to help refocus and reshape our responses to distress and anxiety (5)(9), thus helping with trigger management and self-regulation.
Indeed, present-moment awareness has also to be understood as intentional concentration (on particular sensations or emotions and not others – called prathyahara in yoga) which is critical to cognitive flexibility of attention and inhibitory control (11). Several studies and authors propose that increased self-awareness (as described above) allows oneself to uncouple the sensory experience from the “self”, giving a sense of perspective to the ED sufferer as it allows them to experience feelings (physical or emotional) in terms of their subjectivity (vs assumed validity) and their transient nature (vs permanence)(11). In other terms, the process of tuning in, noticing without judging, of taking stock, and accepting your body’s limits, is a form of self-regulation. The capacity to self-regulate means that you can learn the ability to notice a physical or emotional feeling, without having to react immediately: it becomes possible to tolerate and manage negative feelings (9). Studies have, in fact, found that food preoccupation and the intensity of ED episodes after yoga classes or workshops are lowered, and improve over time with practice (5)(6)(8)(13), and that negative mood traits are significantly changed before vs after class (12), which come to support that first taste of recovery mentioned earlier.
There are two additional important side notes to be mentioned: firstly, it has been well documented and researched that EDs often co-occur with other mental illnesses such as anxiety, depression, OCD and PTSD, and that yoga is one of the more effective alternative/complementary methods for these mental health issues (4)(6)(8)(9). This is important as specific research for yoga and ED is still in its early stages, comparatively speaking (cfr discussion below), but the overwhelmingly positive results of yoga on mental health difficulties reinforce the confidence in the benefits discussed above. Secondly, several authors note the importance of the motivations when practising yoga in reaping the aforementioned benefits, which calls for two observations: this both reinforces the importance of yoga as a holistic approach (not as a fitness class) and the importance of therapy, as developed below.
Firstly, it is important to insist on the fact that studies remain tentative and small in scale, with no author pretending the results of their work to be wide enough and/or applicable to all, and all insisting on the need for further research. Let’s indeed not forget that EDs are complex mechanisms and difficult to treat. There is no one size fits all for EDs in therapy. Yoga’s benefits might not be applicable to all, either.
Moreover, and as pointed out by several authors, yoga practices can take many forms, with more gentle and restorative practices being more careful and thoughtful options and uses of yoga in the context of EDs (the point not being for yoga to be another exercise method to burn calories). Additionally, some ancient techniques or concepts can be detrimental to ED sufferers (such as some of the shatkarmas, purging techniques, or sauca, cleanliness, another niyama). On top of this, yoga’s representation in the West can also be harmful if presented as a tool to look a certain way or reinforce controlling behaviours: perfect gym bunnies, in figure-hugging lycras, practising in front of mirrors, praising detox cleanses or postures will not be a favourable environment where one will be able to develop the benefits discussed in this paper.
Finally, yoga, because it can put one back in touch with feeling (physically and emotionally), can bring pain and questioning up to the surface. And those still require being talked about in a supportive environment… i.e. (most probably) in therapy.
The process of researching and writing this essay has reinforced my personal conviction that yoga has been a key tool for my recovery, by helping getting in touch with my body, through movement and breath, and developing some of the benefits discussed above. After all, yoga seems to serve as a “metaphor for life”, where tolerating a potential discomfort of being in a particular asana may be similar to tolerating any other discomfort in life***.
It also established the importance of dharma talks and samkalpas in the context of a yoga practice or class. As without intention or reminders of self-compassion, patience, perspective, etc., a yoga practice loses impact. As much as yoga is not a religious practice, its spirituality is of great value.
I am further convinced that one class has the power to be enough for the start of a good habit, as benefits can be reaped very quickly (such as food preoccupation or mood traits after a practice) but also that yoga, in the context of ED disorders should (if used) remain a complementary process to therapy, for the reasons discussed above, and because one rarely has the benefit of a guru-student relationship that yoga (therapy) calls for.
I am conscious of my privilege to have (had) access to therapy and yoga, and am grateful that both have taught me that I am my own healer, empowering me to dive in, to figure the hard stuff out once… and then again (… and with, surely, more lessons ahead).
*Note on the methodology : the papers were selected based on a few key words, including eating disorders, yoga and mindfulness. Some of them are reviews of past research studies and reference a larger selection of papers. I only refer, in this paper, to the main review, including when using observations and conclusions from other (original) papers, as I based myself mostly on the reviews. ** Indeed, the recognition and reliance on internal bodily signals is negatively impacted by dietary restraints and ED behaviors (9) ***Lose suggests this to be the case for fullness and food (9), though it could be argued, especially based on the spirit of many papers I read, as well as my own experience, that this could be scaled up… “in my opinion”, I guess would be fair to add
(1) “The Yoga of Healing: Exploring Yoga’s Holistic Model for Health and Well-Being: An Introduction”, Kausthub Desikachar, assisted by Liz Bragdon and Chase Bossart, International Journal of Yoga Therapy, Volume 15, 2005
(2) “Yoga for Breath, Body and Mind: A Guide to Personal Reintegration”, AG Mohan, Shambhala Publications, 1993 (revised edition 2002)
(3) “Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach to Recovery That Integrates Mind, Brain, and Body”, Abigail H. Natenshon, IntechOpen, 2019
(4) “Is Yoga an Effective Management Strategy for Disordered Eating?”, Patricia G. Byrne, Philadelphia College of Osteopathic Medicine, Physician Assistant Studies Student Scholarship. Paper 132, 2013
(5) “Integration of Mindfulness-Based Approaches in the Treatment of Eating Disorders: A Review of the Literature”, Kimberly Hubinger, National Louis University, Dissertations, 373 (2019)
(6) “The Effects of Yoga on Eating Disorder Symptoms and Correlates: A Review”, Jessalyn Klein and Catherine Cook-Cottone, PhD, International Journal of Yoga Therapy — No. 23 (2) 2013
(7) “The Heart of Yoga: Developing a personal practice”, TKV Desikachar, Inner traditions international, 1995 (revised edition)
(8) “The Use of Yoga in Eating Disorder Treatment: Practitioners’ Perspectives”, Jennifer E. McMahon, Master of Social Work Clinical Research Papers, University of St. Thomas, 2014
(9) “An exploration of experiences of yoga practice and eating disorders from the perspective of women with a history of eating disorders.”, Anna Lose, thesis submitted in partial fulfilment of the requirements of the University of East London for the degree of the Professional Doctorate in Clinical Psychology, 2016
(11) “Potential self-regulatory mechanisms of yoga for psychological health”, Tim Gard et al., Frontiers in Human Neuroscience, September 2014, Volume 8, Article 770
(12) “Yoga as a Complementary Treatment of Depression: Effects of Traits and Moods on Treatment Outcome.”, David Shapiro, Ian A. Cook, Dimitri M Davudov et al., Evidence-based complementary and alternative medicine journal: eCAM, 4(4), 2007
(13) “Yoga and eating disorders: is there a place for yoga in the prevention and treatment of eating disorders and disordered eating behaviours?”, Dianne Neumark-Sztainer, Advances in Eating Disorders: Theory, Research and Practice, 2014, Vol. 2, No. 2, 136–145
📸 by Cécile Belhomme