Hatha Yoga as Adjunct for Eating Disorders Treatment

June 6, 2016 by Gretchen Newmark, MA, RDN

Hatha yoga, once the province of Indian yogis and ‘60’s hippies, has become mainstream. It is offered in most gyms and Y’s, as well as in yoga centers, many of which have sprung up in the last few years. Yoga is Sanskrit for “union.” Union can be seen as balancing the active-alert and quiet-relaxed states of body/mind, and, in Western culture, where we see the body and mind as separate, bringing the experience of mind and body into one. 

Although hatha yoga was developed as physical training to enable people to sit in meditation, many classes in the U.S. are non-sectarian and would appeal to people from almost any religious background. There are eight main types of yoga, developed some three to five thousand years ago, before there was written language. These eight types of yoga include such disciplines as studying the yoga scriptures, devotional practices, meditation, concentration, breathing practices, and physical development, or hatha yoga. Although various teachers have named their particular style of yoga, any yoga that involves physical postures and movements is hatha yoga. In this article I will refer to hatha yoga as “yoga” as well as “hatha yoga.”

The benefits of yoga are many. For someone with an eating disorder, these benefits can be as powerful as psychotherapy and nutrition counseling and can be an important adjunct. Hatha yoga teaches stillness and awareness--mindfulness. A weekly or more frequent class gives the opportunity to practice relaxation and mindfulness, with instruction on breathing and body posture. “Stress management” training tends to fail because people don’t have ongoing support to practice the techniques. Unconsciously, we all “practice” being stressed all the time. Our habitual breathing is relatively shallow and rapid. We hold our bodies as one who is threatened, shoulders elevated, muscles tensed, prepared to run or fight. Regular hatha yoga training teaches the opposite—how to notice tensed muscles and relax them and how to breathe fully to reverse the physiology of stress by lowering cortisol and epinephrine levels. Julie Lawrence, director of the Julie Lawrence Yoga Center in Portland, Oregon, is an internationally known teacher. She describes yoga as, “teaching us self-reliance and self esteem. It shows us how to listen to and trust our own body and its wisdom. This presents an alternative to the “shoulds” of our society and to the perceived imperative that we must always be in control.”

In addition, hatha yoga offers a wonderful training for people to come back into their own bodies. A good yoga teacher will give continual prompts to notice what the body is feeling and how one is breathing. Often a class will begin with some kind of centering, with focus on any held tension and on the breath. As the class moves into the yoga “asanas” or poses, the teacher should begin to ask students to notice whether a pose is comfortable or uncomfortable, and whether any discomfort is the useful sensation of a body stretching or using strength beyond its “comfort zone” or reflects forcing the body beyond it’s ability. Experienced teachers will give detailed training in breathing and will continuously remind students to notice their breath and lengthen the inhalation and exhalation. Well-trained yoga teachers will also focus on body alignment, helping students learn how to position the body to create a relaxed posture with a long spine to facilitate breathing, stamina, balance and prevent injuries. Good classes will also stress noticing what the mind is doing. Students have the opportunity to practice tuning into their habitual thoughts and feelings, such as self-critical thoughts that make depression and anxiety worse.

Yoga offers an unparalleled opportunity to heal negative body image. The various poses challenge people to use balance, strength, stamina, stillness, mindfulness, and flexibility. Teachers invite people who have habitually focused solely on their body’s outer appearance to notice these inner qualities instead. Students are encouraged to let go of competition with themselves and others. Traditional yoga studios, unlike those for dance, do not have mirrors, but rather rely on the student’s internal experience and the teacher’s external suggestions for learning. This diminishes our culture’s emphasis on appearance. Hatha yoga classes provide consistent training and practice in noticing many aspects of the physical body’s function, inhancing empathy and de-emphasizing appearance. Ms. Lawrence says, “Yoga teaches self-acceptance—in the poses and in life. People come to yoga for a variety of reasons. Without expecting it, through the practice of yoga they gain a deep sense of well being.” Regular attendance in a good yoga class also gives us a chance to become part of a community that is focused on health and wellness, as opposed to the obsession with looks and possessions in the culture at large.

Many people with non-restricting, binge-type eating disorders have difficulty with impulse control. Hatha yoga again offers training and practice in restraining acting on impulse. Most people will find a number of the poses uncomfortable, especially in the beginning. There is a natural tendency, exaggerated in our culture, of wanting to escape anything that causes psychological or physical discomfort. We escape by thinking, working, food or substance abuse, and other distractions. In yoga, teachers encourage students rather to notice their discomfort, to breathe, and to listen carefully for what the body/mind is conveying. Teachers suggest that students come out of a pose only if is actually hurting the body, and to stay with it if it is merely unfamiliar or uncomfortable. Outside of yoga or meditation, there is little repetitive training available for people to create the habit of staying present to difficult thoughts, feelings, or sensations. This training is extremely valuable to people who need to learn to avoid using food or starvation to numb painful emotions.

However, the recent popularity of yoga is a two edged sword, a blessing and a curse. Choosing a skillful yoga teacher has become more difficult as it becomes more lucrative to teach it. Well-trained teachers have typically completed at least five years of their own yoga practice before they enter training programs. Effective teacher training programs take months or years to complete, and include an apprenticeship with an experienced teacher, written and practical exams. Recently however, more people with very little training or experience are teaching yoga. A company called “YogaFit” gives a certification in yoga to fitness instructors after one weekend of training. Needless to say, two days is not enough. People with this training are likely to view yoga as just another means of shaping the body, and are likely to miss the most valuable features of the form. Certain forms of yoga, such as Iyengar, Kripalu, and Integral yoga, have been around for decades, and require extensive training for teacher certification.

There are many kinds of hatha yoga being offered in the U.S. and more every day. Some are better or less useful for people with eating disorders. Ashtanga yoga is a strenuous series of postures. The teachers tend to be well trained. It would be useful for someone who is eating enough calories to fuel intense physical activity, and might be attractive to someone who is athletic and doesn’t enjoy the quieter forms of yoga. However, for someone who is restricting calories, this form of yoga would be of less benefit. “Power yoga” usually refers to individual teacher’s interpretations of Ashtanga. These forms will probably be strenuous like Ashtanga; the teachers possibly, but not necessarily as well trained, and would vary according to the teacher’s individual style. The extremely popular, Bikram or “hot room” yoga, is also a strenuous form that would be counter-productive to people who are under-eating. Bikram’s franchised teachers tend to put less emphasis on breathing and alignment, focusing somewhat more on the outer form of the poses. The room is heated to above 90 degrees, and with the strenuous practice it tends to create a feeling of relaxation without actually teaching people how to relax their muscles and change their habitual breathing and thinking patterns. And any form of yoga that teaches the same series of poses every time might be more of a “follow me” approach rather than teaching self reliance and listening to one’s body.

Other forms of yoga, like Iyengar, Integral yoga, Vini yoga, and Anusara yoga typically offer certified, well-trained teachers and emphasize the inner experience. The movements are slower so demand fewer calories. The slower pace and the emphasis on breath, alignment, and noticing body sensation and emotion offer good practice to people who need to improve awareness, relaxation skills, impulse control, and body image. Many forms of yoga may bring up emotion, as people relax and release held tension. However, Kripalu yoga focuses primarily on using the poses to release emotions held in the body. This form could be problematic for someone who does not have the support of a psychotherapist, but offers a wonderful adjunct for people who do.

Choosing a teacher is somewhat like choosing a therapist. People need to consider whether or not they like the teacher and feel comfortable in their presence. Especially with the proliferation of yoga, people need to ask detailed questions about the teacher’s training and experience, which may be difficult for someone in the early stages of eating disorders recovery. Some teachers have better verbal skills than others. Students should be able to easily understand what is being asked of them. If they are confused about how to do the poses, perhaps they could use a teacher who can describe and demonstrate better. Well-trained teachers will move around the class, giving suggestions to ease tension, improve form, or will adjust the student’s pose with their hands. Students must be able to tell the teacher if they don’t want to be touched. This would require a good rapport and a degree of trust with the teacher, who would need to have a certain capacity for understanding and compassion. Experienced teachers will tell students initially that it is OK if they don’t like to be touched. It is most helpful when the teacher has a soothing voice, and offers support and encouragement to people who are learning unfamiliar ways, and avoids criticism or judgment.

Health care providers who want to recommend yoga classes to clients and patients would do well to familiarize themselves with one or more yoga centers, experiencing different forms and teachers. If you aren’t interested in yoga yourself, but want the benefits for clients, seek out well-established yoga centers and interview the directors and teachers as you would any other potential referral. Ask them how they teach over-weight people. Ask what they emphasize in class. If your client is taking yoga, ask him or her about the teacher, their training and emphasis. Ask if they are getting training in breathing and alignment. Find out if the teacher is focusing on “abs,”“butts” or other outer appearance, especially if the class is offered at a health club or the Y. Ask your client how they feel when they are in class and after, and whether they are learning anything that stays with them. Encourage your client to be discerning when choosing a yoga teacher and to ask questions about their background. A good yoga teacher will reinforce the skills that people are learning in nutrition counseling and psychotherapy. Unfortunately, a poorly trained yoga teacher will inadvertently reinforce the negative stereotypes of the culture, and can cause shame and physical injury.

I encourage my clients to try yoga if they are open to it. If they come from a conservative religious tradition and express interest in yoga, I direct them to classes that do not include chanting, study of the yoga sutras (teachings,) or meditation. If a client chooses a teacher I don’t know, I gently ask questions to discern the teacher’s training, style, and emphasis. If it is a strenuous form, I remind my client that it is increasing their need for calories. I reinforce their yoga training by inquiring about it regularly and answering any questions they have about it. Even with clients who aren’t open to yoga training, I incorporate aspects of it in my care, sometimes just referring to it as “stress management.” I teach simple breathing techniques to alleviate anxiety and invite the client to practice both in sessions with me and on their own. I also teach yoga poses that might be useful, such as poses for deep relaxation or digestion.

Because I have practiced and taught yoga for so many years, I love it when one of my clients finds a good teacher. It gives us a common language that is health-focused. I can use their training to give examples and metaphors, “Do you know how it is when you are doing Trikonasana, and you are learning to be aware, strong, relaxed, focused, and balanced all at the same time? Well, that’s the way this process is.” Or, I can say, “You know when you are in a pose you don’t like and your mind is telling you to run out of the room, but you breathe and remain in the pose? Well, that’s how it is to stay aware of disturbing emotions and the urge to eat to make them go away.” If they say they feel fat, I can inquire how their yoga practice has been and what they are noticing about their body/mind while doing it. I can ask how their balance, strength, stamina, flexibility and focus are developing, and help them recognize the many faceted qualities of their own body/mind. I find I can easily build on the training that hatha yoga provides, and clients are usually able to generalize the skills they learn to other physical activity and their eating.

Ms. Lawrence says of her students, “Yoga practice gives people a positive relationship with themselves. They get to know and feel comfortable with themselves for the first time.” It is a source of great joy to me that health care providers are waking up to the benefits of ancient practices like yoga, chi gung, tai chi, aikido, and meditation. We live in an increasingly stressful, empty culture that robs people of the recognition of the simple pleasures in the moments that make up our lives. I encourage anyone who wants to help their client blossom to recommend yoga, or any of these forms that teach relaxation and awareness. Please feel free to contact me if I can be of any help.

Gretchen Newmark