Using Yoga Therapy to Address Eating Disorders

Are you interested in incorporating yoga therapy in your current profession?

Maria Sorbara Mora, Phoenix Rising Yoga Therapist and Certified Eating Disorders Registered Dietitian (CEDRD) has been doing so for 12 years.

She is the co-author (with Joe Kelly) of Incorporating Science, Body, and Yoga in Nutrition-Based Eating Disorder Treatment and Recovery: The Integrated Eating Approach. They have been so kind to share excerpts from their book with us.

The Thread of Yoga
Introduction: Page 8-9

Yoga practice and yoga therapy are common modalities for eating disorder treatment, with good reason. Neuroscience research is showing yoga to have positive impacts on depression, anxiety, addiction, PTSD and eating disorders. Embodiment lives in the DNA of both recovery and yoga.

“Ahimsa,” yoga’s first ethical tenet or yama, means non-violence. The disruptions of eating disorders (e.g., dissociation and blunted sensations) violate the body, mind and soul. Treatment disrupts that harm by challenging clients to inhabit their physical body more fully through the process of feeding. This means the patient must metaphorically bump up to their material body’s edges—a necessary and painful experience.

Integrated Eating grew from Mindful Based Stress Reduction (MBSR) and Phoenix Rising Yoga Therapy to provide clients with safe spaces for exploring physical sensations, thoughts and emotions. When practicing structure, awareness and discernment, clients become present to the realities of their body, minds and souls. They develop deep trust in the body’s guidance.

I can hear a clinician or two thinking: “Whoa there, my friend. Where are you going with all this soul stuff? I can’t get on board with that sort of thing.”

Like you, I value skepticism. Early in Integrated Eating, we teach patients the scientific method (aka, systemized skepticism) and its utility as a recovery tool. The shared experience and practices of psychotherapists, Integrated Eating dietitians, and yoga therapists reveal mutual resonance. They reveal significant overlap between established mental health concepts and yogic conceptions of soul and inner wisdom.

• Dialectical Behavioral Therapy (DBT): wise mind.

• Freudian Psychology: ego.

• Acceptance Commitment Therapy (ACT): valued direction.

• Internal Family Systems (IFS): the self.

• Cognitive Behavioral Therapy (CBT): accurate information.

• Dietetics: inner eater.

• Eye Movement Desensitization and Reprocessing (EMDR): cognitive insight.

• 12-Step programs: conscious contact.

• Gestalt: whole forms.

In real life, most eating disorder treatment providers come to see yoga, nutrition, psychiatry, talk therapies and somatic therapies as synergistic partners. Each modality stirs up and contains therapeutically necessary experiences. Yoga helps patients embody the challenge of exploring their edges and experiencing safety in their body. We can also practice yoga in nearly any setting. Partnership between modalities provides amazing, integrated, and mutual support for healing.

Eating disorders (and their common comorbidities) are traumatic life events. When we experience trauma, our body stores the impact on a deep cellular level in muscles, fascia, joints, organs, nervous system, and the brain. As trauma researcher Bessel van der Kolk, MD, says: “The body keeps the score.” The body responds to this profound somatic integration with physical ailments, mind distortion, emotional instability and spiritual unrest.

Yoga therapy helps to process and heal what trauma leaves behind by leaning into parts of the body where trauma is stored. It uses breath, movement, mindfulness, meditation, and the grounded pillars of yoga philosophy.

Yoga therapy and yoga practice do numerous things for people with eating disorders:

• Increase body responsiveness.

• Aid body acceptance.

• Reduce disordered eating thoughts and tendencies.

• Decrease cortisol.

• Facilitate compassion.

• Strengthen parasympathetic nervous system response.

• Strengthen recovery intentions.

• Reframe “disorder” energy as creative energy.

Yoga therapy and yoga practice also provide clinicians from different disciplines additional language to use when treating patients and collaborating with other members of the treatment team.

When Yoga Walks into a Meal
Page 113

Because people with eating disorders usually feel disconnected from their bodies, clients practice gathering more data about their body—especially during meals, mini meals and snacks. We guide the practice with statements like these:

• Rub your hands together for 10 seconds, and then put them on your lap.

• Rub your hands together for 10 seconds, and then touch your chair.

• Take off your shoes and place your feet flat on the floor. Then, close your eyes and feel the ground or floor for 15 seconds.

Clinicians can deepen this centering/noticing practice in meal support groups or treatment center eating events. Once the patients are grounded, we do a simple breathing exercise to bring awareness to the body—and containment to the person. Next, we move into about five minutes of noticing sensations, thoughts and emotions.

We close this short group or individual mediation by ask participants to create an intention. This simple combination of actions usually creates a palpable sense of presence in the room—before anyone begins to eat.

People with trauma history and dissociative episodes are drawn to the safe containment that this pre-meal practice can provide. Some of our patients use it regularly during other meals when they feel close to dissociation.

In the Structured Eating chapter, I mentioned a patient convinced that leaving her apartment clean before work is more important than eating breakfast. During sessions with our program’s meal support coaches, we observed that she was very anxious, wanted to get through the meal quickly, and therefore ate rapidly.

When I shared this observation, she said: “Yeah, I want this to be over. Like, I can’t connect to my body right now. I do not want to be here doing this. I guess that’s why I’m rushing.”

However, patient ate incredibly slowly when sharing breakfast with her therapist! The therapist and I agreed that swift and slow eating both reinforce the patient’s body disconnection.

She disconnected from her body for fear that intense feelings would prohibit her from getting through the meal. Understanding this apparent fast-slow contradiction helped everyone on the treatment team to train the patient in awareness and presence while eating. This helps her develop moderately-paced eating—which creates space to notice and connect with her body.

One common yoga therapy scenario provides a good example of facilitating mutual data access. During a stretch, a client may say: “I’m feeling sad.” I will ask: “Where in your body are you feeling that sadness?”

Them: It’s deep in my chest.

Me: Can you stay with the feeling of sadness in your chest and describe the sensation of “sad?” Them: No, it’s too much. I just can’t.

Me: OK, it sounds like you’re over your edge. (I’m aiming to help the person walk away from the edge, while continuing to gather data.)

Them: Yes. Yes, I am.

Me: OK, what’s happening with your breath? Tell me with words what you notice about your breath. (I’m aiming to help the person walk away from dissociation and stay in their body to gather data about things other than being at the edge.)

Them: It’s hard.

Me: I know. Let’s take a breath. Now, can you notice your breath, your physical sensations, thoughts?

Them: My breath is shallow. My chest feels tense and my thoughts are racing.

ME: OK, breath shallow, chest tense, thoughts racing.

Them: Yes.

Me: Say more about what you notice about the sad?

Them: I can see it as dark grey and heavy; it’s almost throbbing.

Me: Good. Can you connect the information to something happening in your life now?

Them: I think so, a little bit. I feel this kind of sad when my mother doesn’t call every day. It’s like she abandons me.

Me: It sounds like this sadness is connected to abandonment.

Them: It certainly does.

Her ability to witness her edge and observe the “sad” naturally begins the process of processing the emotion and experience. Rather than invite indescribable feelings that overwhelm a person, we invite them to observe the edge (e.g. deep in my chest) with a minuscule change in perspective (while noticing my breath). We didn’t jump over the edge and plummet down. We tiptoed up to the edge, stepped back, and noticed. This safe, contained yoga practice produced valuable data.

Mindfulness practice gives our clients a safe way to ride the waves of the sympathetic nervous system while staying in their body. As in the “sad” example above, mindfulness practices like yoga provide non-verbal ways to can acknowledge our experience. Mindfulness helps people resist bingeing, restricting, purging, compulsively exercise, and more.

However, we don’t deny, dismiss, or take them out of their experience. We understand that they are safe when they have “big scary” feelings. Mindfulness practice doesn’t buy into the eating disorder’s melodrama. Mindfulness undermines the belief that feelings are dangerous or bad. Instead, it helps clients embody the truth: feeling is.

Practicing mindful observation steadily increases the person’s level of tolerance for discomfort. A sustained practice of noticing expands (often incrementally) their capacity to expose themselves to uncomfortable feelings—and their ability to explore them with curiosity.

Self-Mentoring
Page 166-167

In recovery, yoga therapy, and virtually every other growth or healing tradition, practitioners rely on mentors. For example, every monk has a spiritual director with whom they examine and explore what the monk “hears” in prayer and meditation.

As in other traditions, recovery and yoga call us to practice self-mentoring. Indeed, practice itself is a self-mentoring process familiar to most experienced psychotherapists, dietitians, physicians, electricians, heavy equipment operators, chefs, schoolteachers, etc.

A yoga therapy mentor has always supervised my work with clients, my technique and the inner work I must do. When I started providing yoga therapy, my self-mentoring was much more critical than my mentor’s mentoring was. Fortunately, after years of practice, I learned to master authentic self-mentoring in real time. I’m not perfect, but I can be embodied in my self while simultaneously being fully present to my client. In each moment, I can dialogue with myself without judgment. While working with a client, I can ask myself:

• What was my intention in saying “good?”

• Can I consider how to create a smoother transition?

• I see my agenda was here in the room when I asked this question.

• I notice I want her to get something out of this session. Do I do this technique and risk it?

With, my self-mentoring inner dialogue became energy, like an internal wind I experience flowing one way or turning another way. Each time I consider and clarify intentions, expectations and agenda, I create a clearer channel for my client to receive their session.

One of our greatest thrills in this work is witnessing clients self-mentor. I have a 50-something patient with a trauma history, and who is recovering from bulimia. She’s had a complicated relationship with exercise. Like many patients, she used it to burn calories and get “in shape.” Other times, she had no motivation to move for fear exercise would stir trauma memories.

During treatment, she embraced yoga and did some amazing work in our yoga therapy group. Now a year or so out of treatment, her eating disorder support session are less frequent and prescriptive. She recently joined a local gym where her recovery-focused practice is to exercise based on how she feels. She explained:

“I’m not looking for my personal best time anymore. I’m exercising to honor my boundaries. If that means walking instead of running, that’s OK. I have to work at it, though. Last week, after a really long day, my judgey voice started pressuring me to go to the gym. I had to stop and think–or notice–before I realized how tired I was. I honored that and decided that taking the evening off was the right thing to do.”

She wanted to know why I had such a big smile on my face. I replied:

“I just started thinking about exercising to achieve a “personal best” time. Now, you’re moving with awareness, exercising within your energy, and resting when you need to.  That sounds like using exercise to get a best personal time.

She got the wordplay and laughed. We both acknowledged her major leap of mastering gym time to serve her relationship with her body and self. In the process of showing what is and what can be, mastery debunks old stories of how and what things used to be.

Self-mentoring is an endless path to deeper knowledge, acceptance, gratitude and joy. My fellow dietitian and yoga teacher Lisa Diers expressed this recently while reflecting on leaving an eating disorders treatment agency where she worked for many years.

“Today marks exactly TWO YEARS since I said goodbye to people & familiarity that I held so dear to my heart. Although I had a deep knowing that all would be OK. I worked hard to remember that sensation when in the midst of CHALLENGING CHANGE. Those are the moments to RISE UP, MEET IT, GREET IT and WELCOME the lessons that TRANSFORMATION will bring. THANK YOU I could not have made this transition without all the amazing family, friends, colleagues and people in my life!”

Earlier in recovery, moving into unknown levels of life while feeling joy seems impossible to the people in our care. Mastery shows that it’s doable.

Sorbara Mora, Maria and Kelly, Joe. Incorporating Science, Body, and Yoga in Nutrition-Based Eating Disorder Treatment and Recovery: The Integrated Eating Approach. New York and London, Routledge, 2020

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Maria Sorbara Mora, MS, R.D., CEDRD, C-IAYT, PRYT is the Founder and Executive Director of Integrated Eating Dietetics-Nutrition PLLC. Maria’s practice includes nutrition guidance and therapy, meal support and yoga therapy, yoga therapy groups, clinical supervision, and professional trainings. The Co-Founder of the former Aurora Behavioral Health Center in NYC, she served as its Director of Nutrition and Yoga Therapy for 3 years. Maria strongly believes in the holistic model for recovery, allowing for change and transformation. To learn more about Maria Sorbara Mora and Integrated Eating head over to IntegratedEating.com. Purchase the book here.