Yoga for teens with eating disorders

I never intended to teach yoga to teens with eating disorders. Until a couple of years ago, I didn’t know much about either teenagers or eating disorders, but my limited experience had taught me that both could be challenging.

But then I volunteered as the training co-ordinator with A Sound Life, a charity that brings yoga to people in hospitals and care facilities. One of the first facilities we visited was Westmead Children’s Hospital where psychologists in the Adolescent Mental Health Unit were keen to add yoga to their program for kids with eating disorders.

Having seen recent studies that demonstrate the benefits ofyoga for people with eating disorders, the lead psychologists wanted to explore how it could be integrated into their pioneering Intensive Family and Adolescent Eating Disorder Day Program (IFAED) program.

There's a growing body of evidence to suggest that yoga could and should play a much bigger role in the prevention and treatment of eating disorders.  This has sparked interest in the from charities, hospitals and other organisations that are helping people with anorexia, bulimia and other related conditions. 

  • A 2010 study found that personalised yoga therapy significantly reduced food preoccupation in adolescents with eating disorders. 
  • A 2014 review found that yoga and body awareness therapy significantly lowered scores of eating pathology and depressive symptoms in patients with anorexia nervosa.
  • A 2013 review of 14 studies found that yoga practitioners were reported to be at decreased risk for eating disorders, and eating disorder risk and symptoms were reduced or unchanged after yoga interventions. 
  • A 2014 review noted that mindfulness meditation effectively decreased binge and emotional eating in populations engaging in that behaviour.

The psychologists at Westmead Children’s Hospital wanted to introduce yoga to the IFAED program for three reasons: 

1. To provide participants with a safe experience of reconnecting with their body in new ways.

2. To give participants an experience of using the body in a healthy way that is not connected to their eating disorder.

3. To help participants develop a mindfulness practice, promoting awareness of the present moment. 

To determine how well the yoga program measured up to these objectives, we ran a 10 week pilot and introduced two very basic assessment tools. Firstly we asked the participants three simple questions immediately before and immediately after each class, with answers marked as a cross on a sliding scale:

Q1. How calm do you feel right now?
Q2. How confident do you feel right now?
Q3. How much do you like yourself right now?

The next step was deciding what type of yoga to teach. The practice had to be sufficiently active to keep the participants engaged, but had to avoid any suggestion of exercise. The kids on the program were still closely supervised both at home and in the hospital to avoid compulsive exercise and purging. Several of them had dance backgrounds and, even when we taught fairly simple poses, they would find ways to turn them into extreme stretches that made my eyes water. We had to find the right balance between challenge and self awareness.

We borrowed from the work of psychiatrist Bessel van der Kolk and yoga teacher David Emerson, whose trauma-informed yoga helps people reconnect with the physical body and experience it as a place of safety rather than a site of pain and anxiety. As a result, the class plans became very non-directive with teachers handing the power over to the students. Every pose came with lots of options and the teachers would use invitational rather than instructive language– instead of telling students to put their right hand beside their right foot in a lunge, the teacher might say ‘if you’re ready, see how it feels to put your right hand down on the floor. You can move than hand closer to the right foot if that feels OK’. The kids on the eating disorders program are often perfectionists and giving them permission to let go of trying to do things a certain way and do what feels good on the inside instead is immensely valuable.

Each class would begin with a seated centring practice and end with a body awareness relaxation. And it would all end with Oms – I’m a big fan of chanting and I figured the benefits had to outweigh the awkwardness of introducing chanting to a group of teens who had never done yoga and, frankly, weren’t keen on being there in the first place.

The kids were really excited when we arrived to teach the first class. However, the nurse explained that was because they expected yoga would offer some calorie burning opportunities. They were not impressed with the slow, simple and repetitive practice they got. This was evident during the second class when they didn’t look anywhere near as enthusiastic and a couple of the girls disrupted the class by pretending to fall over. They started asking if they could do full wheel and other strong poses. It was time to change tack.

Without increasing the intensity of the classes, we encouraged the students to work with poses that took a little more effort and practice to achieve, such as balances and inversions that demand greater concentration and co-ordination. The response was positive. The disruptive behaviour stopped and the relaxation time at the end of the class took on a deeply peaceful quality. Towards the end of the term, the students were Omming enthusiastically and the eye-rolling that had been a staple of the earlier classes had disappeared entirely. 

At the end of the 10 week pilot, we sat down with staff at Westmead to look at the results of the assessments - the self-assessment questionnaires showed that the participants had responded positively to the yoga classes. 

In consultation with the psychologists, we agreed to run a second 10 week program and add some new components, based on feedback we had received. We would now start each session by initiating a conversation with the students, asking what they’d like to do during the yoga class and how they felt about the previous class. This innovation started to build a more trusting environment and the students have been coming up with their own suggestions for how they’d like to practice. We also introduced ‘homework’, a weekly practice sheet that has three very simple techniques (one breathing, one concentration and one movement) that students are encouraged to try during the week. 

Of course, encouraging students to practice at home brings it’s own challenges. These children are given to extreme behaviours and one girl explained how she’d held cobra pose for over two minutes at home during the week (cobra hadn’t been taught during the in-hospital classes and certainly wasn’t on the home practice sheet). When I asked how her back felt afterwards, she said simply ‘it hurt’. 

That was the perfect opportunity to talk about Sthira and Sukha, the balance of steadiness and ease that we aim for in every yoga pose. We also got talking about the principles of counterposing and all the kids joined in with an improvised game of ‘pick a counterpose’ with somebody choosing a pose and everybody suggesting an effective counterpose. This piece of unexpected improvisation turned out to be a great learning experience for everybody.

Both students and the staff participating the IFAED program yoga classes at Westmead have provided positive feedback and the results are promising. Future plans include a more thorough research project that will help us understand how we can continue to adapt and evolve the way we teach yoga to best serve these young students with eating disorders. Thank you to A Sound Life for creating this opportunity for both teachers and students serve, learn and benefit from therapeutic yoga.
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Carei TR, Fyfe-Johnson AL, Breuner CC, Brown MA (2009) Randomized controlled clinical trial of yoga in the treatment of eating disorders. J Adolesc Health. 2010 Apr;46(4):346-51. 

Vancampfort D1, Vanderlinden J, De Hert M, Soundy A, Adámkova M, Skjaerven LH, Catalán-Matamoros D, Lundvik Gyllensten A, Gómez-Conesa A, Probst M. (2013) A systematic review of physical therapy interventions for patients with anorexia and bulemia nervosa. Disabil Rehabil. 2014;36(8):628-34.

Katterman SN1, Kleinman BM2, Hood MM1, Nackers LM1, Corsica JA (2014) Mindfulness meditation as an intervention for binge eating, emotional eating, and weight loss: a systematic review. Eat Behav. 2014 Apr;15(2):197-204.

Carei TR, Fyfe-Johnson AL, Breuner CC,  Marshall MA. (2010) Randomized Controlled Clinical Trial of Yoga in the Treatment of Eating Disorders. J Adolesc Health. 2010 Apr; 46(4): 346–351.