The Importance of Standardizing Yoga Offered in Eating Disorder Treatment Centers

Yoga instructor. Yoga teacher. Yoga therapy. Yoga therapist. In the eating disorders treatment community, these terms are often used interchangeably. But are they one in the same? No. They are not.

When I brought yoga to eating disorders treatment over 20 years ago, eating disorders professionals were quite skeptical and uneasy. Questions included, “Is yoga a new religion that I am proselytizing?” Or those who practice Westernized yoga might ask concerningly, “Are patients jumping up and down, while contorting their bodies into dangerous positions in a hot and sweaty room?” or “Will weight compromised patients burn calories doing yoga?”

Over the years of incorporating yoga into eating disorders treatment and creating a yoga-based comprehensive eating disorders treatment center, which was a Joint Commission accredited and state licensed PHP, IOP and outpatient therapy, I developed an evidence-based system to integrate yoga vs using yoga as an adjunct to treatment. As other eating disorders treatment experts learn from my professional yoga therapy training programs and begin follow suite, it has been gratifying to watch my vision unfold. Listening to presenters at iaedp that incorporate somatic interventions into treatment, and reference yoga, has absolutely delighted me.

However, in speaking with eating disorders clinicians and patients who have undergone care at residential and other higher level care eating disorders treatment centers, I become disturbed. The yoga component offered at various centers are fraught with concerning issues that I will bring forth:

Issues:

  1. Yoga therapy and yoga therapist are used interchangeably with yoga class and yoga instructor/teacher, respectively.
  2. Yoga “instructors” are brought from outside that do not have the knowledge nor experience in working with patients who struggle with eating disorders across the spectrum.
  3. Yoga is referred to as the “exercise” component of eating disorder treatment programs.
  4. Yoga is offered as an “elective” and only provided to patients who are weight restored.
  5. Yoga is not integrated into treatment – the yoga instructor/teacher teaches a “class”, then leaves.

To address these concerns, I offer solutions based on my expertise and training:

A yoga instructor and yoga teacher are not the same. Anyone can call themselves a yoga instructor. Although certified (IAYT) yoga therapists are few and far between, and especially those who have completed the specialty portion of their yoga therapy training in eating disorders, treatment centers will be hard pressed to find such cream of the crop. Therefore, it would be beneficial for treatment centers to recruite registered yoga teachers (RYT) that have completed teacher training programs accredited by Yoga Alliance – the credentialing body for yoga teachers. Yoga teachers are trained to “teach” – meaning they offer words of wisdom, incorporate a theme, use language that resonates, and provide sequencing. Some RYT training programs offer modules on eating disorders treatment, as I have been fortunate to have the opportunity to teach these segments around the country.

Yoga therapy is the application of teachings and practices in a therapeutic context to support a consistent yoga practice that will increase self-awareness and engage the client’s energy in the direction of desired goals. Foundational understanding of yoga theory and practice, biomedical and psychological foundations, teaching and therapeutic skills, along with yoga therapy tools and their application are part of an accredited yoga therapy training program along with professional practice that includes legal, regulatory, and ethical issues pertaining specifically to yoga therapy. Yoga therapists are certified through a governing and accrediting body, the International Association of Yoga Therapists (IAYT), and must complete an 800-hour yoga therapy training program accredited by the IAYT. Specialty programs are also accredited through the IAYT and offered independently such as yoga therapy for heart disease, cancer, pain management and eating disorders.

Yoga is not “exercise.” There is no score card, it is not competitive, and there is no judgement. A competent registered yoga teacher and a certified (IAYT) therapist understands yoga from an entirely different lens, while coming from a distinct point of orientation then a gym teacher or coach.

Offering yoga as an “elective” promotes fragmented care, while offering yoga to only a select population deprives the respective patient of all treatment benefits. At the Inner Door Center, which I owned and operated from 2008 through its sale in 2016, the yoga component of our program was designed as “group therapy” as any other therapy group (emotion regulation, pattern recognition, body image, DBT, CBT, etc) as yoga is congruent with so many of these traditional interventions. Individual yoga therapy was also provided.

Our assessments and treatment plans incorporated a yoga assessment and yoga treatment plan to dove-tail with comprehensive assessments and treatment plans of all patients. For example, patients who were not weight restored had a treatment plan that may have focused on yin yoga (no muscle involved) or simply sitting on one’s mat and breathing – the highest form of yoga. In addition, yoga aids in lowering cortisol levels which in turn increase calcium absorption and bone formation, which in turn can benefit patients at risk for osteoporosis. Those with bulimia or binge eating disorder were offered a yoga treatment plan that took into consideration their symptoms, behaviors, and medical involvement. As vitals and morning assessments are typically taken each day in higher levels of care, results can guide yoga therapy intervention for that respective day.

It is a gift to offer yoga to all patients as their initial group of the day. Yoga can increase levels of gamma aminobutyric acid (GABA) in the brain by more than 20% thus reducing anxiety. Yoga dovetails with the polyvagal theory in that yoga can promote a state of calm, connectedness, and safety. Yoga decreases the activity of the sympathetic nervous system (flight/fight), while regulating the parasympathetic nervous system (immobilization/freeze). Therefore, yoga centers the patient so that they can focus on their recovery. With proper training of yoga practitioners, yoga therapy can also be offered virtually.

When yoga practitioners are part of the comprehensive treatment team, the patient receives the best experience possible. In the patient’s medical record, they should document the theme of their session and each patient response to the yoga session. They should also be part of case consultation and continuing education programs that are required of all treatment staff members. Yoga practitioners also need clinical supervision just like any other treatment provider to provide safe and effective care. This was the system at my former treatment center, which resulted in positive outcome data.

In my experience in training professionals in yoga therapy for eating disorders treatment, those that have an interest in incorporating yoga and eating disorder recovery tend to have struggled with an eating disorder. It is important that these individuals are grounded in their recovery and are open to continued growth and learning. I am aware of individuals, who have struggled with eating disorders, who have developed yoga and eating disorders programs. In turn, they have offered their programs to various treatment centers who have followed blindly. Unfortunately, these centers have been sold a bill of dangerous goods as they failed to do their research on such programs. It is a bonus when licensed eating disorder clinicians (therapists, registered dietitians, physicians, nurses) further their training in the yoga therapy realm to enhance the care of their patients, and their own professional growth, whether in a private practice setting or in a comprehensive treatment center.

It is imperative that those in leadership roles, at eating disorder treatment centers, embrace these concepts if they are to have a safe and effective yoga program at their facilities. Following the standards of care in providing yoga therapy is equally important as upholding the standard of care in any clinical intervention provided by an eating disorder treatment professional in all treatment settings.

BEVERLY S PRICE is a certified eating disorder registered dietitian and iaedp supervisor, experienced registered yoga teacher and IAYT certified yoga therapist. Beverly is recognized for bringing mindfulness-based yoga to the eating disorder treatment community along with yoga therapy training programs in eating disorders for professionals. Beverlysprice.com

References:

Benson, Herbert, Harvard, Relaxation Response, Research Patient Data Registry, BHI Relaxation Response Resiliency Program (3RP) from 2006 to 2014

Kavuri, Vijaya, Raghuram, Nagarathna, Malamud, Ariel Malamud, and Selvan. Irritable Bowel Syndrome: Yoga as Remedial   Therapy. Evid Based Complement Alternat Med. 2015; 2015: 398156.

Manikappa, Subhash, Chimkode,Sendil D. Kumaran,V.V., Shivanna, .Kanhere, and Ragunatha. Effect of Yoga on Blood Glucose Levels in Patients with Type 2 Diabetes Mellitus. J Clin Diagn Res. 2015 Apr; 9(4): CC01–CC03.

Porges, Stephen (2011) The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self Regulation.

Streeter, CC., Gerbarg, PL., Saper, RB., Ciraulo, DA., Brown, RP. Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Medical Hypothesis. 2012, 78(5): 571-579.

*The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders and not intended as endorsement by iaedp™ Foundation, Inc. or its Board of Directors.*

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