Eating Disorders in Adult Women: A long term therapy group through the lens of Relational-Cultural Theory

Karen Samuels, PhD

Isolation is the glue that holds an eating disorder in place. (adapted from Laing, K. 1998). Seven women wait expectantly for everyone to settle in their seats to begin group therapy, focused on women at midlife. Ranging from 45 to 60, these women represent decades of secrecy and suffering alone. Collectively, they have lived hundreds of years with various aspects of their eating disorders. They have come together to heal and learn in connection.

We know that age does not immunize women across the life span from the challenges and symptoms of disordered eating (Maine, 2010; Bulik, 2013; Gagne, et.al. 2012; Samuels & Maine, 2012; Maine, Samuels & Tantillo, 2015).   Growing evidence indicates that increasing numbers of adult women experiencing both clinical and subclinical eating disorders areseeking treatment (Zerbe, 2013). Treatment centers for eating disorders offer adult programs and report a rise in the numbers of women in their later 40’s, 50’s and 60’s seeking a higher level of care. While previously these adult programs targeted women “over 30”, women at and beyond mid-life report a need for treatment that takes into consideration issues such as: later life health concerns such as a pregnancy or symptoms of menopause, an aging body, divorce and remarriage, children entering and graduating college, career changes and retirement, and grand parenting (Maine, 2010, Maine & Kelly, 2005). Another distinctive characteristic described by women at mid-life: their eating disorder is a chronic illness, long past the acute disorder that emerged in their teens or early adult years.

Mid-life poses numerous challenges to treatment. The eating disorders continue to manifest in all ways: AN, BN, BED, and NEC, and sub-acute or partial variations. These bring the full gamut of physical complications including compounding physical deficits, advanced bone density disease, co-morbidities like depression, anxiety and substance abuse, and long term social isolation. Since a larger proportion of these women experience NEC and subclinical symptoms, seeking care is more of an obstacle (Maine, Samuels, & Tantillo, 2015). Many health care providers do not inquire and these adult women may be reluctant to identify their eating disorder as a contributing factor to other health conditions. Medical professionals, not aware that eating disorders continue or emerge later in life, may pursue a variety of tests to identify other physical diagnoses instead of eating disorder related complications.

Finances may be another obstacle to treatment. Savings are often earmarked for children’s education or retirement planning at this time. Demanding careers may compete with the need for intensive care. Care for children, significant others and elderly parents may also compete with necessary medical, dietary and psychological treatment. Adult women at and beyond midlife have spent much of their lives working. The job of caregiver has been consuming: family, peers, jobs, careers, service work, and balancing the needs of everyone else in their life. They appear to have a rich life while feeling internally empty, alone and unfulfilled, struggling in secret (Maine, Samuels & Tantillo, 2015).

This specific mid-life ED therapy group has been meeting for over four years. The seven women have a range of experiences; everyone describes challenges with disordered eating began in their teens. Onset of one woman’s eating disorder was age 12, not diagnosed or specifically treated until age 45; another woman went for residential treatment in her 20’s and considered her eating disorder in remission until her mid-50’s when life events triggered relapse along with associated significant medical concerns. Another woman reports a strong genetic predisposition: the third generation of women in her family to experience a clinical eating disorder. She returned to treatment as her daughters approached adolescence, determined that the cycle NOT continue yet another generation.

While rarely bitter or upset, each woman shared her understanding that her ongoing struggles with the symptoms and consequences of the eating disorder were “unmentionable”. They consider eating disorders a teenager’s problem; since they were now approaching or beyond menopause, they were “beyond help.” Most of the woman agree their adolescent years marked the onset of disordered eating, weight preoccupation and dangerous methods of restriction, binge-purge, excessive exercise, etc. Everyone reported prior psycho-therapeutic experiences. Most commented that their eating disorder had not been addressed, or minimized. As one woman stated: “I understood my problems were anxiety and major depression, and was assured the eating disorder would resolve when my mood disorder was better managed.”   Another woman described her spouse’s decade’s long sobriety and continued involvement in 12 step meetings and fellowship. She “longed for something similar” for herself. These women were eager to meet and develop a “safe environment” to share their concerns, support one another and seek recovery.

Eating disorders in adult women may present in many levels of severity. Some may have previously experienced years of Anorexia and Bulimia, or Binge Eating Disorder, meeting full clinical diagnostic criteria. Today they may suffer with the manifestation of their disordered thoughts consuming the day, but are classified as Feeding and eating conditions not elsewhere classified, or NEC, BED or subclinical eating disorders, such as orthorexia. Some struggled since youth and have never escaped the grip of these obsessions. Others have struggled, recovered and relapsed over many decades. Some have been preoccupied with food and weight for a lifetime, but never at clinically significant levels until now (Maine & Samuels, 2014). These women ALL relate to one another’s disordered eating, changing and aging bodies, and the desire to live with more peace.

Relational-Cultural Group Process emphasizes the focus on teaching the importance of an intersubjective perspective within the group by encouraging group members to be empathetic, to listen, to inquire and to resonate with others. Group members learn, and hopefully appreciate, the other’s perspectives and feelings. Yet an effective relational group will also include a feedback model of “This is how I see you”. It is in integration of an Other-Centered working group that creates an “Us” rather than just a “You” or “Me” perspective. When group members fully listen to each other and think about how the other individual’s perceptions compare and contrast with their own, then a new experience emerges — an experience that is uniquely different from what each individual has previously known. New understandings emerge, old beliefs change, and new emotional experiences occur (Jordan & Dooley, 2000).

It is through shared affect and perceptions that old emotional experiences can be integrated with current relationships that are uniquely individual and simultaneously uniquely relational. In doing so, we create a place that belongs solely to no one in particular and yet it belongs to each and all – a creative place of relationship (Jordan, 2000).  Relational-Cultural theory shifts the primary models of psychology from an emphasis on the “separate self” to an appreciation of the centrality of relationship in our lives. Shifting this paradigm from separation to connection transforms the group experience, both in the therapy room, and in the larger culture and society (Jordan, 2010). Empathy is understood as a cognitive-affective resonance, joining with the other person in a shared state of human connections. There is compassion, a lessening of the suffering of separation. Mutual empathy moves us toward one another, out of isolation (Jordan, 2000). This group seeks to demonstrate and learn to implement the experience of mutual empathy, both in the sessions and brought into their lives.

Four years later, these women have witnessed and welcomed the relational group support through the passages of life: menopause, major illness, challenges of relationships and divorce, deaths of close family members and friends, career changes, new business ventures, sending children to and graduating from college and birth of grandchildren. The rates and progress in managing disordered eating symptoms vary; but the resounding centerpiece of each meeting remains to prioritize self-care, self-empathy and practicing mutuality in connections. Isolation is the glue that “holds the eating disorder in place.” (K. Laing) This response, to no longer withdraw into preoccupation with harmful symptoms of the eating disorder, has frequently been replaced with motivation to connect, reminders of CBT and DBT strategies discussed in group, and self-soothing practices. The relational “we” is the chorus in these group therapy meetings. We do understand, we see and hear your struggles, we appreciate that “recovery” may appear different as menopause challenges the “loss of status” in a youth-obsessed world:  at the core these women do not want their “sisters” in recovery to go through the healing process alone.

The group sessions begin with a round robin, borrowing from the work of Martin Seligman’s Positive psychology (Flourish, 2011). “What went well?” This question is posed to each woman as she reflects on her experiences with recovery since the last group session. The group is invited to inquire and support the threads of continuity from previous group meetings. Thus trends of positive outcomes are emphasized, following up on intentions and goals of treatment and the forward focus. The focus of the group’s opening activity is to accept positive emotional feedback, the sense of engagement with the group, the deepening of connections in these relationships and the sense of enlargement: serving something bigger than one’s self (Seligman, 2011). The women learn to advocate for themselves: stating their achievements, stepping forward amidst the challenges of very full, demanding lives, practicing self-empathy and receiving compassion and encouragement.

Many times these women have dedicated themselves to the service of others. To claim their strides forward, to receive the empathy and resonance of the group members, and share the sense that “we are no longer alone; in this together”, creates meaning and context (Seligman, 2011; Miller & Stiver, 1997). Next is the challenge: asking for time to discuss their personal difficulties and challenges. Adult women frequently are reluctant to ask for time and attention. The group encourages and invites one another to reveal their recovery roadblocks, impediments to self-efficacy, as well as success. The practice of mutuality in relationship, self and other-empathy, especially pertaining to their disordered eating, becomes another layer of relational learning and growth fostering connections (Miller and Stiver, 1997). Each session ends with a didactic handout. These may include exercises (CBT, DBT, EFT based), recommendations for recovery related to seasonal or holiday demands, recent articles especially related to adult women with eating disorders, and text that highlights recurring group discussion topics.

Further strategies of recovery support have been to challenge one another to practice exposure to feared stimuli: shared meals via phone, text and skype. Reaching out to a peer, driving carpool, or at the workplace, these women have learned to “share a meal”, and use technology to incorporate much needed encouragement amidst busy and demanding lives.   The concept of “text support”— when faced with potential relapse “triggers”— has become the “language of recovery”.   During the holiday season one year, each group member handcrafted gifts for one another. The theme was recovery and connection. The gifts included: hand sewn embroidered “Cope-ing bags” containing stones marked with body acceptance affirmations; beaded bracelets with an arrow pointing out the “road to recovery”; laminated book markers each with a recovery theme; crocheted scarves in favorite colors and targeted meditations that emerged from group themes. These shared “creations” aided the women to join together and maintain a sense of “connection” between group sessions.

Ella studied dance at a conservatory from age 12 to 18. Always slim, her eating disorder went undetected during these years of endless hours in the studio. Battling low weight, depression, anxiety and a myriad of injuries from dance studies, she never put the “face and name of anorexia” to her restrictive eating and battle against a maturing body. Prior psychotherapy addressed her mood disorder. At the age of 45, she returned to psychotherapy following the death of her father. The therapist concentrated on early trauma and the recurring patterns of depression since puberty. Steadily dropping weight again, she was confronted with “having an eating disorder” and directed to enter a 4 week residential program 5 hours from home. Her daughters were 9 and 12, and she couldn’t fathom leaving them in the care of her husband, 20 years her senior, now retired. In this eating disorder program, she expected to be informed she did not belong there and it was a big mistake. Quite the contrary, her team was dedicated to weight and meal restoration and addressing the 30 years of body hatred and despair. Upon her return home, her therapist resumed work on grief and childhood sexual trauma. Within months her weight plummeted again and she could not fathom spending another $35,000 of the family’s life savings to return to treatment. Terrified, she changed therapists to an eating disorders specialist and joined the adult women’s eating disorder recovery group.

Two years after her initial entrance into residential treatment for her eating disorder, her depression worsened, weight dropped and she was urged to return to a higher level of treatment. Again the decades of denial led her to believe that this was unfathomable. At her last meeting with the adult women’s group, she finally understood. Each woman in the group expressed their fears for her survival and admitted they were terrified she would not be alive by the next group’s meeting. The group encouraged and supported her residential care, sending dozens of cards and messages. Upon her return from intensive treatment, she was welcomed and supported by her group, treatment team, family and peers. Some three years later, she attributes the strength of these connections, working with a specialized treatment team and acquiring relational skills as key to her stabilization and recovery. Coming back from treatment the second time to a strong network of women offering relational engagement contributed to Ella’s health and healing. She now describes the value and benefit of finding trust and safety receiving care and support, confidentiality and “acceptance without judgement”.

“Knowing that as an adult, I am no longer alone and silent, with no one in my life or family who got my eating disorder: this has made a great difference, and been a relief to find understanding and acceptance from our group. There is also wisdom shared about the nature of recovery and life’s challenges, such as relationships, loss and menopause.”

Jean Baker Miller (1976) describes the “Five Good Things” of growth fostering relationships: zest, sense of worth, clarity, productivity, and a desire for more connection. The women who gather in Relational Cultural group describe these five and more. A recent discussion about the nuanced nature of “eating disorder recovery” for women post-menopause brought a collective sigh of relief. I am deeply moved and inspired by the shared wisdom and determination these women bring both individually, and in “sisterhood”. Recently, when the group was asked about adding new members, the resounding response was: “YES! We have suffered alone for too many years.”

No one else needs to.

These women demonstrate the healing connections possible in treating long term eating disorders in group therapy. More research and practice will further understanding and sharpen clinical understanding of the unique treatment needs and benefits of working with women at and beyond mid-life.

Living with your Body & Other Things You Hate: How to Let Go of Your Struggle with Body Image Using Acceptance & Commitment Therapy

By Emily Sandoz, PhD and Troy DuFrene

Emily Sandoz, PhD and Troy DuFrene joined us for the following book interview. What follows are our questions in italics, and their thoughtful responses.

In addition to your print book, Living with your Body & Other Things You Hate: How to Let Go of Your Struggle with Body Image Using Acceptance & Commitment Therapy, you
offer the reader access to audio files at www.newharbinger.com/21044. What kind of feedback have you received on this option?

Readers we’ve heard from really seem to benefit from the guided exercises available on audio. This seems to allow them to let go of having to remember the steps of the exercise and participate more fully. We’ve also received feedback that they felt more connected with us, the authors, by being able to put a voice to the words on the page.

For those unfamiliar with Acceptance and Commitment Therapy (ACT), can you please provide a description and some examples of this framework?

Acceptance and Commitment Therapy is based on the idea that our psychological struggles are primarily attributable to psychological inflexibility. Psychological inflexibility is characterized by our unwillingness to contact the full range of human experiences, the cognitive rigidity that functions to protect us from the confusion, complexity, and pain that is fundamental to life, and the loss of meaning and purpose-driven action that occurs when our efforts become more about managing difficult experiences than living fully.  For example, if I experience my body as “disgusting,” I am likely to be driven to manage my appearance, others’ opinions, and even my own thoughts in ways that buy me some relief from “disgusting,” but pull me away from things that matter to me.  I may avoid meals with friends so that I can restrict my eating.  I may limit intimacy in relationships because I don’t want to be touched. I may be underemployed because I don’t want to be in a job where I interact with people who might judge how I look.   ACT aims to facilitate psychological flexibility, or willingness to contact the full range of human experiences – pleasurable, painful, predictable, unpredictable, tangible, abstract – in service of some chosen value.  Through ACT, I might learn that my relationships and my work are important enough to me to feel “disgusting” and come to embrace that willingly.

This book aims to help readers use ACT-based work to increase body image flexibility, or to contact fully with their complex and dynamic bodily experience in service of action towards the things they care about.

You invite your readers “to take a risk …we invite you to risk feeling uncomfortable, disappointed, disgusted, and frustrated.” A unique invitation.

What are some suggestions you offer to support those who accept your invitation?

I would suggest that folks accept this invitation only if it feels like a real choice.  We come at this work, not as experts who know what folks must do to get free from their struggles with body image. Rather as fellow travelers, offering a perspective on a path that might be useful.  We want folks to follow this path, only if they have a sense of what it might be worth when doing something new and hard. In other words, we would like them to start by identifying why this work is worth it for them, and to come back to that when it gets really difficult.

The guided exercises you present include the use of breath work. Can you please speak to this?

The use of breathing is threefold.  For one, deep breathing exercises facilitate relaxation, which positions folks to gain more, psychologically, from exposure to difficult experiences.  In addition, breathing is a process that is always occurring in the present, and to which we can return our attention when our minds get lost in thoughts or concerns. Our breath can act as a tether, helping us to repeatedly come back to our ongoing experience.  Finally, breathing is something our bodies do, and attending to our breath carefully and with compassion means approaching our bodies with something other than loathing or avoidance.  In this way just noticing breathing is a little step toward body image flexibility.

Can you please explain the skill of body defusion and how this can impact body hatred?

Cognitive fusion is when rigid thoughts dominate our experience and our behavior is limited by these thoughts rather than being sensitive to everything that is happening in and around us.  Body hatred is an example of body-related fusion.  When my body hatred comes up, I’m likely to tune out from everything else that is happening, as that hatred fills my mind, coloring my experiences and taking over my behavior.  Body defusion is a skill that involves noticing an unwanted aspect of the bodily experience, such as hatred, without it dominating.  In this way, body hatred may come and go as we intentionally broaden our awareness to incorporate the hatred along with everything else that comprises our experience.  I might notice my hatred, and my breath, and my concern about a project at work, and the air conditioning being particularly loud, and my stomach growling…  This is particularly important when folks have struggled with body image inflexibility for a long time because any negative experience begins to be translated into body hate or disgust.  Defusion allows me to make contact with the more nuanced experiences I might not even realize I’m avoiding.  For example, I’m hating my body because I’m scared I might not navigate this new project effectively.

You develop the concept of experiential acceptance. Can you please explain what this is and what it is not?

By experiential acceptance, we mean a willingness to feel the full range of experiences as they occur in the moment.  Experiences of events that occur outside the body, those that occur within the body, and those that occur within the mind.  With body image acceptance, we simply mean being willing to experience the body, and our thoughts and feelings about the body, even when that experience is painful or unwanted.  In this way, body image acceptance does not mean liking the body or having good thoughts about the body.  It means being open to not liking the body sometimes, to having painful thoughts about the body when they come up.  Body image acceptance doesn’t even mean forbidding efforts to manage or change the body itself. We can fully accept things and still strive to make them different.  In fact, my clinical experience suggests, that it is often through making peace with the body as it is that folks find themselves effective in changing the body to better fit the lives they want to live.

Are people surprised to learn your book is about living their lives with freedom, purpose and committing to their values versus about tips to conquer body image distress?

They are.  Almost invariably, folks are surprised.  I haven’t heard from anyone that they are disappointed with that, however.  Most folks seem to know, on some level, that there’s no real way to manage distress that doesn’t have serious costs to their lives.  And most folks seem to be relieved to turn from that job to one that’s more important – being the person they want to be!

Dialectical Behavior Therapy Groups for Individuals with Eating Disorders

By Craig Boas, LCSW-C, and Kate Clemmer, LCSW-C

Dialectical Behavioral Therapy (DBT) has proven to be a very effective and beneficial modality of treatment. The overarching goal of this treatment is to help people manage and regulate overwhelming or intense emotions that can lead to destructive impulses and behaviors, what is often referred to as emotion dysregulation. Dr. Marsha Linehan developed DBT in 1993 with the primary aim of treating people who were diagnosed with Borderline Personality Disorder. Since that time, an enormous amount of research has been conducted providing evidence of its efficacy in reducing dangerous behaviors and improving global functioning for individuals with BPD.1 While DBT remains the treatment of choice for this 
population, it has also been applied and studied in the treatment of others impacted by mood disorders, trauma, substance abuse, suicidality, self-harm behaviors, ADHD and eating disorders. Specifically, two small-scale and one larger study have looked at the effects of DBT Skills Training for individuals with bulimia and binge eating disorder.2 All three found DBT skills led to significant reductions in binges or binge/purge behaviors.3, 4, 5 More extensive research could help clinicians to increase efficacy and determine which specific skills are most important for behavior change among those with eating disorders.

An extensive summary of the research on DBT is available from The Linehan Institute.

In addressing this topic, it’s helpful to understand that symptoms such as restricting calories, bingeing, purging and over-exercising, are often used by individuals with eating disorders to cope with painful or unpleasant emotional states. Unfortunately, eating disorders are progressive illnesses and typically worsen over time. As one becomes more and more ill, he or she develops a sort of tolerance to the symptoms, eventually needing to go to more extreme measures, or use symptoms more frequently, to experience the same level of emotional numbing or temporary relief from overwhelming feelings like anxiety, anger or loneliness. As you might imagine, developing skills to help regulate these emotional states and endure them without turning to harmful behaviors becomes invaluable during the recovery process. That’s where DBT comes in. Participating in DBT groups helps individuals with eating disorders to develop the skills to identify, tolerate, and validate painful emotions that could otherwise foster maladaptive behaviors around food and weight.

The Four DBT Modules: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness

At The Center for Eating Disorders at Sheppard Pratt, DBT skills are utilized in individual therapy and in groups at all levels of care, from our outpatient department to our partial hospital and inpatient settings. Our weekly outpatient groups for adults provide the most comprehensive training of the skills within the context of structured DBT practice. Prior to beginning this treatment modality, it is recommended and requested that each group member commit to attending the group for at least 10 months in order to go through two rotations of each of the four skill sets. This time commitment builds competency and, ultimately, mastery in utilization of the skills. The groups are open during this time period providing there is availability, and potential new members may join the groups at the beginning of each new skill to be taught. Here’s a brief look at each of the skill sets we cover in DBT group.

Mindfulness Skills

Mindfulness skills are the first set of skills taught in the groups because they are considered the foundation of DBT and are vital to the effectiveness of the other three skill sets. Mindfulness is a state of active, open attention to the present moment. Commonly, individuals with eating disorders have automatic or intrusive thoughts driven by perfectionism, ambivalence, and low self-esteem. Practicing mindfulness can help to diffuse those thoughts and raise awareness of one’s judgments about them. Through mindfulness, an individual can gain more flexibility and freedom in their thoughts.

Mindfulness skills are actually derived from Buddhist practices of non-judgment, acceptance, and focusing on the present moment. Thus, the goal behind the Mindfulness module is not to change, but rather to notice and accept whatever one is feeling in any given moment. Mindfulness can help eating disordered clients to tolerate anxiety that directs their behavior. For example, someone might struggle with tolerating fullness after eating a challenging meal or with negative body image thoughts while on a date. In these moments it can be helpful for an individual to engage in a deep breathing exercise where the person focuses on breathing through their diaphragm as they inhale and exhale slowly. Some clients feel that counting their breaths as they engage in this exercise makes it easier to stay focused on the present moment.

Since Mindfulness is also the most challenging of the skills to master, each group begins with a five-minute mindfulness exercise. Most of the exercises are guided meditations. An example of an exercise we use frequently in group is, “Leaves on a Stream.” In this exercise, group members are encouraged to visualize placing their thoughts, emotions, and sensations on leaves as they visualize them floating beside them and then gradually away from them. This is known as a thought defusionexercise that reinforces the impermanence of particularly unpleasant thoughts and emotions, and steers us away from rigid and absolute forms of thinking.

Distress Tolerance

Some individuals are naturally prone to be hyper sensitive to negative emotions, and even mild levels of stress may be experienced as unbearable or overwhelming.  If someone with an eating disorder is not able to tolerate distressing feelings without acting on symptoms, then those impulsive actions will continually interfere with efforts at recovery. This is where Distress Tolerance, the second module covered in our DBT groups can be helpful. This skill set helps individuals distinguish between pain which is an inevitable part of life, and suffering – the result of continued resistance to or non-acceptance of pain. While both pain and suffering can be unpleasant, pain is more tangible and short-lived. Suffering, on the other hand, is more pervasive because of the shame and denial that it encompasses.

In the distress tolerance module of DBT, group participants learn that there will be times when pain is unavoidable and that learning to accept and tolerate the short-term distress can help mitigate longer-term emotional suffering. A major concept taught during this module is radical acceptance which invites group members to stop fighting against reality or resisting painful emotions, and to instead accept that in life which is outside of their control. For example, practicing radical acceptance of the body can help to create a powerful shift away from negative body image thoughts to statements of truth such as “I have the body I have” or “I am living in this body”.

Other skills in the Distress Tolerance module include distraction, self-soothing skills, and crisis survival skills. Often times when Eating Disorder patients are struggling with food challenges or experiencing what feels like overwhelming fullness after a meal, distraction or self-soothing are among the most effective ways to ride out that discomfort. DBT participants have an opportunity to develop each of these skills during the group and to practice on their own between each session.

Emotion Regulation

The goals of the third DBT module, Emotion Regulation, are to help clients identify and validate emotions, decrease emotional vulnerability and to decrease emotional suffering. People with eating disorders often have difficulty validating their own emotions because of a genetic predisposition coupled with invalidating environmental factors such as lack of social support and peer pressure. This heightens one’s vulnerability to acting on eating disorder symptoms which becomes preferable to tolerating and experiencing painful emotions.

One of the primary objectives in Emotion Regulation is to get clients to first validate their emotional pain, which is a necessary step to regulating emotions. Another key component of Emotion Regulation is addressing and reducing one’s vulnerability factors. In applying this to eating disorders, some typical vulnerability factors include avoidance of adequate nutrition, social isolation, over-exercise, and other destructive behaviors such as substance abuse or self-harm.

The cultivation of one’s values is a vital part of participation in the DBT group and can also play an integral role in recovery from an eating disorder. This is based on the principle that emotions alone provide a flimsy foundation for action in comparison to values. During DBT group, clients learn about and practice living their lives in accordance with what they value. Some of the more commonly identified values among group members include family, work, religious or spiritual beliefs, volunteer work, or hobbies and talents.

Interpersonal Effectiveness

Difficulties with self-esteem, perfectionism, impulsive reactions to distress, and the drive to please others are some traits commonly shared by individuals with eating disorders. These traits can also negatively interfere with the development of healthy relationships. Interpersonal Effectiveness, the fourth and final module addressed during DBT groups, covers this aspect of relationships and teaches the skills needed to ensure they are balanced and fulfilling instead of toxic or destructive.

A major part of the interpersonal effectiveness module includes assertiveness skills, or asking for what you want and need from others. Another important aspect is setting boundaries, or learning to say no and resist pressure from others. During this module, members learn how to be strategic in getting their emotional needs met and practice specific strategies for resolving conflicts. This often involves learning how to assess and prioritize the objective needs, relationship needs and individual needs (self-respect).

Although, many group members may initially be resistant to role playing, this strategy can be particularly valuable in not only learning this skill but in providing an opportunity for group members to work through fears of asserting themselves. 

Creating a Life Worth Living

The term “dialectical” in Dialectical Behavior Therapy, is defined as an integration of opposites. This duality is central to DBT as clients are encouraged to practice the acceptance-oriented skills of mindfulness and distress tolerance, while also working towards positive change through emotion regulation and improved interpersonal effectiveness. This can be a difficult concept for clients to grasp initially, however most group members go on to appreciate both the emotional validation they receive and the changes they are able to make as a result of new skills learned. It’s not uncommon for group members to say “I wish I had learned these skills a long time ago.” Perhaps it’s because they are embracing the overarching tenet of DBT which is to build a life worth living. In doing so, clients learn to accumulate positive emotions and to build mastery. To “build mastery” is to set yourself up for success as opposed to taking on too much, to cope with potentially difficult emotions ahead of time and to take care of your body. When it comes to healing from eating disorders, these skills can be invaluable.

How I Learned to Satisfy My Insatiable Hunger and Feed My Soul

Kimber Simpkins joined us for the following book interview. What follows are our questions in italics, and her thoughtful responses.

What motivated you to write your memoir about your recovery journey?

After hating my body since I was about 12, starving myself when I was 15, and spending the next dozen years wishing that I was still anorexic, I finally realized how horribly I was treating my body. I credit my yoga and meditation practice for showing me how my destructive thoughts caused me to panic about something as simple as eating a donut. Meditation also gave me tools to nudge myself in the direction of being kinder about both what I was putting in my mouth and how I looked in the mirror. I started writing Full because I had an inkling that these tools could help me heal, but I wasn’t sure how. Writing the book became a sort of internal therapy for me, noting every day in my journal whether I felt hungry or full and whether I was bullying my body or treating it like a friend. Those 15 minute journal entries over several years grew into the pile of notebooks that eventually became Full.

You comment, “the excuse of using my body to not embrace life fully was a habit too ingrained.” (p.68) Can you please tell us more about that time in your life?

From around the time I first started dieting as a girl, my mantra became: “When I finally reach my ideal weight, then my life will begin. Then I will be beautiful. Then I will be confident. Then I will be lovable. Then I can light the world on fire.”  The result of that mantra repeated every day over many years was that I felt that I wasn’t entitled to start a serious relationship, or think about how to save the world, or challenge myself to do something worthwhile and important, all because my body wasn’t “worthy” in my own eyes. My perception of my body became both an actual barrier and my go-to universal excuse for not living a big amazing life.

Your pregnancy brought you a beautiful child and, for the first time in your life, a sense of trust in your body. What are your reflections on that experience?

Being pregnant was the first time in my life where my body wasn’t just about me, but also about the little being growing inside me. I felt a responsibility to treat my body with more respect, which wasn’t hard since it was doing something awesome: making a baby from scratch. Another helpful thing about being pregnant is that due to my eating disordered past, I’d become pretty inured to my body’s subtler signals — but my body signals during pregnancy were anything but subtle. More like neon light disco balls flashing: “You’re hungry! You’re full! Your legs are cramping! That smells disgusting! If you don’t eat that delicious smelling thing right now, you’ll die.” Listening to my cravings and aversions set the stage for me to be more aware of my body’s internal signals and open to the distant possibility of eating intuitively, which I didn’t discover until several years after my son was born.

By naming your inner “voices,” you help the reader appreciate the internal distress that accompanied your eating disorder. What helped you displace the intensity of “the pushy one, “ the inner anorexic critical voice, “Svetlana” with the “voice of reason?”

For years I thought the pushy, critical voice in my head was “my voice”. I identified with it completely. Yoga helped me notice–for the first time–the voice of my snarky inner narrator and how I unquestioningly believed everything it said. Thinking about these voices as “inner demons” instead of “me” gave me a little distance from them. Then, my meditation practices encouraged me to both hold those negative voices with compassion and listen for the voices that spoke with more kindness and wisdom. I slowly disentangled my identity from the negative voices and today think of them as aspects of myself that were well-intentioned, but destructive. I also began to listen for and identify with the voices that remind me that I am whole, beautiful, and lovable no matter what. It was a long process of recognizing the negative voices and saying no to them and at the same time inviting in more positive voices (the actual voices of my yoga and meditation teachers helped role model this). Then instead of allowing the same old mean voices to sing their song on repeat, I had to consciously repeat the refrains spoken by the loving voices and let them become my new favorite playlist.

You define your relationship with yoga as the key to your healing. Please share a few of the insights you’ve integrated in relation to your self and your body.

Here are just a few of the benefits yoga gave me as I went from struggling with, to recovered from my eating disorder mentality: 1) Yoga helped me slow down my mind and be present in my body. 2) Yoga helped my body grow stronger and more coordinated which led me to trust it and respect it more. 3) Yoga helped me increase my sense of where my body was in space (proprioception) and my awareness of internal sensations (interoception), which allowed me to see it as an alive being rather than as an object I should manipulate and control. Also, more internal awareness made it natural for me to start listening to my body’s signals of hunger and fullness, which I had previously overridden and ignored.  4) Yoga philosophy helped me reframe my body not as something that I had to overcome, but as something to be celebrated, appreciated, and enjoyed beyond its appearance, a view that can be summed up as: “Yay! I have a body! I’m alive!” It’s simple but profound.

Can you please elaborate on some of the mental “shifts” you’ve experienced through your practice of yoga?

One important shift was the transition from self-discipline to self-devotion. I always felt like I was willpower deficient, and that if I were really disciplined I would never get hungry or have to eat (definitely an anorexic mindset). Because I used my self-discipline to punish my body by depriving myself of food and forcing myself to exercise, my relationship with self-discipline soured. Later, I felt I had to be really careful how I used self-discipline, because there was always the danger I would use it against myself. Every week I would go to my favorite Indian restaurant for their lunch buffet and I let myself go through the line just once and no more, because I was afraid I would eat too much and feel terrible later. I was worried because it felt somewhat punishing, like I was a dangerous tiger who had to be restrained from eating everything. My yoga philosophy teacher, Carlos, reframed it for me by saying how wonderful it was that I could let myself enjoy a whole plate of my favorite food and eat just enough and not so much that I felt unwell or uncomfortable later. He showed me that eating this way is an act of love, and that I could think of it as being compassionate and kind towards myself. I was listening to my body and responding to what it needed: I gave it yummy food, but not so much that I’d have a stomachache later. That mental shift helped me find my way to intuitive eating and movement, where what I eat and how I move come from a place of self-devotion and love instead of self-discipline and willpower. It’s a lot easier and much more fun.

You grew from feeling “endlessly hungry” to joyfully teaching “a special Love Your Body Workshop.” What would you like your readers to “take away” when they read Full: How I Learned to Satisfy My Insatiable Hunger and Feed My Soul?

I don’t want readers to come away with a sense that there’s a paint-by-numbers, one-size-fits-all approach to loving your body. I do want them to come away inspired to undertake their own journey to find out what helps them feel less hungry and more full, and what helps nudge them in the direction of less self-hatred and more body love. Some of the practices I use in the book might help them, and some might not. They might find practices (like dance or prayer) that weren’t part of my book but are healing for them personally. We’re all different: our pasts and experiences and the reasons we feel how we do about our bodies are going to overlap in some places and vary widely in others. Even though we’re different, I hope Full gives readers the sense that it is possible to move from a place of suicidal self-hatred to a place of genuine adoration and love for the body. I didn’t know it could be done until I lived it. I hope the book supports others in living their way into healing and joy in their bodies, just the way they are. If there’s one overall message from the book, it’s this: No matter the setbacks and obstacles, keep heading towards love.

The Use of Yoga as an Intervention for Binge Eating in Eating Disorder Recovery

By Christina Gaunce, RDN

While in recovery from an Eating Disorder, behaviors are often a guide. Observing behaviors can give clues to deeper thoughts, feelings, beliefs, and needs. An identifying marker for ‘binge eating’ is a feeling of being out of control, a disconnection if you will from one’s whole self. Yogic movements and breathing techniques can help someone to connect with their whole self, as well as a higher/wiser self and can therefore be an effective intervention for those who struggle with binge eating.

As a Registered Dietitian and trained yoga teacher specializing in Eating Disorders, I have come to understand that there are different forms of binge eating and not all experiences are the same: there are binges driven by a force of frenzied energy, a yearning for recognition/self-care, or a desire to escape what is. The following are yoga based interventions that I have observed as helpful behavior modification techniques.

Binges driven by a force of frenzied energy, anxiety, or stress (what a yogi might call the ‘monkey mind’):

This type of binge might include eating standing up, taking large bites, not fully chewing food before swallowing, and eating at a fast pace. Those who struggle with this form of binge eating often struggle in a broader sense to slow down, to surrender to the flow of life, and to be in the present moment with all that currently is. Transitions during the day from one task to the next, or coming home from a day of work are high-risk times for these individuals. Using yogic techniques during these transition periods as an outlet for energy flow and to re-connect with self can be profoundly helpful. A suggested yoga sequence: In a seated position, lion’s breath three times and Kapalbhati breath for thirty seconds to one minute, followed by three to five minutes in legs up the wall pose (Viparita Karani).

Binges driven by a yearning for recognition, self-care, or love (in yoga an imbalance in the solar plexis and heart chakras):

Markers of this type of binge include eating in a comfortable place such as a couch or bed, eating highly palatable food, and savoring every taste/flavor of said food. It is all rather romantic while also surprisingly self-loathing and comes from a place of longing and deserving. Suggested yoga poses for intervention: bow pose (Dhanurasana) three times for five breaths, reclined bound angle pose (Supta Baddha Konasana) with one hand on heart the other on navel for three to five minutes, and corpse pose (Savasana) while covered with a heavy blanket for three to five minutes.

Binges driven by a desire to ‘shut-down,’ ‘power-off,’ ‘numb-out,’ or escape the current reality (what a yogi might call not being present):

This type of binge is often planned in advance and entails completely mindless eating without recognition of the foods’ flavors. It often occurs while simultaneously watching TV or using alcohol or other substances. The eating itself in combination with the outside distraction is used in an attempt to stuff down or escape uncomfortable and intolerable thoughts and emotions. Those who experience this form of binge eating benefit from practicing therapeutic techniques of emotional tolerance and titration. Recommended yoga asanas: uncomfortable poses with breath such as hip-opening poses (figure four, thread-the-needle, and pigeon). However, in the moment of a behavior urge, a more effective yogic intervention might include a few sun salutations (Surya Namaskara), A or B, to assist with the flow of energy, release of intense emotion, and grounding to the earth/reality.

As with all forms of activity included as part of Eating Disorder recovery, it is important to use yogic intervention in combination with other interventions and coping skills so that physical activity is not the only method of emotional and energetic management solidified.

“In the rubble of your shaken spirit, an illusion and a truth”

-Kylie Johnson

The Use of Yoga in Binge-Eating Disorder Recovery

By Shirley Kessel, RYT

The person with BED, binge-eating disorder, may find it hard to manage difficult emotions and bodily sensations without using food. Bingeing is a way to numb out and disconnect from emotions that seem overwhelming and intolerable. Paradoxically, the thought of giving up the use of food also brings up uncomfortable and negative emotions such as anxiety and fear.

Repressing bodily experiences of sensation and emotion causes a person to become disembodied – a state of leaving abandoned the experiences that frighten or make us vulnerable, such as pain, sexuality, hunger and satiety, and the emotions that may be negative or even positive.

Yoga can be a component of binge-eating disorder recovery because it helps to re-embody the person who has withdrawn from her body.

How does this somatic experience play out on the yoga mat? I like to use the acronym CARE, because yoga is a form of self-care that suggests to the BED yoga practitioner to begin by taking care of herself on the yoga mat.

C: Check in: When starting a yoga practice, begin by checking in to the present moment by gently taking an inventory of what’s arising right now in the three components of the Triangle of Awareness (Fig.1). It’s nice to begin by becoming grounded and centered. I like to begin in mountain pose, a go-to posture that can be used away from the mat when the yoga practitioner feels off kilter. Begin at the feet and scan your body from toe to head, noting areas of tightness, ease and no sensation.

Next, check in to the present emotional state in the mind and body. Perhaps you feel negative emotion such as anger or sorrow. If you are feeling positive emotion, then notice that. Is it happiness, gratitude, hope? If there is no emotion, then we say the present emotional state is neutral. It’s important to note what’s happening and allow a moment of reflection of what’s arising while letting go of judgment or trying to change the experience to how we think things should be.

Now, check in with your thoughts. Are they racing or steady? Is the mind in the past or future?

A: Acknowledge and Allow: While scanning the body and mind during a check-in, acknowledge whatever is arising with kindness. Most of the time, our minds say negative phrases to the body such as, “You are not good at yoga” or “Look how much better she is at yoga than me.” When the thinking mind chimes in with negative thoughts, allow them to be present because you may notice an emotion or bodily sensation that comes along with these negative thoughts. With practice, you can let these thoughts be and return to the breath or sensation of the asana in the body as an anchor.

As you move through the yoga poses, continue to notice what the thinking mind is saying to the body. Angela (not her real name), a student in my class, noticed that whenever she came into child’s pose, her belly was too large to fit between her thighs, and immediately her chatterbox mind turned up the volume: “You’re too fat for this child’s pose. You have been fat since the day you were born.”

With practice she was able to respond with care.

R: Respond: Each time Angela noticed her mind chiming in during child’s pose, she was encouraged to turn her attention to her body. She noticed stiffness in her body and shared with me later that she was reacting to the anger she had toward her body (body hatred) in this posture. With encouragement, she was able to stay with the emotion of anger. She noticed how it morphed into sadness as she had the desire to be in a different body that was not large.

When she felt she had explored these emotions long enough in child’s pose, she responded by coming back to her breath. She listened for the sound of the Ujjayi breath – the sound that the body makes that is similar to the wind in the trees or the sound of the ocean. Ujjayi means “to become victorious” or “to gain mastery.” Angela turned her attention to the sensation of the breath in her chest. As Angela mastered this technique, her experience shifted. Each time Angela experienced the thinking mind taking her away from the present moment of feeling into the asana practice, she came back to her body for assistance as her anchor.

E: Embody: The final step is to re-embody the body and mind by being mindful of using the CARE process. With time, the BED yoga practitioner relearns the practice of mindful eating – a skill that we are born with but lose with diets, trauma, and disconnection due to life experiences.

With time and practice, Angela was able to cultivate gratitude for her breath and body because she realized that her body was a necessary vehicle to keep her grounded and present in both difficult and pleasurable moments on the yoga mat. She learned to take this practice from her mat to the table.

When a binge was preparing to take over, Angela was able to check in to what was arising that drove her to use food. When she did decide to binge, Angela used her mindful awareness to:

• Check in to the Triangle of Awareness.
• Allow the emotions and thoughts to be present while noticing where in the body the sensation of the emotion was residing.
• Respond by letting them be present while knowing she did not want to or always need to react.

The experience of yoga practice encourages the student to remain present with what’s arising in the given moment. As the present moment is unfolding, the student is guided to practice acceptance and to respond right there on the yoga mat. For example, as a pose becomes more difficult and the sensations experienced in the body become more intense, yoga helps the student to delay the impulse to jump out of the pose by staying present in the difficult pose. As the student remains present in the posture, she is guided to observe the thoughts and emotions that come along with intense sensation.

These same difficult sensations, thoughts, and emotions also arise away from the mat during a binge or other unwanted eating practice such as numbing out with food, or running away from uncomfortable feelings around food.

Trusting the inner wisdom of the body also allows the BED yoga practitioner to know when he/she is hungry for food, or when he/she needs something else, such as other forms of self-care in life that do not involve food. While on the yoga mat, the practitioner learns to decide what is enough of a pose. In life, we carry over this practice to learn what is enough of work, volunteering, or chocolate cake. When we learn how to respond on our yoga mat, we learn how to respond in life and at the table (or the refrigerator or over the kitchen sink). This is the practice of mindfulness that can help the yoga practitioner cultivate a mindful eating practice.

The Use of Yoga in The Treatment of Anorexia and Bulimia Nervosa

By Beverly Price, MA, E-RYT

For an individual struggling with Anorexia or Bulimia Nervosa, Yoga therapy can be a powerful treatment tool. The role of a Yoga therapist in a treatment setting is much different than what a Yoga instructor can provide. The role of a Yoga instructor is to take what one knows about the practice of yoga and lead a group of students through a class. Typically Yoga instructors teach group classes at studios and gyms, although some do teach individuals privately. A Yoga therapist is trained to work with individuals not only physically, but on an emotional and spiritual level as well. They are also trained in an area of specialty, such as eating disorders, in order to focus on facilitating healing and transformation of an individual.

This article will take you through a Yoga Therapy session with an individual patient or group of patients diagnosed with the eating disorders described above:

The Yoga therapist sets the tone of the treatment room by dimming the lights and warming the room to a cozy and comfortable temperature (not too hot, not too cold). There is no “front” or “back” of the room. It is the Yoga therapist’s job to circulate within the space and observe the patients, in terms of their body language and response to the flow of postures given. This is not the place for the Yoga therapist to model postures or perform his/her own practice. There may be soft background music or absence of music, as the Yoga therapist sets a theme at the onset and follows through with dialogue to support the theme.

For example, a theme about judgment may open with the following story by the Yoga therapist, as patients are in seated meditation:

“There was a woman who placed her laundry on drying racks in her front window. A neighbor walked by daily and wondered with disgust why the woman placed her dirty laundry in the front window for all of the neighbors to view. After at least a week went by, the neighbor walked by to find that the woman’s clothes hanging in the front window were now clean. When the neighbor finally confronted the woman, the neighbor exclaimed with sarcasm, “I am glad to see that your clothes hanging in the window are now clean!” The woman responded, “My clothes have always been clean. I just washed the windows.”

As the Yoga experience shifts to a moving meditation, the Yoga therapist allows the individual or group to move in any way that feels right — from “cat-cow,” to “cobra,” to “down dog,” — the Yoga therapist invites the patient to work with their eyes closed as to not judge themselves or other patients that may also be in the room. “Feel what it is like to be inside of your own body at this very moment,” states the Yoga therapist, “Yoga is not a competition or a race. There is no scorecard… Just you on your mat in your own personal practice.”

The Yoga therapist then moves the patient to a dynamic sequence, such as reverse table to boat pose with at least 15 breaths held per pose, along with a sequence of three of each alternating poses. As the Yoga therapist moves the patient towards their “edge,” that place which is not too much but not too little, the intensity of the sequence is geared to the strongest patient offering modifications to the least strong and/or more compromised. The Yoga therapist describes the edge as follows, “You find yourself in a heated discussion. Embrace this discussion as a learning exchange in speaking each other’s truths. When it becomes a heated argument, you may be beyond your edge and need to know when to walk away. Your edge at this moment may be seated meditation or child’s pose.” It is important for the Yoga therapist to give permission to the patient to take child’s pose at any time, but yet empower the patient to understand when he/she is using child’s pose to avoid confrontation with issues that need to be worked out, without judgment, on their Yoga mat. For many patients, child’s pose may be their edge. Softening around the edge is also encouraged with the message from the Yoga therapist that the patient “should not be so hard on himself or herself.”

A series of long holding postures, moving side to side, that strengthen the mind may be brought in next by the Yoga therapist, as the therapist encourages the patient to make a strong determination to stay in the posture as uncomfortable as it may feel…equating this discomfort to uncomfortable emotions that may surface at anytime. “Breakdown often happens before breakthrough. As we release physical pain, we release emotional pain,” the Yoga therapist directs. The Yoga therapist may offer adjustments stating, “If I come around to adjust you, please know that I am making a connection, not a correction. The Yoga therapist is trained to intuitively know when the patient does not want to be touched. In this case, an “adjustment” may consist of simply sitting next to the patient, while he/she is in their personal practice, and listening to their breathing while energetically encouraging him/her to work through obstacles on their mat. “Our obstacles are our greatest teachers, this is how we grow and transform,” offers the Yoga therapist.

The Yoga therapist then brings in static, dynamic postures such as a long holding chair posture or Buddha squat, encouraging the patient to stay present and in the moment. “Light always comes after a dark storm,” may be an appropriate metaphor here.

As the Yoga therapeutic session winds down, long holding Yin postures, that require no muscle work, may be brought in at this time such as pigeon pose or a long holding forward folds. “There is nothing to do now but just be – without self-judgment,” notes the Yoga therapist, “For some of you, your work is to be still…which may be the hardest thing you will do all day.”

Following the Yin postures comes Sivasana, an ending resting pose lying on one’s back. Sivasana with eyes open or seated meditation should be offered as an alternative for those patients working through trauma issues. An appropriate song relating to the theme may be played here or simply silence. Seated gratitude may be a way to close the experience, followed by journaling of the experience by the patient and discussion, along with medical record documentation and communication to the entire treatment team. Keep in mind that the techniques outlined in this article may be used for individuals with Binge Eating Disorder, and my colleague and trained Reconnect with Food® Yoga Therapist, Shirley Kessel, will elaborate more in her article within this issue.

Trained Yoga therapists in an eating disorder setting are an integral part of the treatment team. At the Inner Door Center®, the Yoga therapists don’t just walk into our clinic, facilitate a therapeutic movement sequence then leave. They facilitate group process and therapy to assess what has come up for the patient during the therapeutic movement hour, they chart in the medical record, they attend case consultation and they have a significant report with program patients. Keep in mind that conversation can be a barrier to intimacy and therefore, patients can talk their way out of feeling. Studies indicate that approximately 55% of communication is body language, 38% is the tone of voice, and 7% is the actual words spoken. The Yoga mat can be a great tool for self-expression.