Introduction

Mind-body interventions, which encompass a large range of approaches, including qigong, tai chi, yoga, and meditation, combine body movements with mental focus [1]. They are practiced both to reduce psychological distress and boost well-being [1]. Because of their high potential for both the prevention [2] and management of anorexia nervosa (AN) [3], they have been progressively implemented in multidimensional treatment programs for eating disorders. Instructors of these techniques contend that they contribute to the recovery process in a wide variety of ways: through relaxation, enhancing body awareness and acceptance, and modifying perceptions of life events [4].

Qigong is a mind-body intervention and a branch of traditional Chinese medicine [5]. It involves slow movements, breathing, and meditation exercises. Qigong challenges the foundations of modern Western biomedical thought, sharing as it does the philosophy of traditional Chinese medicine and its aim to strengthen qi (life energy) throughout the body. Although scientific evidence of its efficacy is undeniably scarce, a recent meta-analysis suggests that qigong exercise reduces stress and anxiety in healthy adults [6]. In qualitative studies exploring its perceived benefits, older adults report body-mind-spirit integration as a main effect as well as physical, mental, emotional, social, and spiritual benefits [7], and participants’ sense of strong connection to both themselves and the other participants during group practice appear to produce positive psychosocial effects [8].

In 2008, our multidimensional treatment program [9–11] for adolescent inpatients with AN, in the adolescent and young adult psychiatric department of the Montsouris Medical Institute (IMM Hospital), began a weekly qigong workshop. AN is characterized by food restriction, severe weight loss, a distorted body image, and a pathological fear of becoming fat [12,13]. Prevalence estimates among adolescents from the most recent epidemiological studies range from 0.3% [14] and 0.5% [15] to 1.7% [16]. Intense physical activity, anxiety concerning weight and shape, and recurrent negative thoughts about their distorted body image are major features of AN. The association of severe AN with poor outcomes, including mortality and chronic morbidity [17], underlines the need to develop new approaches.

Qigong focuses on interoceptive processes (proprioception and visceroception), that is, awareness of stimuli that arise within the body. For that reason, it appears to be a promising approach in AN, whose features include difficulties in perceiving internal bodily signals [18], that can either be measured in an objective manner (interoceptive accuracy, measured with the heartbeat detection task [19]) or with psychometrics (interoceptive awareness, measured with the interoceptive awareness subscale of the Eating Disorder Inventories [20]).

Despite a careful search in Medline and PsychINFO, we have found no data about qigong in AN. A few studies have evaluated other mind-body therapies in eating disorders but both quantitative and qualitative data are scarce. Recently, Vancampfort et al. [21] reviewed the existing randomized controlled studies of the use of aerobic exercise, yoga, massage, and basic body awareness in the management of anorexia and bulimia nervosa, but the paucity and heterogeneity of the studies prevented them from reaching any firm conclusions. Among patients aged 11–21 years with eating disorders, including AN, yoga reduced preoccupation with food immediately after all sessions and significantly lowered EDE (eating disorders examination interview) scores after 12 weeks compared to control patients on a waiting list [22]. A qualitative study provided enlightening information about how the practice of yoga by women in a program for binge eating helped them move from a state of distraction and feeling physically absent (associated with binge eating) to a state of feeling focused and physically present (associated with satiation) [23]. Likewise, a study among patients with eating disorders of the Feldenkrais method, based on "awareness through movement", reported that it contributed to the development of "a felt sense of self, self-confidence and a general process of maturation of the whole personality" [24].

Because our program’s qigong workshop was popular among our adolescent patients, and psychiatrists perceived clinical benefits that deserved further exploration, we undertook this study. Our objective was to obtain a deeper understanding of how young patients with severe AN experience qigong and to determine the incentives and barriers to adherence to qigong, to understanding its meaning, and to applying it in other contexts. We also sought to ascertain its potential benefits and risks. We anticipated that this information could help clinicians to understand which patients might benefit most from the qigong program and would also provide useful insights into how best to supervise and integrate this program into each patient’s overall management to maximize its benefits and minimize its risks.

Methods

Participants and recruitment

Patients were recruited from January 1 to March 30, 2014 from eligible subjects hospitalized in the adolescent and young adult psychiatric department of IMM Hospital for AN or EDNOS (eating disorders not otherwise specified, i.e. diagnosis of AN missing 1 or 2 criteria), aged 13–21, with current or previous access to a qigong group session. To facilitate reading hereafter, we will refer to all patients as patients with AN. Qigong attendance was offered throughout the entire duration of hospitalization (which generally lasted several months), once patients were medically stable. Most patients participated voluntarily, attending regularly or irregularly, depending on their schedule (since it could conflict with their school programs) and their preference. If the physician in charge deemed it appropriate, the activity might have been strongly advised (prescribed) and therefore not dependent on the patient’s free choice.

Sampling was purposive [25] and inclusion continued until sufficient data were obtained [26]. Accordingly, we included patients as heterogeneous as possible, including those who attended qigong regularly and those who came irregularly. We were therefore able to consider a wide range of situations and experiences.

Finally, data from 16 young women were sufficient; because 4 refused to participate, we ended up asking 20; the 16 participants freely consented, as described below. Their median age was 17 years (13–19) at the interview. Qigong was prescribed for 1 adolescent; the remaining 15 reported that their attendance depended only on their schedule and personal choices. Ten had a history of regular attendance (see Table 1). Patients with irregular attendance will be referred as (irreg) in the quotations. Attendance could be irregular for various reasons, including low adhesion, refusal to participate, and concomitant activity (such as class). This number of subjects sufficed for in-depth analysis according to the methodology we used, Interpretive Phenomenological Analysis (IPA) [25,26], described below.

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Table 1. Participants' characteristics.

https://doi.org/10.1371/journal.pone.0170885.t001

Procedure—data collection

Participants (and their parents, for minors) received complete written information about the scope of the research, the identity and affiliation of the researchers, the possibility of withdrawing from the study at any point, and confidentiality. Participants (and their parents, for minors) provided written consent. This research received approval from the institutional review board of the hospital involved, Institut Mutualiste Montsouris, Paris (n°2013–005), and was registered with the French data protection authority (the Commission Nationale de l’Informatique et des Libertés–CNIL) (n°1734833v0).

Data were collected in 16 individual semi-structured face-to-face interviews (by JG) that took place at the IMM hospital, in a consultation room, between January 20 and April 20, 2014. They were audio-recorded and subsequently transcribed verbatim. An interview topic guide was developed in advance and included 9 dimensions with open-ended questions and several prompts (Table 2), constructed to elicit in-depth and detailed accounts of the subject’s feelings during and after the qigong experience, the meaning it had for her, its impact on her body image, and the effects she connected to the qigong practice. Our overall objective was to explore the meaning of the qigong experience for each participant.

Researchers discussed their own feelings about the interviews during study group meetings, to take their potential influences on the data collection and analysis into account (reflexivity).

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Table 2. Interview topic guide.

https://doi.org/10.1371/journal.pone.0170885.t002

Results

Eleven themes describing the incentives and barriers to adherence to, understanding the meaning of, and the application of qigong were identified and organized into three superordinate themes: individual, relational, and organizational dimensions. The first superordinate theme, the individual dimensions, comprises the attitudes and explanations that the adolescents saw as related to themselves; it includes the themes: (1) attitude towards movement: from hyperactivity to ability to relax, (2) attitude towards a new cultural frame: from Cartesian rationalism to an opening to Eastern philosophy, (3) mind-body attitude: from dualism to integration, and (4) time-related effects. The second superordinate theme, relational dimensions, involved issues with others and were categorized into three subthemes: (5) perceptions of the group, (6) role of the instructor, and (7) family attitude towards qigong. The third superordinate theme covered organizational dimensions, that is, issues related to (8) qigong access policy, (9) setting and degree of compartmentalization of the activity in the overall patient program, (10) focus of the activity, and (11) the activity’s schedule. Within each dimension and even within each theme, we identified drivers and barriers to adherence to qigong, to understanding its meaning, and to applying it outside the workshop. The barriers, in particular, could be specific to the experience of AN or involve the experience of adolescence more generally. Table 3 summarizes the themes and notes the barriers exacerbated by AN. Overall, the participants described a great variety of experiences (S1 File).

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Table 3. Incentives and barriers to adherence to qigong, to understanding its meaning, and to applying its techniques in other spheres.

https://doi.org/10.1371/journal.pone.0170885.t003

We develop and illustrate the individual, relational, and organizational dimensions of the participants’ experiences.

Organizational dimensions

Organizational dimensions included four themes: the activity access policy (open access versus constraint), setting (degree of compartmentalization of the activity in the overall program), scope of the activity, and schedule.

Activity access policy: constraint versus freedom.

As mentioned before, the qigong program was prescribed for only one of the 16 patients, and she did not adhere to it and tried to find ways not to participate. None of the others felt that the activity had been prescribed to them, even if it might have been strongly recommended by the staff. The patients welcomed this open-access policy. Nevertheless, a delicate balance must be found to ensure they try out the activity, because attendance can lead to experimentation with it, and experimentation to understanding and adherence.

P (irreg and prescribed): "Well, I went there as little as possible (…) either I would say ‘no’ or I would go somewhere else, or I would say that I was going to another workshop, or something like that.”

L (irreg) "and given that I was there and I did it, and then after, I saw, I sort of understood how it worked.”

The workshop itself was considered quite flexible. Nevertheless, some experienced constraint in imposed moves and were ambivalent toward it: they disliked feeling constrained or required to do something, but acknowledged the potential benefit of experimentation with something new that could lead to learning and progress.

Setting—degree of compartmentalization.

A form of geographical compartmentalization was implemented as the activity was generally offered outside the hospitalization unit (on a different floor, except when a meeting was scheduled in the room). This form of compartmentalization promoted patients' sense of freedom and their personal investment and they enjoyed it.

O: "Well um… I don’t know, qigong was… was on the first floor, well, not in the department.

Investigator: “And if it was in the department, what difference would that have made to you?

O: “Well I think it would have been more complicated to really care about it so much.."

Moreover, patients experienced this activity as clearly separate from the rest of the global management program, and they did not talk much about it with either the nursing or medical staff.

An activity not focused on AN.

Patients appreciated that the activity, like many of the group activities in our program, was not focused on their disease. Instead, it promoted involvement and activity.

F: “to not think and not see our problems, be in another universe, a moment that we’re not being talked to about… everything you talk to us about here. Yes, it’s nice. Because for once, we are told ‘Exactly, forget it! Don’t worry about that, you have 90 minutes just for yourself, keep it for you!’”

Time schedule.

The workshop was scheduled after lunch, at a moment of postprandial anxiety when the principal alternative activity was quiet time in their room. This was an incentive to participate, as patients were happy to be diverted from their anxiety and to avoid rest time. It was also however a barrier to full involvement in the activity, because the patients felt especially uncomfortable at this moment. In practice, avoiding rest time was one of the main incentives reported for participation. Although some patients reported difficulties in becoming involved due to the scheduling, the timing was more generally considered adequate because it provided the patients with a solution to their rest-time distress, at least once a week.

B (irreg): “For me it was more to fill in the gaps and not be depressed in my room.”

I (irreg): " Well, it was good because it was after the meal. So it was a time when we were all tense in general so um… it was good to be able to be the tiger or the wild goose after that.”

Fig 1 summarizes the different dimensions and their effect on qigong adherence and its application to other contexts.

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Fig 1. Summary of main incentives and barriers to adherence and application of qigong.

https://doi.org/10.1371/journal.pone.0170885.g001

Discussion

Our study aimed to (I) investigate the experience of qigong from the perspectives of adolescents practicing it as part of an multidisciplinary inpatient treatment program; and (ii) describe the incentives and barriers to adherence to qigong, to understanding its meaning, and to its application outside the program. The experience of our participants was described by 11 main themes, belonging to 3 superordinate themes or dimensions: individual, relational, and organizational.

- The individual dimensions identified in the participants’ accounts—attitudes toward movement, toward the mind (and especially towards rationalism and Eastern philosophies), body-mind integration, and the passage of time—are all factors that help to explain patients’ level of adherence and the meaning they attribute to the activity. Their varying degrees of hyperactivity and different perceptions and conceptions of the interrelations and interactions of mind and body all played an important role. A strong mind-body cleavage and especially excess physical exercise are major features of AN that tend to be barriers to initial adherence. Excess exercise is characteristic of up to 80% of patients with AN [32] and includes a strong drive to exercise and improved muscle tone as a priority reason for exercise [33]. These points explain why patients find it difficult to cope with the slowness/stillness and relaxation of qigong. Hyperactivity can be both a weight-loss strategy and a kind of compulsion or even addictive behavior [34]. Obsessive thoughts too can be part of AN and can, as shown above, make the process of "letting go" really challenging.

Experiential avoidance, perfectionism, and lack of flexibility—all widespread in patients with AN [35–37]—are described as factors involved in the maintenance of AN [38] and even associated with poor outcome [39]. Qigong addresses these issues by inviting participants to participate in a non-competitive, non-Cartesian activity and to experiment with different internal experiences. Qigong confronts young women with questions about body awareness, emotions (recognition and regulation) and even spirituality. From the patient’s perspective, these are all known to be key factors in the recovery process, which includes self-acceptance, determination, and spirituality as equally important elements [40]. In a dualist attitude, mind and body are considered as two separate entities [41]. The body is perceived as “muscles and flesh” with no connection with the mind. In a phenomenological approach, we can distinguish the physical or object body (German: Körper) from the lived or subject body (German: Leib) [42]. In eating disorders, effects at the level of the physical body may disturb embodiment related to the body image [42,43]. Qigong invites people to focus on both physical body sensations and subject body experience and can thus lead to what is also called “mind-body integration", that is, an embodied sense of self. Focus on the object body can, however, reactivate the disturbance of some patients’ embodiment and force them to face an unpleasing body image. Awareness of this risk is essential for clinicians to detect and manage it on an individualized basis for each patient.

Interoceptive abilities are known to be affected in eating disorders [18]. Interoceptive awareness assessed by the eating disorder inventory-2 (or 3) is reduced in BN [44] and in ED in general [45], whereas interoceptive accuracy, assessed by the heartbeat detection task, was only reported to be reduced in AN [19]. Interoceptive accuracy has been reported to be negatively correlated with self-objectivation, i.e. the tendency to experience one’s body principally as an object. People with lower interoceptive accuracy tend to evaluate their body for its appearance rather than for its effectiveness [46]. Moreover, interoceptive accuracy is considered as “a potential independent and stable factor of AN,(…) that is not touched by state-of-the-art cognitive behavioral therapies” (see p.6 in [18]). Mindfulness techniques and interventions using interoception as a core element, such as qigong, could therefore be of great interest to potentiate interoceptive accuracy and improve interoceptive processes [44]. Difficulties in perceiving one’s own internal sensations may well be associated with problems in recognizing and paying attention to emotions, which manifest themselves both physically [47] and mentally. Recognition and regulation of emotions are known to be impaired in AN [48], and alexithymia is associated with the persistence of AN [49]. Benefits of qigong, as reported by some patients in our study, include access to interoception, "the process of receiving, accessing and appraising internal bodily signals" [50] and to emotion regulation. Awareness of emotional states is a prerequisite to emotion regulation, which implies another prerequisite: interoceptive awareness, that is, awareness of bodily signals. It appears crucial for regulating the intensity of emotional experience and for higher order processing of emotional stimuli [42]. In particular, interoceptive awareness can facilitate successful emotion regulation through reappraisal [51]. Qigong practice could thus help to identify and regulate emotions through enhanced interoceptive awareness. This could be of great interest both in AN and BN, as both share reduced interoceptive awareness, as measured by the Eating-disorder-inventory-3, that more specifically investigates interoceptive awareness of emotional states [45]. These benefits in terms of interoceptive awareness and emotion regulation could in turn potentiate psychotherapy.

To summarize, individual dimensions frequently observed in patients with AN can present serious obstacles to qigong adherence. Once these are overcome, however, patients do report positive effects: satisfaction associated with relaxation and with the experience of mind-body integration. Accordingly, an essential question is whether individual characteristics (such as excessive exercise and mind-body cleavage) should be considered as barriers to qigong practice or should be overcome by this practice. The answer lays probably partially in figuring out the right time to introduce qigong to each patient.

Certainly, time issues seem major: if initiated too early, patients may be less prone to adhere and in some cases, even subject to additional difficulties. Priority for patients with severe AN must go to renutrition [9], which must precede activities such as psychotherapy and qigong. After that, qigong and other body awareness therapies can serve as a first step in erasing mind-body divisions and thereby potentiate psychotherapy. The right moment to introduce qigong must be determined individually for each patient, for their incentives and barriers to qigong adherence differ, as does their readiness to change. Motivation to change, which is an important predictor of outcome in AN, can be worked on and can increase during hospitalization [52]. We suggest it can also affect adherence to qigong and helps explain why it increases over time. Multidimensional programs require patients to deal with many healthcare providers and involve different coordination and communication schemes among the professionals. We think it is important that the psychiatrist in charge assess the motivational aspects and the risk-benefit balance of the qigong program for each patient. Individualizing the treatment approach to each specific patient is of key importance for effective outcomes [53] and may be facilitated by a debriefing with a psychiatrist after the first session to distinguish patients who can benefit from qigong from patients for whom it should be postponed and to decide how to best support each patient. Some patients could then be advised to try at least 3 sessions before another debriefing.

- Relational dimensions, that is, how patients perceive the group (as a threat or support), family attitudes about qigong, and the relationship with the instructor, also help explain level of adherence to and ability to find meaning in qigong. This dimension appears predominant in the adherence process.

Because most patients consider the group supportive, group qigong practice seems appropriate to them, even though the negative body image in AN [54] and frequent social phobia [55] can reinforce fears of judgment by their peers. These fears, moreover, are valid: females with AN estimate other women's weight higher than healthy women do and consider extremely underweight women to be more attractive and normal- and overweight women less attractive [56].

The instructor is considered a role model and an inspiring figure. Research has shown that the therapist matters and is indeed the most important contextual factor determining the effectiveness of complementary and alternative medicine [57]. Our results confirm the primary importance of the provider. A better understanding of human effects in any therapeutic mediation is still needed.

Patients reported that a positive family attitude promoted adherence, consistent with studies showing that parental motivation and parent-therapist alliance predict positive child outcome in a variety of treatments for indications ranging from mental health to diabetes [58,59]. Moreover, the parents’ and children’s alliances with the therapist may interact synergistically: it has been suggested that the parental alliance may promote treatment completion, while the child’s therapeutic alliance affects treatment outcome [60]. More generally, family involvement is important in AN management. For example, the addition of family therapy focused specifically on intrafamily dynamics to an established integrative multidisciplinary outpatient treatment program for adolescents with AN significantly improved outcome at 18 months of follow-up [61].

In summary, we see that most aspects of the relational dimensions appeared to serve as incentives to participate and helped make the activity meaningful, through conviviality, a sense of belonging, and sharing. Motivation thus relies mostly on these relational dimensions, whereas the individual dimensions played a much more mixed role in adherence. This point may also explain the very limited continuation of qigong after hospitalization: the group- and instructor-related motivating factors are no longer present.

- Organizational dimensions. Access policy, time schedule, scope of the activity, and the integration of the qigong activity in the multidimensional treatment program are important motivation factors. Different adjustments and settings may have important consequences on adherence to and continuation of qigong. In our study, these dimensions tended to increase qigong adherence, but also to limit its post-discharge continuation.

First, the balance between freedom of access and constraint merits discussion. Constraint may be necessary to compel patients to experiment [62] but freedom, or at least a trusting relationship, is also needed to promote adherence [63]. A qualitative study reports that young women with AN agree that compulsory treatment is justified in life-threatening conditions but not otherwise. Most important to them, however, was not the restriction of freedom but the nature of their relationships with the professionals, for "within a trusting relationship compulsion may be experienced as care" [63]. As the NICE guidelines state, "a precondition for any successful psychological treatment is the effective engagement of the patient in the treatment plan. Health care professionals involved in the treatment of AN should take time to build an empathic, supportive and collaborative relationship with patients and, if applicable, their carers" [64].

Second, the timing of the program, here after lunch, can be especially difficult for some patients. Patients may be prone to postprandial anxiety and want an active treatment to deal with it [65]. Moreover, as mentioned above, the workshop was scheduled during a rest period that many patients wanted to avoid; patients with AN perceive bed rest negatively, as a source of isolation and boredom [66]. A different timing (before dinner or before bedtime) might alleviate the disadvantages associated with the postprandial schedule. Ideally patients could start with an evening program and then add or switch to the after-lunch program.

Third, the degree of both compartmentalization and integration in the overall treatment program should be discussed: compartmentalization promoted access to the activity in the first place, simply by offering an activity not focused on AN. This focus on quality time unrelated to their disease appeared to be an incentive to adherence here, as reported in previous studies [67]. Nevertheless, it remains an activity focused on the body, and ambivalence is present: focus on the body can arouse interest and slowly lead to another perspective on the body, but it also risks exposure to the body and increases negative emotions [68]. Integration and involvement of the care team can potentiate the scope of the activity, encourage the application of qigong techniques, and increase patients' involvement and empowerment. Other studies have stressed the importance of staff involvement in activities for people with psychiatric disabilities [69]. However, the borderline between involvement and intrusion is a fine one. Different forms of organization could be considered. For example, a team member besides the instructor could attend the workshop. This would make linkage and communication with the staff easier and avoid regular direct patient interviews that might be perceived as intrusive. A scheduled discussion period could be routinely proposed to participants at the end of the activity on a given schedule (every session, every two sessions, once a month…).

Taking ownership of qigong and continuing it outside the institution appeared limited in our study sample. This may be partly explained by the prominent role of the instructor: the activity is personified for these patients, so that they find it difficult to experiment with qigong with someone else. More generally, this is probably related to issue of motivation, discussed above. Motivation in this case depended mostly on the social and relational benefits of the group activity, i.e., extrinsic factors. Strategies involving those extrinsic factors could be used to encourage continuation of qigong, such as allowing patients to continue the program at the hospital after discharge, providing them with the benefits of the group. This could offer a continuum and a successful transition. Referral to another qigong provider by the instructor might also reassure the patients and provide a sort of launching pad. Still, some general questions remain, including the type of group (therapeutic or not?) to which they should be referred, and the financial aspects, which may be a barrier for some. Beyond those points, however, consistent continuation of qigong after discharge probably requires intrinsic motivation factors. Serious consideration of how to support patients in finding autonomous motivation would be beneficial. Certainly, self-determination theory suggests that autonomous (i.e., intrinsic and identified) forms of motivation are much more effective than controlled (i.e., introjected and externally regulated) forms [70].

Conclusions

Qigong appears to be an interesting therapeutic tool that can potentiate psychotherapy and contribute to the recovery process in patients with AN. Individual dimensions associated with AN may curb adherence, whereas relational dimensions appear to provide incentives to join the activity. Further analysis of the best time window for initiating qigong and of its place in overall management might help to overcome some of these barriers, limit the risks, and maximize its benefits. Systematic debriefing with a psychiatrist after 1 to 3 sessions should be considered, and scheduled time to discuss the activity could be included in the workshop.

More globally, the development and evaluation of mind body activities (such as qigong) for patients with eating disorders appears as an asset. Such activities could lead patients to perceive their body in a positive way, counterbalancing the negative experience of impaired body image and food associated uncomfortable body sensations existing in eating disorders, and ultimately allow them to access to an enhanced sense of self. Moreover, it could lead patients to reconsider their perception of stillness and rest and allow them to access to relaxation and benefit from it. Taken together, increased relaxation, reduced body-related anxiety and better body acceptance could promote the adhesion to the renutrition program.

Future research dedicated to assessing the impact of qigong and other mind-body interventions on bodily signals perception, body acceptance, emotional awareness and emotion regulation would be of great interest.

Supporting Information

Acknowledgments

The authors thank the participants of this study, and Ms Jo Ann Cahn for language polishing.