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Content uploaded by Rachel M Calogero
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Section III
Primary Nonverbal Approaches
Rosenbaum’s (2005) recent paper about the neglect of motor control as
the pariah of psychology finds definite parallels in the neglect of the
nonverbal medium in psychotherapy and prevention. Rosenbaum documented
this neglect in textbooks, journals, and in the Social Science Citation Index.
He developed some hypotheses about this neglect: (1) there aren’t celebrities
in the science of motor control while there are many in the cognitive area,
(2) talk is human while motor control is animal, (3) motoric activities do
not need the same kind of intelligence that is needed for talking, (4) motor
behavior is too hard to study, (5) we think before we act, therefore why
worry about what seem to be automatic actions? (6) motor control is the
baby but talk is the bath water, and (7) motor behavior should be studied by
neuroscientists and not by psychologists.
By the same token, we can find the same neglect in psychotherapy as well
as in prevention treatises. Rather than accept this conclusion as a given, this
writer made a summary check on samples of psychotherapy journals and
textbooks to search for how many among these sources included nonverbal
motor therapies. He found none. There are no references to nonverbal therapies
in psychotherapy textbooks and journals. This area, however, has journals of
its own but they are not read by the prevention and psychotherapy commu-
nities. They are a separate area of intervention independent of talk-based
therapy.
The nonverbal medium is just not mentioned or used in psychotherapy.
L’Abate and Baggett (1997, pp. 315–322) reviewed many of the nonverbal
methods to improve behavior, and concluded: “The use of nonverbal behavior
for therapeutic and para-therapeutic purposes has had, thus far, limited appli-
cations in clinical circles” (p. 315). L’Abate and Baggett mentioned some
of the leaders who stressed the importance of using nonverbal techniques in
psychotherapy, like Virginia Satir, Frits Perls, Albert Pesso, Ida Rolf, William
Schults, and many others. L’Abate and Baggett also offered a rationale for
the use of nonverbal techniques in psychotherapy (pp. 316–317) and gave
examples of nonverbal exercises for groups of individuals, couples, and
families (pp. 318–321). Unfortunately, as far as this writer knows, the liter-
ature on nonverbal approaches to psychotherapy has not been validated by
research as much as the verbal medium, to the point that if positive results
are shown, they have been ignored by the prevention and psychotherapy
professions. A great many nonverbal techniques received validation by the
influence and mystique of a guru rather than by controlled evaluation. That
state of affairs is unfortunate because it decreases the options that can be
given to those who need help.
139
140 Section III Primary Nonverbal Approaches
Why has this area been neglected by prevention and psychotherapy oriented
professionals? In addition to the hypotheses raised by Rosenbaum (2005),
some possible answers come to mind. First, the history of psychotherapy
started with talk, and talk continued to be the preferred, if not the only, medium
of communication and healing over the last century, and spilled over into this
century. Second, it is easier to talk with someone in an office than to exhibit
behavior that would be contextually inappropriate, i.e., one would not dance
with a patient in one’s office. Third, while nonverbal methods of therapy
need to be integrated into the psychotherapeutic process, they, by definition,
do not fit into the promotional approaches. They are based on a prolonged
interaction with a professional, are expensive, and there is no knowledge
about how many of these techniques become self-administered, independently
of the presence and direction of a professional. Fourth, nonverbal behavior is
for children, and while therapies for children do stress the nonverbal medium,
adults do not need to be bothered with “childish” behavior.
In spite of these conclusions, there are indeed many nonverbal approaches,
as shown in this section. They are easy to learn, become self-administered
once the learning is completed, and last a lifetime.
References
L’Abate, L., & Baggett, M. S. (1997). The self in the family: A classification of
personality, criminality, and psychopathology. New York: Wiley.
Rosenbaum, D. A. (2005). The Cinderella of psychology: The neglect of motor control
in the science of mental life and behavior. American Psychologist, 60, 308–317.
7
Daily Practices for Mindful Exercise
Rachel Calogero and Kelly Pedrotty
The idea that participation in physical exercise is essential for a healthy body and
mind has been espoused in Eastern and Western cultures for thousands of years
(Dalleck & Kravitz, 2002). Contemporary scientific research has supported
this idea demonstrating that physical exercise can play a significant role in the
primary and secondary prevention of certain physiological and psychological
conditions including cardiovascular disease (Bassuk & Manson, 2003; Lee,
Hsieh, & Paffenbarger, 1995), Type II diabetes (Chipkin, Klugh, & Chasan-
Taber, 2001), cancer (Knols, Aaronson, Uebelhart, Fransen, & Aufdemkampe,
2005), osteoporosis (Kohrt, Snead, Slatopolsky, & Birge, 1995), sleep distur-
bances (Montgomery & Dennis, 2002), negative mood (Arent, Landers, &
Etnier, 2000), depression (Byrne & Byrne, 1993; Dunn, Trivedi, Kampert,
Clark, & Chambliss, 2005), anxiety (Byrne & Byrne, 1993; Long & van
Stavel, 1995), psychological stress (Norris, Carroll, & Cochrane, 1992;
Throne, Bartholomew, Craig, & Farrar, 2000), low self-esteem (Fox, 2000),
and all-cause morbidity and mortality (Blair et al., 1989; Manson et al., 2002).
Despite this wealth of evidence that physical exercise can protect against a
wide variety of human ailments, the relationship between exercise behavior
and health is not always so positive. There is a dark side to exercise that is
often masked by its social and scientific sanctioning as good for health. When
an unhealthy relationship with exercise develops, physical and mental health
can be compromised instead of optimized. This chapter presents a broadened
conceptualization of unhealthy exercise that extends previous definitions of
the phenomenon. First, the nature of unhealthy exercise as mindless exercise
is considered, and its concomitant dangers are delineated. Second, the nature
of healthy exercise as mindful exercise, and programmatic efforts to foster
it, are described. Finally, this chapter concludes by offering some guidelines
and techniques for the practice of healthy, mindful exercise at the individual
and community level.
What is Unhealthy Exercise?
“I work at 100 % all the time push as long and as hard as I can.”
Previous research on unhealthy exercise has applied such labels as “exercise
addiction” (Adams & Kirkby, 2002), “exercise dependence” (Hausenblaus &
Downs, 2002), “obligatory exercise” (Davis, Brewer, & Ratusny, 1993),
141
142 Rachel Calogero and Kelly Pedrotty
or “excessive exercise” (Shroff et al., 2006) to describe the maladaptive
or disordered behavior. A common quality shared by these conceptualiza-
tions is a compulsion to exercise, which often stem from addiction/abuse
models (Steinberg, Sykes, & LeBoutillier, 1995; Veale, 1995) or individual
psychopathology (Davis et al., 1993; Pasman & Thompson, 1988). If we
compare unhealthy exercise patterns to other behavioral disorders such as
pathological gambling, indeed the similarities are apparent. Table 7.1 lists
the criteria for pathological gambling modified for unhealthy exercise based
on the fourth edition of the Diagnostic and Statistical Manual for Mental
Disorders (DSM-IV; American Psychiatric Association, 1994). Based on these
modified criteria, it is clear that unhealthy exercise can follow patterns of
addiction, dependence, obligation, and excessiveness (Davis, 2000).
We propose, however, that unhealthy exercise can take many other forms.
Unhealthy exercise extends beyond frequency/intensity-based descriptions of
activity to include a variety of other contexts in which exercise may or may not
be undertaken (e.g., Robison, 2000; Taylor, Baranowski, & Sallis, 1994; Trost,
Owen, Bauman, Sallis, & Brown, 2002). These contexts refer to the particular
nature, meaning, and purpose of exercise for the individual, and they consider
the social and cultural forces influencing exercise behavior. Engagement in
exercise behaviors encompasses psychological and social components as well
as physical components. Individuals’ thoughts, feelings, and behaviors related
to exercise are shaped by a multitude of social and cultural influences that act
upon them all the time (Otis & Goldingay, 2000; Rejeski & Thompson, 1993).
Thus, instead of pathologizing the individual in regard to their exercise, we
emphasize the various contexts in which this “pathology” has arisen and is
maintained.
Unhealthy Exercise in Context
Exercise-relevant contexts can include, but are not limited to, an individual’s
exercise history, physical condition, emotional experiences, belief systems,
social relationships, ecological factors, and sociocultural pressures. For
example, exercising without proper nourishment and hydration or in
Table 7.1. DSM-IV criteria for pathological gambling modified for unhealthy
exercise
•Feel preoccupied with exercise (think about it when not exercising).
•Feel a need to exercise with increasing amounts of time in order to achieve satis-
faction.
•Have an inability to control your exercise use.
•Feel restless or irritable when attempting to cut down or stop exercising.
•Use exercise as a way of escaping from problems or of relieving a poor mood
(feelings of helplessness, guilt, anxiety, or depression).
•Lie to family members or friends to conceal the extent of involvement with exercise.
•Jeopardize or risk the loss of a significant relationship, job, educational, or career
opportunity because of exercise.
•Keep returning to exercise after spending an excessive amount of money on exercise-
related expenses.
•Go through withdrawal when not exercising (increased depression, anxiety).
•Exercise longer than originally intended.
•Why don’t I want to go to dancing with my friends?
Chapter 7 Daily Practices for Mindful Exercise 143
unsafe environmental conditions would be considered physical contexts that
constitute unhealthy exercise. This is demonstrated by an avid cyclist who
reported cycling in a severe rain storm because he could not continue his
day without his scheduled workout. Avoiding exercise because of feelings
of shame or guilt would be considered an emotional and social context that
constitutes unhealthy exercise. This is demonstrated by an avid exerciser who
reported that she no longer exercised because she had lost her “ideal” body
shape and “ruined” her exercise regimen, and therefore could not face others
who knew her as the “exerciser.” Exercising for the sole purpose of weight
loss would be considered a cognitive and sociocultural context that constitutes
unhealthy exercise. This is demonstrated by a woman who reported doing
calisthenics in the bathroom of an airplane after she ate because she believed
she would gain weight otherwise.
This broadened conceptualization of unhealthy exercise that considers
various contexts for exercise behavior is significant particularly for identi-
fying patterns of unhealthy exercise and the development of intervention
and treatment protocols. First, asking questions about these various contexts,
and not only about the quantity of exercise, can provide a more compre-
hensive picture of an individual’s experience with exercise. Second, by
following a context-based model, treatment efforts can focus on changing
the contextual factors contributing to the unhealthy exercise, and actually use
the exercise itself as a therapeutic tool as it becomes redefined over time
(Hays, 1999). This is in contrast to behavioral treatment protocols that tend
to focus on reducing and ultimately eliminating the abusive behavior. Third,
these contextual factors can be applied to understand the unhealthy exercise
behavior and particular exercise issues of people across age, ethnic, and weight
spectrums. Fourth, this approach does not ignore the pervasive, overarching
cultural context perpetuating beliefs and/or myths about exercise. Currently, in
many Western cultures, particularly American culture, there exists an almost
religious fervor toward being fit, which has essentially normalized unhealthy
exercise attitudes and behaviors (Otis & Goldingay, 2000; Robison, 2000).
Media messages are saturated with promises of achieving the ultimate combi-
nation of weight loss, health, and happiness by performing the “right” exercise
program: “Six-Pack in Six Days!” or “Lose 10 lbs. in 10 days!” or “Tone
Your Way to Happiness!” These messages about fitness and exercise are
distorted, confusing, and dangerous, and they do not consider the specific
needs of individuals. Even the exercise prescriptions put forth by estab-
lished authorities on fitness can be considered arbitrary and change regularly
(Corbin, LeMasurier, & Franks, 2002). Not surprisingly, however, individuals
consider these valid sources for determining their exercise goals, practices,
and possibilities. It seems virtually impossible to disentangle the influences
of the multiple contexts contributing to unhealthy exercise behavior. In order
to understand the scope and impact of unhealthy exercise, it seems critical
to address the historical, psychological, social, and cultural contexts that
foster it.
Unhealthy Exercise is Mindless Exercise
Drawing from the work of Ellen Langer (1989), we have come to identify
many of these exercise-relevant contexts as fostering “mindless” exercise.
Individuals who mindlessly exercise approach it with particular beliefs about
144 Rachel Calogero and Kelly Pedrotty
why and how they should exercise that are based heavily on outcomes.
According to Langer this outcome orientation develops early, “From kinder-
garten on, the focus of schooling is usually on goals rather than on the process
by which they are achieved” (p. 33). A focus on outcomes fuels mindless
exercise by keeping individuals focused narrowly “out there” on what can be
gained, lost, fixed, numbed, quieted, or undone. Attention is directed toward
the outcome, and not the process of exercise itself.
An outcome orientation may explain the considerable dependence people
seem to have on fitness “experts” to tell them how to exercise. There is this
assumption that someone else (e.g., magazine models, people at the gym,
personal trainers) knows better than us about what our bodies need, how they
should look, and how they should feel regarding exercise. Importantly, this
reliance on others for how we should exercise fosters mistrust of our own
bodies’ preferences and needs related to exercise. Certainly, there are fitness
professionals who consider individual needs and promote mindful exercise,
but many people do not have direct or safe access to these resources (Wilson,
Kirtland, Ainsworth, & Addy, 2004). An outcome orientation may also explain
people’s adherence to rigid definitions for what constitutes exercise, thereby
contributing to individuals’ fundamentally distorted reasons for why they
should exercise and how they will exercise.
Mindless exercise as described throughout this chapter includes any of the
following experiential patterns: exercising solely for weight loss or reshaping
the body, self-punishment, affect regulation, acquiring “permission” to eat,
identity maintenance, in all or nothing patterns, in obsessive, rigid patterns,
surreptitiously, to avoid social interactions, when sick, in pain, injured, physi-
cally fatigued, malnourished, undernourished, and/or dehydrated, avoiding
exercise completely, being consumed with thoughts of exercise whether one
actually exercises or not, dreading it or feeling it to be a “chore,” and when
exercise presides over all other experiences. Together, the patterns described
above represent an overuse/misuse of the body and a disconnection between
the body and mind, which is referred to as “mindless” exercise.1
Based on this broadened definition, it is clear that mindless exercise
can be completely unrelated to the actual frequency or volume of exercise
undertaken. In fact, recent research has demonstrated that individuals who
experience frequent negative thoughts and feelings about exercise, but do
not actually exercise, report lower self-esteem, more depression, and more
disordered eating compared to individuals who frequently engage in exercise
without these negative thoughts and feelings (Ackard, Brehm, & Steffen,
2002). Thus, it is not the amount of exercise per se that contributes to an
1In determining the extent or severity of unhealthy exercise, it is important to consider
the consistency of the patterns and the length of time they have been experienced.
For example, individuals may have thoughts such as “I must go to the gym today to
make up for what I ate last night” or “I need to run to alleviate my stress” or “I just
need to do 10 more stomach crunches even though my back hurts.” Not everyone
who has had these thoughts practices unhealthy exercise. While these thoughts are
not part of a healthy, mindful mindset (to be discussed shortly), they may not reflect
the individuals’ overall approach to exercise, and should be considered along with the
other aspects of their exercise experience. However, depending on the context these
thoughts can lead to a distorted, mindless approach to exercise over time, and thus
should be considered seriously in the identification of unhealthy exercise.
Chapter 7 Daily Practices for Mindful Exercise 145
unhealthy relationship with exercise, but rather the particular mindset by
which the exercise is guided. Mindless forms of exercise may account for the
relatively low participation rate in regular physical activity despite its highly
popularized usage and promoted health benefits (Centers for Disease Control
and Prevention, 1995; Rosenberg, 1998).
To further illustrate this point, consider the exercise programs of the
following individuals: Case 1: Swimming, weight training, and cycling 4 hours
per day, 6 days per week. Case 2: Treadmill for 30 minutes and 200 stomach
crunches before bed, 7 days per week. Case 3: Yoga, weight training, and
racquetball or running, 4 days per week. Case 4: Aerobics classes, running,
and spinning 3 hours per day, 5 days per week. Case 5: Dance class 1 day
per week, walking 5 days per week, stretching most days per week. Can
you identify the unhealthy exerciser? Now, consider these cases again with
the following additional information. Case 1: History of being a competitive
athlete, no injuries, prioritizes proper nutrition, and “athlete” is not the primary
identity. Case 2: Severe anxiety and guilt if exercise is missed, no rest days
or variety, and dreads doing it. Case 3: Enjoys the activities, incorporates
variety, exercises with others, and no known negative affect associated with
it. Case 4: Exercise is primary focus, no rest days, no enjoyment, never feels
like it is enough, inadequate caloric intake to support the activities, and uses
it to avoid other social interactions. Case 5: Enjoys the activities, previous
history of exercise avoidance, feels good moving in body, and the focus is
not weight loss.
When presenting this simple illustration in workshops, Case 2 is most
often identified as the healthiest and Case 4 is most often identified as the
unhealthiest when the quantity of exercise is used to make the diagnosis.
However, the additional information tells a different story and in fact, Case 2
is just as unhealthy as Case 4 even though their quantities are not comparable.
Case 3 and Case 5 are actually the healthiest based on the overall quality
of their exercise experience. Case 1 also appears healthy, but it is critical
to probe athletes about their genuine pleasure and enjoyment, which is often
assumed just because they continue to participate in a sport. In sum, the
nature, meaning, and purpose of the exercise expands the scope and impact of
unhealthy exercise considerably (Calogero & Pedrotty, 2004; Cox & Orford,
2004), and warrants the development and implementation of more specific
intervention efforts.
Prevalence and Consequences of Mindless Exercise
“I like the pain. I want to feel the pain. If I can’t exercise, I cut.”
The generally accepted views of exercise as good and beneficial place exercise
in a different category from other types of behaviors, thus making it difficult
to identify a problem (de la Torre, 1995; Tanji, 2000). In fact, unhealthy
exercise practices are often viewed as disciplined and not disordered. In
addition, the literature is plagued with different labels and definitions for
the phenomenon (Hausenblas & Downs, 2002). However, some evidence
does exist from community and clinical samples suggesting that other factors
besides quantity constitute unhealthy exercise, and that unhealthy exercise is
a significant problem.
146 Rachel Calogero and Kelly Pedrotty
Emphasizing the multidimensional nature of obligatory exercise, Ackard,
Brehm, & Steffen (2002) demonstrated an association between negative
emotionality and exercise as the best predictor of disordered eating,
depression, and self-esteem. Based on self-reports of the exercise frequency,
exercise fixation, and exercise commitment among 586 college women, a
remarkable 42 % of this sample were identified as having a dysfunctional or
unhealthy relationship with exercise: Almost half of this sample of college-
aged women engaged in mindless forms of exercise. Recent research by Jon
Mond and colleagues has attempted to refine the definition of “excessive
exercise” for the purposes of the treatment and prevention of eating disorders.
In a community sample of women aged 18–45, exercise related to (a) changing
appearance or body tone and (b) feeling guilty about missing an exercise
session were the two qualities most strongly associated with eating disor-
dered behavior and reduced quality of life (Mond, Hay, Rodgers, Owen, &
Beumont, 2004). Based on these criteria, 14.2 % of 169 women were identified
as excessive exercisers. Notably, the self-reported frequency of exercise was
unrelated to disordered eating and quality of life. Replicating these findings in
a larger general population sample, 17 % of 3,472 women aged 18–42 reported
either exercising solely to influence appearance (i.e., weight, shape, or body
tone), guilt about missing an exercise session, or both of these qualities,
indicating their “excessive exercise” (Mond, Hay, Rodgers, & Owen, 2006).
Again, notably, the self-reported frequency of exercise was unrelated to disor-
dered eating and physical and mental health.
This research underlies the importance of the quality of the exercise,
and in particular people’s motivations for participating in exercise. Research
examining the relationships between exercise motives and psychological well-
being has demonstrated that extrinsic (or outcome-based) exercise motives
(e.g., social recognition, changing appearance) are significantly related to
poorer psychological well-being whereas intrinsic (or process-based) exercise
motives (e.g., feeling revitalized, personal enjoyment) are significantly related
to better psychological well-being (Maltby & Day, 2001). Adkins and Keel
(2005) examined the distinction between the quality versus the quantity
of exercise as they relate to disordered eating symptoms in a sample
of college students. These researchers demonstrated that appearance-based
motives for exercising were associated with higher levels of drive for
thinness, bulimic symptoms, body dissatisfaction, and other disordered eating
patterns compared to nonappearance-based motives (Adkins & Keel, 2005).
Furthermore, in appearance-based exercisers, it was the quality of the exercise
behaviors, and not the quantity of the exercise itself, that was associated with
eating pathology. For nonappearance-based exercisers, neither compulsive
nor excessive exercise predicted eating pathology. An additional interesting
finding in this research revealed that health and fitness motives for exercising
were associated with less disordered eating, but a greater compulsion to
exercise. While health and fitness motives may be considered intrinsic
motives, it is clear from this research that these intrinsic motives do not
foster better psychological well-being with regard to exercise attitudes and
behaviors. Thus, at first glance, intrinsic motives for exercise may seem
“healthy,” but may actually stem from an outcome-based orientation toward
exercise that can be masked by the ubiquitous messages that indiscriminately
link “exercise” and “health.” Together, these findings suggest that outcome-
based exercise motives such as exercising for the purpose of weight loss,
Chapter 7 Daily Practices for Mindful Exercise 147
changing appearance, or social approval negatively affect people’s psycho-
logical well-being and contribute to disordered eating patterns.
Pathological patterns of exercise have been implicated in the etiology,
development, and maintenance of eating disorders since the early 1970s
(Beumont, Arthur, Russell, & Touyz 1994; Brewerton, Stellefson, Hibbs,
Hodges, & Cochrane, 1995; Bruch, 1973; Davis, 2000; Davis et al., 1997;
le Grange, & Eisler, 1993; Shroff et al., 2006; Thompson & Sherman,
1992; Yates, 1991). Clinical studies have estimated that the prevalence of
“excessive” or high-level exercise in individuals diagnosed with inpatient
eating disorder populations varies between 33 and 100 % (Calogero &
Pedrotty, 2004; Davis, Kennedy, Ravelski, & Dionne, 1994; Davis et al.,
1997; Katz, 1996). In a 10-year follow-up study of 95 participants with
anorexia nervosa, the compulsion to exercise at discharge predicted earlier
relapses and chronic pathological outcomes (Strober, Freeman, & Morrell,
1997). High levels of total and aerobic exercise reported by participants
with eating disorders have been significantly related to high levels of drive
for thinness and longer periods of hospitalization (Solenberger, 2001). In
a sample of 254 women in residential treatment for eating disorders, 40 %
of the women reported that their unhealthy exercise behavior preceded the
onset of their eating disorder, with some identifying the onset of excessive
types of exercise as early as 11 years old (Calogero & Pedrotty, 2004). In a
sample of 1,857 women across subtypes of eating disorders, 39 % of the entire
sample met criteria for excessive exercise (Shroff et al., 2006), which was
defined as interference with important activities, exercising more than 3 hours
per day, inappropriate times and places for exercise, and exercising despite
injury, pain, or illness. In this sample, the highest prevalence of excessive
exercisers (54 %) was indicated for the purging subtype of anorexia nervosa.
Thus, although the definitions vary, mindless forms of exercise appear to be
prevalent to varying degrees in both community and clinical populations.
Other Negative Consequences
It is perhaps not surprising that engaging in mindless exercise places
individuals at risk for a multitude of physical injuries. A non-exhaustive list of
these dangers includes stress fractures (Burr, 1997), non-fatal, often disabling,
injuries (Plugge, Stewar-Brown, Knight, & Fletcher, 2002), decreased immune
function (Fry et al., 1994), osteopenia and osteoporosis (Golden, 2002), and
even death (Davis 1997). Anecdotal reports from women communicated to the
authors illustrate the permanent physical damage that can result from mindless
exercise. For example, a collegiate runner who continued to run every day
despite persistent knots and cramps in her legs damaged her leg muscles so
severely that she will never be able to run again. A middle-aged woman
reported doing thousands of stomach crunches every day in an effort to obtain
a flat stomach, and eventually damaged the protective skin surrounding her
spine to the point of causing permanent damage to her lower back.
Beyond the direct influence of mindless exercise on the body, when the
focus of the exercise is outcome-based compared to process-based it can
place people in dangerous or unsafe situations. Although there is little to
no documented research about these physical dangers related to unhealthy
exercise, the case example below illustrates their significance in the lives of
mindless exercisers.
148 Rachel Calogero and Kelly Pedrotty
Robin often woke up at 4 a.m. and went for a 5–10 mile run. Instead of staying in
bed with her husband who she rarely saw because of their work schedules, Robin
would run, regardless of the weather or season. Although the paths and streets she ran
were not completely desolate, she said that it was almost always dark when she began
running, and she felt uneasy being alone. She remembers her heart racing many times
when she heard a car slow down behind her. On several occasions, men, presumably
intoxicated, yelled obscene remarks or whistled/called to her. She admitted that more
than once she barely avoided being hit by a drunk driver. However, she believed
firmly that nothing “bad” would actually happen to her.
By rigidly adhering to the same routine for purposes clearly unrelated to
genuine physical health and well-being, the case of Robin and many others
illustrates the serious effects of mindlessness on personal safety and awareness
of environmental threats and/or dangers.
Although lacking in empirical research, individuals have provided anecdotal
reports to the authors describing the deleterious effects of mindless exercise
on their social relationships, including relationships with partners, children,
parents, siblings, friends, and/or co-workers. For example, a woman reported
that she exercised for 3 hours every day on her honeymoon. When prevented
from exercising, she became irritable and fought with her spouse. In another
example, a married couple admitted that they spend most of their day
exercising, and they prioritize it over spending time with their daughter. In
sum, considering both the qualitative and quantitative evidence presented here,
mindless patterns of exercise are detrimental, and not beneficial, to health.
Instead, mindless exercise appears to be a significant problem that warrants
direct treatment independent of any concomitant eating-related problems
(Beumont et al., 1994; Calogero & Pedrotty, 2004; Solenberger, 2001).
What is Healthy Exercise?
“I have far more strength than I expected, and I have better access to that strength.”
Healthy exercise is conceptualized here as “mindful exercise,” which is based
on process and not outcomes (e.g., Douillard, 2001). The practice of mindful
exercise should adhere to the four basic principles outlined here. First, exercise
should be used to rejuvenate the body, not exhaust or deplete it. Second, exercise
should enhance mind–body connection and coordination, not confuse or dis-
regulatethe mind–body relationship. Third, exercise should alleviate mental and
physical stress, not contribute to and exacerbate stress. And finally, exercise
should provide us with genuine enjoyment and pleasure, not provide pain and
be dreaded. Approaching exercise with a mindful orientation should lead to
feelings of control, greater freedom of action, and less burnout (Langer, 1989).
The original development of these conceptions about healthy (mindful)
and unhealthy (mindless) exercise emerged out of a need to directly identify
and address the exercise issues of women in residential treatment for eating
disorders. Despite the significant struggles with exercise that women with
eating disorders often experience, disordered patterns of exercise have been
viewed often as symptoms that will subside with general eating disorders
treatment. As indicated above, Strober and colleagues (1997) have demon-
strated that this is clearly not the case. However, this common wisdom has
prevailed and it has prevented exercise issues from being treated specifically
Chapter 7 Daily Practices for Mindful Exercise 149
and systematically over time. The exercise program developed by the first
two authors (see Calogero & Pedrotty, 2004) provides women with eating
disorders the opportunity to experience, practice, and process exercise in new
ways. With guidance and supervision from Exercise Coordinators, the women
in the program are challenged in weekly group settings to sense, support, and
strengthen themselves through a variety of physical activities. One key focus
of the program is to enable the women to identify the differences between
mindful and mindless patterns of exercise, and actually practice new ways of
being physically active and moving in their bodies. A second key focus is
to raise their awareness of the various contexts that foster mindless exercise,
and how to change these contexts. A third key focus is to enable the women
to distinguish between what they like to do and what they experience as fun,
as opposed to what their eating disorder/unhealthy mindset “likes” to do, or
“tells” them to do. Normalizing an exercise program so that it is healthy and
beneficial requires a capacity to address internal needs rather than external
concerns. Over time, by learning to rely upon adequate rest and nutrition, and
working to develop self-respect and self-care, many of the women have been
able to make healthier, more mindful choices about their exercise.
The exercise principles and interventions utilized in populations with eating
disorders are applicable to everyone’s exercise experience, and therefore can
be extended to the broader population. Generally, almost any community
member can use these daily practices to challenge, change, and ultimately
circumvent unhealthy exercise in their own lives and the lives of others.
The remainder of this chapter describes the basic guidelines and techniques
that we have found to be most effective for promoting mindful exercise in
people’s lives.
The Practice and Process of Healthy Exercise
Sensing the Self
The first fundamental element of healthy exercise includes sensing the self.
Individuals who engage in mindless exercise are not utilizing exercise to
sense and stay connected to the body. Instead, exercise activities and environ-
ments are selected that direct people’s attention away from themselves and
not to how they feel during the activity itself. Individuals who are not sensing
themselves do not focus on breathing, do not know when to stop certain
movements or activities, and often compare themselves to others during
exercise. It is important that individuals pay attention to their own bodies,
which allows them to be aware of themselves experientially during periods of
physical activity. Sensing the self requires paying attention to how the body
feels while it is in action, and not only after it has acted.
Supporting the Self
The second fundamental element of healthy exercise includes supporting the
self. Individuals who engage in mindless exercise are not utilizing exercise
to support the body in a way that maintains their psychological and physical
balance. Instead, individuals adopt exercise practices that often serve only
one purpose or need, which is often the attainment of the goal (usually weight
150 Rachel Calogero and Kelly Pedrotty
loss). When balance is absent from an exercise program, it is difficult to
know how much exercise to do, which exercises are most appropriate for us,
when other social experiences should take priority, or how to fuel ourselves
with appropriate amounts of food. This, in turn, increases reliance on external
sources to guide our bodies instead of our internal experiences. For example,
Zoe, a former dancer, only considered dance-related activities to be exercise,
and her main goal was to be able to do a split again. She declined opportunities
to be active with friends (e.g., biking) because it was a waste of time for
her – it did not count as exercise. Attaining balance requires making mindful
choices about what activities (exercise and non-exercise) to incorporate into
our lives. Variety, flexibility, and enjoyment are key elements to supporting
the body with healthy exercise.
Strengthening the Self
The third fundamental element of healthy exercise includes strengthening the
self. Individuals who engage in mindless exercise are not utilizing exercise
to strengthen the body and mind. For some individuals, exercising is a
way to punish the body or to “beat up” the self. For other individuals, the
exercise performed does not foster their natural strengths, which can hinder
the potential for genuine enjoyment and satisfaction in the activity. And
still for other individuals, the label “exerciser” becomes the primary identity
(Anderson & Cychosz, 1995), which renders them vulnerable to feelings of
invalidity and inadequacy if they stray from their exercise routines. This
mindset serves to weaken, not strengthen, the body and mind over time. For
example, Ava belonged to the track team in high school and identified herself
as a runner. In college, Ava did not make the track team and decided to
continue running on her own. She admitted that running always felt like a
punishment, but she had to do it because she was a runner. Running inter-
fered with other social activities and she was often too exhausted to complete
her coursework. In this way, exercise served to drain and weaken her mind
and body over time. Individuals should be encouraged to engage in activities
because they enjoy them, not because they define them.
A Prescription for a Mindful Exercise Program
There is no magic number of calories, minutes, miles, laps, repetitions, or
classes. In fact, it would be contradictory to prescribe mindful exercise in
terms of numbers. Mindful exercise does not need to be counted. Instead,
building on the elements of sensing, supporting, and strengthening the self, we
prescribe that activities be selected based on the four components described
below: Function, Feeling, Fun, and Fuel. In order to self-monitor exercise
patterns and identify mindless exercise activities, it is helpful to create a
personalized exercise checklist. This checklist can be created by generating
a list of questions about one’s specific exercise activities. These questions
should address specific issues regarding whether the exercise works toward
sensing, supporting, and strengthening the self as well as identify how these
activities do or do not incorporate function, feeling, fun, and fuel in mindful
ways. Reviewing the checklist before and after exercise may help individuals
stay present and connected to their bodies, and avoid using exercise for
Chapter 7 Daily Practices for Mindful Exercise 151
Table 7.2. Examples of items for an exercise Checklist
•Do I want to exercise because of what I ate today?
•Is there another activity I would rather be doing today instead of exercise?
•What exactly would I like to be doing right now?
•Is today a rest day? What exactly would I like to do with my day?
•Am I feeling guilty because I do not think I am exercising enough?
•Am I avoiding exercise today because I am uncomfortable in my body?
•Do I want to go exercise alone so no one will interfere with what I do?
•Do I feel that if I cannot do everything I planned for exercising than I do not want
to do any of it?
•Did I enjoy this exercise the last time I did it?
unhealthy or mindless reasons. At the very least, asking questions related to
specific exercise issues before exercising requires a moment of pause. Even
if individuals continue to exercise in an unhealthy way, it may not be to the
same degree. The key to its effectiveness is answering honestly and following
through with behaviors that keep the self safe and strong. This checklist
should be reviewed regularly if struggling with unhealthy exercise patterns
and kept in a place where it is easily retrieved. Table 7.2 provides examples of
questions for an exercise checklist based on different types of exercise issues.
Function
Why we exercise determines and guides how we exercise. An important
message to propagate in the community is that the sole purpose of exercise
should not be weight loss (Burgard & Lyons, 1994; Gaesser, 2002). Research
has shown that not all exercising individuals will significantly reduce their
body weight (Gaesser, 2002). More recently, it was shown that exercise
can decrease total and abdominal body fat without observing corresponding
changes in measures of relative weight such as body mass index (Janssen et al.,
2004). Furthermore, debunking the “thinner is better” doctrine, researchers
have found that weight has little bearing on living a long life; it is about being
physically fit, not physically fat (Barlow, Kohl, Gibbons, & Blair, 1995).
Thus, the function of exercise in people’s lives should necessarily focus on
purposes other than weight loss. It is essential to shift from a passive weight
loss mindset to a more mindful reflection about what exercise can and cannot
bring to one’s life overall. Physical activities should be selected that support
a wide spectrum of physical and mental functioning, bring pleasure, and
enhance feelings of strength and self-competence.
Feeling
How we exercise determines and guides what we feel when we exercise. An
important message to propagate in the community is that physical activity
should connect us to our bodies, not disconnect us (Douillard, 2001). It is
especially important to select activities that minimize feelings of body dissatis-
faction, body shame, comparisons with others, guilt, and punishment; instead,
physical activities should foster natural strengths and abilities, and not require
self–other comparisons to feel good or worthwhile. By paying attention to
how the body feels, and how the exercise experience makes us feel, safer
decisions can be made in the moment about if and how we should exercise
on a particular day.
152 Rachel Calogero and Kelly Pedrotty
Fun
Being able to explore how we like to move in our bodies and what makes us
feel healthy and strong can be very empowering, and change our relationship
with exercise. An important message to propagate in the community is that
physical activity should bring pleasure, not pain. Many individuals do not
consider exercise to be fun. As we suggested earlier, this is partly because
the exercise being performed is not truly self-chosen and not a preferred
way of moving in one’s body. However, participation in exercise, and in
particular sports participation, has been associated with personal enjoyment,
personal growth, and improved social integration (Wankel & Berger, 1991).
By challenging and changing our rigid categories, or “preconceived cognitive
commitments” (Langer, 1989), about what constitutes real exercise, endless
possibilities for physical activity become available to us. Ultimately, greater
enjoyment can lead to greater adherence (Wankel, 1993) and reduced depen-
dence on numbers to tell us when to stop. See Table 7.3 for examples of fun
exercises suggested by former mindless exercisers.
Fuel
The dangers of exercising when the body is not properly fueled, hydrated,
or rested can include fatigue, injury, fainting, major organ failure, and even
death. Often individuals feel that exercising gives them permission to eat,
which reflects the outcome orientation of mindless exercisers. Being “in
shape” includes getting adequate nutrition (Otis & Goldingay, 2000). In order
to be safe and obtain the most physical and mental benefits from periods of
physical activity, the selected physical activities should include appropriate
nutritional support.
General Guidelines for Challenging and Changing
Mindless Exercise
In reality, we recognize that it can be difficult to incorporate the missing
pieces of sensing, supporting, and strengthening the self into our exercise
practices, and to challenge the barrage of societal messages and pressures
about what is and is not exercise. We offer some suggestions below about
how to begin identifying and challenging mindless exercise behavior in
Table 7.3. List of fun physical activities generated by
former mindless exercisers
Biking Roller blading Kite flying
Hiking Skiing Trampoline
Rock climbing Making snowpeople Nature walks
Playgrounds Apple picking Dancing
Gardening Walking pet Bowling
Yoga Swimming Kickboxing
Flag football Horseback riding Canoeing
Intramurals Ice skating Playing with kids
Jump rope Walking tours Volleyball
Raking Leaves Karate Tai Chi
Chapter 7 Daily Practices for Mindful Exercise 153
ourselves and others. Each suggestion is accompanied by references to actual
techniques that can be found in Tables 7.4 and 7.5 . Individual-level inter-
ventions are indicated with an “I” and group-level interventions are indicated
with a “G.” These guidelines can be modified to fit the needs of specific
participants, specific persons, or broader groups and communities. It is
important to remember that the overarching focus should be to help individuals
reclaim exercise for themselves by redefining and rediscovering it in a
mindful way.2
Explore exercise history to determine past and present experiences with
exercise. Examine individual reasons for exercising in the past and present,
which will help to understand the present mindset guiding the exercise.
Questions to ask include: What are your earliest memories of being physically
active? How would you describe your relationship to exercise up to this point?
After a workout, do you feel refreshed & energized? Do you feel present and
connected to how your body feels when you exercise? What types of exercise
do you do and what is the usual setting? Are you looking forward to the
activity again? The answers to these questions are important for determining
if exercise is undertaken for unhealthy reasons (#2I, 3I, 12G).
Educate about the specific dangers of mindless exercise and exercise myths.
It is necessary to discuss basic information about how the body uses food as
fuel for the heart, brain, and muscles – food is energy and we need it. Plan
activities around meals to insure proper fueling and refueling of the body.
Remember, we should eat to exercise, not exercise to eat! It is also necessary
to challenge exercise myths. It is important to consider the words that people
use to describe their exercise goals and experiences. We suggest deleting
these words from one’s exercise vocabulary: tone, sculpt, firm, shape, lift,
and tighten. These words reflect media hype and distort rather than clarify our
understanding about the actual structure and function of our bodies. Perhaps
one of the most pervasive exercise myths is that we can get “toned.” It is
important to understand that muscle tone refers to a muscle’s level of fullness
or firmness. Therefore, to be toned is to have muscle. It is often eye-opening
to tell individuals that if you are able to walk and do activities of daily living
your muscles already have tone. It should be stressed that everybody has
tone. This usually leads to challenging another pervasive exercise myth – that
muscle can turn into fat and fat can turn into muscle. Muscle and fat are
two separate types of body tissues and cannot be converted into the other
(e.g., Otis & Goldingay, 2000). Educating ourselves and others about exercise
facts and myths is essential to changing unhealthy exercise practices (#7I, 9I,
1G–13G).
Serve as a role model for safe and healthy exercise behavior. As members
of families, peer groups, communities, workplaces, and society, we transmit
2It is important to emphasize that it is not safe or appropriate for all individuals
who engage in unhealthy exercise to continue exercising. If individuals have been
diagnosed with an eating disorder or have reported disordered eating, are medically
compromised, not adhering to appropriate nutritional guidelines, or not changing their
mindless exercise behavior, then they may not be ready to benefit from participation
in the practices we have described here. In addition, exercise should not be provided
for the sake of exercising itself. This may actually contribute to the belief that exercise
is absolutely necessary despite weight or other health concerns, and thus may further
exacerbate the unhealthy exercise.
154 Rachel Calogero and Kelly Pedrotty
Table 7.4. Examples of individual-level interventions to challenge mindless exercise practices
Intervention Description Example
1. Exercise
World Draw the people, places, things,
feelings, thoughts, actions related to
exercise. Provides powerful, nonverbal
expression of exercise experience and
identifies specific targets for change.
2. Exercise
Journal Record thoughts and feelings before,
during, and after exercise. Provides
check-in and can redirect to healthier
behavior. Record thoughts about
specific topics or questions related to
exercise.
Reflect on questions such as: what have I
missed in my life because of exercise?
what do I feel unwilling to change and
why? what exercise issue did I struggle
with the most today?
3. Checklist Self-generated questions to ask before
exercise that are specific to the exercise
issues. Provides check-in and can
redirect to healthier behavior. Should
leave checklist next to sneakers or in
gym bag.
See Table 7.2.
4. Mindful
Reminders Post positive, informative, individualized
notes in strategic places to remind
about purpose of mindful exercise.
“I stop exercising when tired.” “I will
support my mind and body with fun
physical activity.” “I do not exercise to
burn calories.” “If I look at the time
more than 3 times I stop.”
5. Healthy
Buddy Exercising with a healthy person
encourages mindful exercise choices
and provides a role model.
Walk with friends, play volleyball, bring
buddy to gym. Be careful that you
choose someone who you will not
compare to.
6. Reframe
Goals Setting realistic goals that incorporate
mindful exercise principles can reduce
mindless exercise.
Make your physical activity goals about
enhancing your life overall instead of
just your physical self. Take a dance
class instead of running if you are not a
runner. Start a garden if you like to be
outdoors.
7. Ripped Rip out pages of fitness magazines that
contain triggering images (ads, tips,
interviews) and see what information is
left that would help guide healthy
exercise. Identify mindless exercise
messages. Reduce reliance on mindless
exercise information.
Magazines such as Shape, Fitness,or
Men’s Health work well here. They
depict unrealistic images of men and
women and offer conflicting and
unhealthy exercise tips. Be prepared to
offer evidence and information to
support your critiques.
8. Avoid
Triggers Identify activities that lead to mindless
exercise and stay away from them.
Selecting alternative, pleasurable
physical activities and contexts
enhances adherence to mindful exercise
principles.
Do not run on the treadmill if there is
constant competition between you and
the time or you and the person next to
you. Explore how you like to move in
different ways.
9. Fuel Up Fueling the body properly will reduce
fatigue and overall mindless exercise
tendencies, allowing the healthy
exerciser to feel more pleasurable.
Place snacks next to checklist, in car, in
gym bag, so they are easily accessible
before exercise.
10. Slow Pace Slowing the pace of activity, if possible,
when triggered by environmental cues
(e.g. other bodies, gym) can re-focus
attention to self and staying connected
to the body.
Close eyes whenever possible to focus on
the self. Change activity or stop it
completely if mindless thoughts and
feelings do not relent. Move more slowly
and intentionally, paying attention to all
body sensations. Remind self of
personal, mindful goals to keep focused.
Chapter 7 Daily Practices for Mindful Exercise 155
Table 7.5. Examples of group-level exercise interventions to challenge mindless exercise practices
Intervention Description Example
1. Trust Exercises Creates connection with self and
others through group and partner
work.
Partner squat, partner yoga, kneeling on
exercise ball.
2. Balance Exercises Directs attention toward being calm
and present while increasing mind
and body strength.
Bicep curls on a bosu ball, standing on
one foot, yoga.
3. Channel Aggression Provides safe outlet for negative
feelings so they are not directed
toward the self and can be shared
with others.
Ball slap, kickboxing, karate, tug of war,
yoga.
4. Conscious Cardio Use different senses to notice
surroundings and be present during
activity.
Smell flowers, listen to different sounds,
focus on the breath.
5. Cross-Training Creates variety and enjoyment while
strengthening body and mind. Basketball, swimming, gardening, yoga,
bike riding, dance, change activities
when you can.
6. Circuit Training By moving through different exercises
consecutively it reduces time, can
be at home or with friends, adds
variety.
Swimming, squats, kicks, core work,
jumping jacks, jump rope, yoga poses,
dance.
7. Touching Muscles Touching a muscle to feel it
engaged during exercise increases
connection to physical and overall
self.
Touch upper leg while sitting against
wall to feel quad muscles working.
8. Slow and Steady Moving with purpose and control
increases connection and focus on
form rather than momentum and
numbers.
Try to kneel on exercise ball.
9. Fun in the Sun Be active outside whenever possible
to increase fun and stay connected
to social world.
Take a long walk, play catch, rollerblade.
10. Recess Engage in activities that have positive
associations to enhance enjoyment
and get out of ruts.
Play on a playground, swing, jump rope,
run the bases, tag.
11. Numbers and Colors When doing repetitions, count random
numbers or use colors to avoid
obsessing.
17, 80, 44, 2, 53 or purple, red, green,
blue, yellow.
12. Process Talk to others before and after
physical activity about thoughts and
feelings experienced during the
activity.
After a run or playing ball, talk about
what thoughts/feelings arose and what
to repeat or change next time.
13. Breathe Creates mind–body connection by
maintaining a focus on the breath
throughout activity.
Practice watching and noticing breath to
monitor exertion and be mindful.
and reinforce social information about exercise. If we are uncomfortable with
our bodies, exercise mindlessly, or believe that exercise is really about weight
loss, then we cannot expect others to trust new experiences or new information
about exercise that we provide to them. In order to address mindless exercise
at a community level, it is first imperative to attain a shift in the individual’s
approaches to exercise. Expect resistance to debunking the myths such as “no
pain, no gain”, “more is better”, “cardio is the best form of exercise,” or “If
I take a day off I will loss my fitness level.” We cannot just tell others that
these are myths; we have to actually practice and model something different
156 Rachel Calogero and Kelly Pedrotty
for them to observe directly. By working alongside others, it is possible to
direct their attention to how their body moves and feels; and thus to how
healthy, mindful exercise feels. In the case with participants, a disingenuous
leader can be counterproductive to facilitating a new experience with exercise
(see Calogero & Pedrotty, 2004) (#6I, 1G–13G).
Raise awareness about societal pressures to attain unrealistic body ideals
and give permission to challenge these dangerous messages. Acknowledging
and addressing the societal contexts that promote thinness and obsessive
exercise is imperative. Practice critiquing sources of fitness information. If
others choose to continue reading fitness magazines, encourage them to use a
healthy filter. This may be difficult because a large portion of the information
presented is focused on weight loss and achieving unrealistic body shapes.
Remind them that the exercise tips and workout programs offered do not
consider individual needs, especially if the individual struggles with an eating
disorder. Individuals need to be aware that not all fitness professionals are
trained to identify unhealthy patterns of exercise and/or eating disorders.
Again, distinguishing between fact and fiction regarding exercise can help us
make better choices for our bodies and minds (#7I, 8I).
Incorporate the elements described above into your program of activity.
Expand the variety of activities that “count” as exercise. Remember – there is
no “best” exercise, only what is best for us. Visiting parks, dancing, hiking,
biking, walking, yoga, or just being outside, playing with children, or doing
yard work constitute exercise. Attempt to create a program that is fun, and
includes a variety of activities and other people. A mindful exercise program
allows for the unexpected so “workouts” can be missed (#1G–10G). Plan rest
days and stick to them! Rest is an essential component to a healthy exercise
program. The guidelines put forth by the American College of Sports Medicine
(ACSM) may provide a starting point if needed in regard to “appropriate”
amounts of exercise, but remember that general guidelines cannot address
specific exercise issues. These recommendations should be modified to fit the
needs of the individual, especially in regard to what exercise activities bring
the most pleasure (#1I, 3I, 4I, 6I, 8I, 9I, 1G–11G).
Identify triggering and non-triggering activities and environments. Triggers
can be any number of people, places, or activities that lead individuals to
mindlessly exercise. In these cases, the context needs to be changed. For
example, if the gym triggers unhealthy exercise thoughts and behaviors,
individuals should seek out other places for physical activity. These can be
wide-ranging and include yoga studios, dance classes, playgrounds, games
of kickball or softball, outdoor hikes, biking, sledding, playing with kids,
gardening, or walking. Recess-like activities are less likely to be triggering.
We cannot enjoy recess and simultaneously count calories or minutes or feel
inadequate too – at least not very easily. For another example, if conversations
about weight loss and obsessive exercising trigger negative thoughts, find
other people to converse with and seek out alternate places to meet people
who do not share this mindless mindset (#1I, 8I, 1G–13G).
Practice mindful exercise practices daily. Individuals will benefit from
listening to their bodies before, during, and after exercise. This will help
guide them toward what activities they want to do in the first place. Thoughts
and feelings can be recorded in an exercise journal and utilized to determine
if and how to exercise on any particular day. Individuals should also practice
Chapter 7 Daily Practices for Mindful Exercise 157
avoiding comparison with others about exercise. Remember that focusing
on others leads to minimizing one’s own skills, achievements, and body’s
needs. Closing one’s eyes can help redirect attention to the self and away
from comparison with others. An emphasis should be placed consistently on
redefining and re-experiencing exercise. Individuals should be encouraged to
experiment with what activities make them feel good and to try new things
(#2I, 5I, 8I, 10I, 5G, 9G, 10G).
Conclusion
“My whole life I have been used to killing myself. It feels so good to know I can stop.”
This chapter extends previous conceptualizations of unhealthy exercise
by incorporating the role of multiple contexts into the identification of
unhealthy exercise. Furthermore, unhealthy exercise is recast as mindless
exercise, with an emphasis on being outcome-oriented versus process-oriented
in our approach to exercise. Considerable evidence exists demonstrating that
mindless exercise can compromise physical and mental health. We may
reduce these dangerous exercise patterns by (a) recognizing the contexts in
which mindless exercise is fostered and challenge them, (b) redefining healthy
exercise as mindful, and (c) re-experiencing exercise in a way that sustains the
body and mind. Efforts toward increasing mindful approaches to exercise may
reduce unhealthy exercise practices as well as improve health and exercise
adherence across diverse groups and communities.
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