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February 2007 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Marsden, P., Karagianni, E. and Morgan, J. F. [Division of Mental Health, St George's University, London, UK]. "Spirituality and clinical care in eating disorders: a qualitative study." International Journal of Eating Disorders 40, no. 1 (January 2007): 7-12.

[This month's featured article is available on-line as a manuscript from the Spirituality and Psychiatry Special Interest Group of the Royal College of Psychiatrists, along with a response. Note, however, that the page numbers given below are not to this on-line manuscript but to the printing in the International Journal of Eating Disorders.]


SUMMARY and COMMENT: This small, qualitative study out of the UK is featured this month partly because of its findings but also because of its suggestion of the potential for similar and further research by chaplains. The eating disorders, anorexia and bulimia, have complex psychodynamics into which spirituality may figure as either a harmful or helpful factor, or both. The potential for chaplains to explore this area with patients seems great, and qualitative research methodology--a fairly "natural" approach for chaplains--may be particularly appropriate here due to the importance of identifying deep issues in personal narratives and beliefs affecting eating behaviors. However, in pursuing qualitative research, chaplains should take to heart the authors' exhortation of "methodological rigor": "Issues of validity, reliability, and generalisability are comparable to those of quantitative studies, and it is crucial that researchers seek to falsify emergent hypotheses by theoretical sampling and awareness of deviant cases…" [p. 11].

The study population consisted of ten Christian women receiving medical treatment: nine for anorexia nervosa (six and three for restricting and binge eating, respectively) and one for bulimia nervosa (purging). Individual, audio taped interviews, lasting approximately 80 minutes, covered "background information, history of [the] eating disorder, religious background, current religious practice, perception of God, attitudes to emotions, attitudes to sin, attitudes to penance, influence of faith, [and] opinion of this research" [p. 8]. The purpose was to "to examine the relationship between eating disorders and religion, and the impact of that relationship on treatment" [p. 7].

From interpretative phenomenological analysis (described in a box on p. 9), five themes emerged: Locus of Control, Self-Image, Sacrifice, Salvation, and Maturation. Each theme is illustrated with quotes from the interviews. For instance, regarding Self-Image:

Negative self-image was common to all participants. While denigratory views of body image were unsurprising[,] [p]articipants more often grappled with the moral dimensions of self-image in a spiritual framework…. Shame, guilt, and self-hatred were recurring themes:
"Whenever I do things wrong, I think of it as being a sin…. [Emphasis is original to the text.] Sometimes I wonder if it is wrong to feel hungry. If I am hungry before I think I should do, then that seems like a sign of weakness and that means I am greedy." (Participant 10, aged 18, anorexia nervosa – restrictive type)
In their struggle for control of unruly sensations and emotions, perceived as "sinful," some participants had welcomed the regulations of their church or the supposed attitudes of an authoritarian God. This was particularly true for those who used impulsive behaviors such as alcohol abuse or self-harm. However, when they were unable to live up to the supposed standards of their God figure, their sense of guilt, shame, and failure was exacerbated.
"By that time I was in a bit of a mess, but I mean I was in a mess inside with guilt… I knew what I was doing was not in accordance with the church’s rules… I knew I wasn’t really living right." (Participant 8, aged 48, anorexia nervosa-binge eating type).
This sense of shame sometimes led to a desire for self-punishment or reparation through sacrifice. [p. 9 --Note: This passage contained printing errors that have been avoided in this excerpt.]

Of special interest to this reader was the theme of Maturation, inasmuch as it touches on the dynamic of spiritual change --a key element in Spirituality & Health research..

In the early stages of illness, some saw self-starvation as God’s will but, surprisingly, several participants came to see the eating disorder itself as displeasing to God:
"But now I look back I realize that I must have got all that wrong because it isn’t God. God doesn’t want you to destroy yourself or starve yourself to death…. Maybe I’ve grown up a bit in that relationship I suppose." (Participant 9, aged 56, anorexia nervosa-restrictive type)
…Prayer provided a dialogue and healing relationship with God. For some, the search for meaning through prayer and through psychotherapy led to maturing of religious ideas:
"It’s (relationship with God) changed a lot since I’ve been here (treatment) actually because my relationship with my dad’s changed… there is a lot more acceptance…now and a lot less battle, a lot more understanding both ways…. Before I think I would just expect to be punished." (Participant 1, aged 28, bulimia nervosa – purging type) [p. 10]

Among other findings, the authors report that "[s]ome participants struggled to disentangle religious practice from illness," and they suggest that "[p]astoral counseling and involvement of hospital chaplaincies may assist in placing religious experience in context, 'neither rejecting it out of hand, nor accepting it completely at face value' [p. 11. Emphasis is original to the text. The quote is from Sutherland, M., "Mental illness or life crisis? --A Christian pastoral counseling contribution," in Bhugra, D., ed., Psychiatry and Religion --Context, Consensus and Controversies (London: Routledge, 1996, pp. 214–230.)] They also encourage the use of chaplains in the concluding paragraphs of the article.

Another note about the findings: the authors say that their study "challenges two basic preconceptions in the existing literature":

First, religious beliefs did not generally translate into sexual guilt. Second, it was more common for participants to view their eating disorder as against God’s will and "sinful" than as a display of virtue. [p. 11]
Of course, conclusions from such a small study must be taken with caution, and the article does address some of its limits [--see p. 11].

This research begs for follow-up, and chaplains who work in hospitals with eating disorder programs should find good opportunity for replication and expansion of this work --perhaps in partnership with other researchers in psychiatry, nursing, and nutrition. The five themes identified by Marsden, et al. would seem reasonable points from with to build a fuller picture role of spirituality in eating disorders and vice-versa. A longitudinal study might track how spiritual/religious changes may occur during treatment and the effectiveness of any spiritual component of that treatment. For further descriptive research, chaplains might be well suited as interviewers, but parlaying this study into interventional research might place chaplains in the middle of a treatment program itself.


Suggestions for the Use of the Article for Discussion in CPE: 

Discussion could begin around one of the five themes identified in the research, and CPE students may well gravitate toward the theme of "Locus of Control" in terms of the authority issues in patients' histories and the potential dynamic of understanding God as a "disciplinarian" [p. 8]. Students might be asked to think about how patients can be motivated by moral issues to adopt unhealthy behaviors. They could also be challenged to think about how their trained attentiveness to personal narratives during pastoral visitation, together with their capacity to deal with moral content, may allow them to play an important part in an interdisciplinary team with patients suffering from eating disorders. The article presents a good opportunity to invite a guest physician, nurse, or counselor with experience with eating disorders, as students may have questions about anorexia or bulimia as physical and psychological conditions. In terms of research, students should look carefully at the brief description of the study's "protocol for data analysis" [p. 9] and consider what the authors mean by their comment about "methodological rigor" and the need for researchers to "seek to falsify emergent hypotheses" [p. 11] in the process of data analysis.


Related Items of Interest: 

I. For research on the role of spirituality in weight management, including issues of obesity, see the September 2005 Article-of-the-Month.

II. A good many articles on spirituality and eating disorders have been published in recent years by people connected with the Center for Change (1790 North State St., Orem, UT 84057), including:

Hardman, R. K., Berrett, M. E., and Richards, P. S. "Spirituality and ten false pursuits of eating disorders." Counseling and Values 48, no. 1 (October 2003): 67-78. [The authors of this article are experienced health care providers and researchers who here offer general reflections on the role of spirituality in eating disorders in light of their work with more than 350 patients over seven years at the Center for Change. In a table on pp. 74-75, they line out counseling suggestions. The authors indicate that they have a special sensitivity to members of the Church of Jesus Christ of Latter-Day Saints, but they state that their suggestions for counseling should be "generally suitable for Christians, Jews, and Muslims, and other clients who believe in God and who see their relationship with God as important to their personal spirituality" (p. 68). The article is a good companion piece to the research articles from the Center for Change.]

Richards, P. S., Berrett, M. E., Hardman, R. K. and Eggett, D. L. [Brigham Young University, Provo, UT;]. "Comparative efficacy of spirituality, cognitive, and emotional support groups for treating eating disorder inpatients." Brunner-Mazel Eating Disorders Monograph Series 14, no. 5 (October 2006): 401-415. [(Abstract:) Spiritual interventions are rarely used in contemporary treatment programs and little empirical evidence is available concerning their effectiveness. The purpose of the present study was to evaluate the effectiveness of a spiritual group intervention for eating disorder inpatients. We compared the effectiveness of a Spirituality group with Cognitive and Emotional Support groups using a randomized, control group design. Participants were 122 women receiving inpatient eating disorder treatment. Patients in the Spirituality group tended to score significantly lower on psychological disturbance and eating disorder symptoms at the conclusion of treatment compared to patients in the other groups, and higher on spiritual well-being. On weekly outcome measures, patients in the Spirituality group improved significantly more quickly during the first four weeks of treatment. This study provides preliminary evidence that attending to eating disorder patients' spiritual growth and well-being during inpatient treatment may help reduce depression and anxiety, relationship distress, social role conflict, and eating disorder symptoms.]

Richards, P. S., Smith, T. B., Schowalter, M., Richard, M., Berrett, M. E. and Hardman, R. K. [Department of Counseling Psychology, Brigham Young University, Provo, UT;]. "Development and validation of the Theistic Spiritual Outcome Survey." Psychotherapy Research 15, no. 4 (October 2005): 457-469. [The article reports reliability and validity data on a 17-item instrument, originally tested on a sample of college students but then subsequently administered "over an 8-week period to a sample of inpatient women with eating disorders and to two samples from inpatient psychological clinics in Germany" (--from the abstract).]

Smith, F. T., Hardman, R. K., Richards, P. S. and Fischer, L. "Intrinsic religiousness and spiritual well-being as predictors of treatment outcome among women with eating disorders." Brunner-Mazel Eating Disorders Monograph Series 11, no. 1 (Spring 2003): 15-26. [(Abstract:) This study investigated the relationship of religious orientation, religious affiliation, and spiritual well-being with treatment outcomes in an eating disorder inpatient treatment program. Participants were 251 women diagnosed with an eating disorder. Gain scores on the Eating Attitudes Test, Body Shape Questionnaire, Outcome Questionnaire 45.2, and therapist improvement ratings were used as outcome measures. Multiple regression analyses revealed that neither intrinsic religiousness nor religious affiliation were associated with treatment outcomes. Pearson correlations revealed that improvements in spiritual well-being during treatment were significantly associated with positive gains in eating attitudes, less body shape concerns, and positive psychological and social functioning.]

Smith, M. H., Richards, P. S. and Maglio, C. J. "Examining the relationship between religious orientation and eating disturbances." Eating Behaviors 5, no. 2 (May 2004): 171-180. [(Abstract:) The relationship between religion and eating concerns is receiving increasing empirical attention. The current investigation sought to examine the relationship between eating attitudes and religious orientation, utilizing the fourfold typology of religious orientation. A curvilinear relationship was found between religious orientation and eating attitudes among a subclinical college population and a clinical population of individuals receiving inpatient treatment for eating disorders, particularly among extrinsically orientated individuals with diagnosis of bulimia nervosa.]

III. Other articles on spirituality/religion and eating disorders:

Grenfell, J. W. "Religion and eating disorders: towards understanding a neglected perspective." Feminist Theology: The Journal of the Britain and Ireland School of Feminist Theology 14, no. 3 (May 2006): 367-387. [(Abstract:) This article seeks to explore a neglected perspective in pastoral theology: namely that of the influence of conservative family culture and church practice on the spiritual, emotional, and physical development of young Christian women, particularly in the area of disordered eating patterns and negative self-image. It shows the ways in which hidden tensions, particularly within somewhat marginal Christian communities, or for groups which seek to define themselves strongly against prevailing secular cultural norms, can play themselves out in the inner conflicts of vulnerable young women. Such conflicts often centre on their difficulties in trying to define themselves in relation to their family and culture when they may have neither the opportunity nor the language to articulate the burden of such hidden conflicts. The author suggests models of pastoral care which involve working with Christian tradition and scriptural narratives to help Christian communities, and particularly women within them, to redefine assumptions about female roles and norms, and to develop a more open and physically grounded spirituality.]

Joughin, N., Crisp, A. H., Halek, C. and Humphrey, H. "Religious belief and anorexia nervosa." International Journal of Eating Disorders 12, no. 4 (December 1992): 397-406. [This older study is cited in this month's featured article. (Abstract:) This study examines aspects of the relationship between religious belief and anorexia nervosa. It uses data from postal questionnaires sent to members of a U.K. national self-help organization for people with "eating disorders" which elicited a profile of symptoms and other clinical data arid information about personal and family religious beliefs. The data suggest that the majority of respondents were or had been afflicted With anorexia nervosa. Subjects with a religion, particularly those with strong beliefs, and particularly those who were Anglican, reported particularly lowest ever adult Body Mass Indices (BMIS). Part of the explanation for these findings would seem to be an increase in the importance of subjects' religious beliefs during their anorectic illness. Conversely, bulimic symptomatology seemed to be associated with a weakening of subjects' beliefs. Religious conversion seemed to serve as a protective function against severe weight loss.]

Miles, M. R. "Religion and food: the case of eating disorders." Journal of the American Academy of Religion 63, no. 3, Thematic Issue on "Religion and Food" (Autumn 1995): 549-564. [This not a report of research but an essay by the Harvard University Divinity School Professor of Historical Theology, and its import stems largely from the academic authority of its author. Professor Miles places eating disorders within a context of historical Christian practice and of a theory of a social need for ritualized fasting. She ultimately criticizes media images that lead women to want to be thin, but she does so in light of an assessment of a lack of symbolic resources for nurturing an "interior life" that were once--and could once again--be supplied by religion. The essay seems at points a bit dated (e.g., in its contemporary references), but it may be interesting to many chaplains, especially Christians, thinking about possible conceptual groundwork for understanding the connections between spirituality and eating disorders.]

Morgan, J. F., Marsden, P. and Lacey, J. H. "'Spiritual starvation?': a case series concerning Christianity and eating disorders." International Journal of Eating Disorders 28, no. 4 (December 2000): 476-480. [This was the study upon which our featured study is largely based. (Abstract:) METHOD: We describe the cases of four patients with eating disorders in whom complex interactions occurred among religious faith, pathogenesis of the eating disorder, and clinical management. RESULTS: In some of the cases, religious beliefs seemed to provide a containment of maladaptive behaviors, partly through prayer and through a sense of belonging to the religious community. In other cases, it proved difficult to separate the concept of a punitive God from the illness process. DISCUSSION: The cases are discussed with reference to a limited empirical literature. Similarities are noted between some religious institutions and eating disorder treatment regimes. This paper explores management issues, including the use of pastoral counseling and the ethics of addressing religious beliefs in therapy. We note the benefits of a rapprochement between psychiatry and religion.]

Watkins, J. A., Christie, C. and Chally, P. [Department of Public Health, College of Health, University of North Florida, Jacksonville, FL]. "Relationship between spiritual well-being and binge eating in college females." Eating & Weight Disorders: EWD 11, no. 1 (March 2006): 51-56.. [(Abstract:) The aim of this study was to examine the relationship of spiritual well-being in college female non-binge, objective binge and binge-trait eaters. Therefore, this study aimed to measure spiritual well-being in non-binge, objective binge and partial/full-syndrome binge eating disorder college females. Survey research was conducted using a randomized sample of 809 female students. The sample was categorized into three binge eating categories: nonbinge, objective binge, and binge eating trait. Chi-Squares and Analysis of Variance determined binge eating group differences on demographics, global spiritual well-being, religious well-being, and existential well-being. Significant differences were found among groups for global spiritual well-being (p< or = 0.000), religious well-being (p< or = 0.000), and existential well-being (p< or = 0.000). Higher levels of binge eating severity were associated with lower global spiritual and existential well-being scores. On measures of religious well-being, significant differences existed between the non-binge and the binge eating trait groups. The results suggest that spiritual well-being and especially existential well-being may be indirectly associated with the severity of binge eating.]


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