A Theistic Spiritual Treatment for Women With Eating

Disorders
m

P. Scott Richards
Center for Change, Orem, Utah and Department of
Counseling Psychology, Brigham Young University
m

Melissa H. Smith and Michael E. Berrett

Center for Change, Orem, Utah
m

Kari A. OGrady and Jeremy D. Bartz

Department of Counseling Psychology, Brigham Young
University

The authors describe a psychological treatment for women with

eating disorders who have theistic spiritual beliefs and illustrate its
application with a case report. They begin by briefly summarizing
a theistic view of eating disorders. Then they illustrate how a
theistic approach can complement traditional treatment by describing
the processes and outcomes of their work with a 23-year-old
Christian woman receiving inpatient treatment for an eating
disorder not otherwise specified and a major depressive disorder
(recurrent severe). & 2009 Wiley Periodicals, Inc. J Clin Psychol: In
Session 65:172184, 2009.
Keywords: spirituality; eating disorders; psychotherapy; theistic;
inpatient

Introduction
Theistic psychotherapy encompasses a theistic conceptual framework, a body of
religious and spiritual therapeutic interventions, and guidelines for implementing
that framework and those interventions (Richards & Bergin, 2005). The foundations
Correspondence concerning this article should be addressed to: P. Scott Richards, 340M MCKB,
Department of Counseling Psychology, Brigham Young University, Provo, Utah 84602;
e-mail: scott_richards@byu.edu

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 65(2), 172--184 (2009)

& 2009 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20564

A Theistic Spiritual Treatment for Women With Eating Disorders

173

of theistic psychotherapy are grounded in the worldview of the major theistic world
religions, including Judaism, Christianity, and Islam. The core assumptions of this
strategy are that God exists, that human beings are the creations of God, and that
there are unseen spiritual processes by which the link between God and humanity is
maintained (Bergin, 1980, p. 99). It also assumes that God is active in the history of
the world and in the lives of human beings (Richards & Bergin, 2005).
The theistic strategy is integrative in that spiritual interventions can be
combined in a treatment-tailoring fashion with a variety of mainstream theoretical
orientations, including psychodynamic, behavioral, humanistic, cognitive, and
systemic. The strategy is empirical in that it is grounded in research about
psychotherapy and spirituality, and submits its claims to empirical scrutiny (Smith,
Bartz, & Richards, 2007). The strategy is ecumenical in that it can be applied with
clients from diverse religious traditions. Finally, the strategy is denominational in that
it leaves room for therapists to tailor treatment with clients from specic religious
denominations.
The theistic strategy assumes that clients who have faith in Gods healing
power and draw upon the spiritual resources in their lives during psychological
treatment will receive added strength to cope, heal, and grow (Richards
& Bergin, 2005). Theistic psychotherapists, therefore, may encourage their clients
to explore how their faith in God and personal spirituality may assist them during
treatment and recovery. In implementing a spiritual approach in therapy, theistic
psychotherapists seek to (a) demonstrate multicultural spiritual sensitivity by
being open to and accepting of diverse spiritual perspectives; (b) establish a
spiritually open and safe therapeutic relationship and give clients explicit permission
to discuss spiritual issues if they wish; (c) set spiritual goals in psychotherapy in
mutual collaboration with their clients; (d) conduct religious and spiritual
assessments to better understand their clients worldviews, cultural backgrounds,
and presenting problems; and (e) implement spiritual interventions in therapy
to facilitate clients spiritual growth and healing. Examples of spiritual interventions
include encouraging clients to pray, discussing theological concepts, using
spiritual imagery techniques, encouraging repentance and forgiveness, consulting
with religious leaders, and recommending religious bibliotherapy (Richards
& Bergin, 2005).
A Theistic View of Eating Disorders
Our eating disorder treatment approach is grounded in current research ndings and
accepted clinical guidelines (American Psychiatric Association [APA], 2006), as well
as in theistic understandings of personality and psychopathology (Richards &
Bergin, 2005; Richards & OGrady, 2007; Richards, Hardman, & Berrett, 2007). We
integrate a nondenominational theistic spiritual emphasis into our multidimensional
approach, which is suitable with patients from a wide variety of religious
backgrounds. During treatment, we encourage patients to explore their own
spiritual beliefs and to draw upon their faith to assist in their recovery (Richards et
al., 2007).
From our perspective, several of the core struggles in eating disorders are spiritual
in nature (Richards et al., 2007). For example, we have observed in our clinical work
that almost all women with eating disorders have lost touch with their sense of
spiritual identity and worth. They lose the ability to see and afrm the various
aspects of their identity (e.g., daughter, mother, friend, artist, athlete), but they see
Journal of Clinical Psychology

DOI: 10.1002/jclp

174

Journal of Clinical Psychology: In Session, February 2009

themselves exclusively as an eating disorder, or as the expression of an eating

disorder. For example, a 22-year-old former patient wrote:
My eating disorder robbed me of my relationship with God. I was in a
personal anguish that shred my soul and threatened my spiritual and
mortal life. I felt no love and saw no mercy. Anger consumed me. I felt
abandoned and worthless. My heart turned bitter and hard. I cut God out
of my life completely. My eating disorder robbed me of my self-worth. I
felt like nothing. I could not feel love, for I was unlovable. I could not give
love, for I was incapable. I lost my self-respect and went against all I
believed to be true. It was a downward spiral that almost led to my death.
Women suffering from eating disorders often feel distant and far removed from
Gods inuence and love. They often feel unworthy, unlovable, and incapable. They
lose their ability to feel connected to family and friends. As their relationship with
God and with family and friends deteriorate, they rely ever more exclusively on their
eating disorder as their way of coping with pain and problems (Richards et al., 2007).
They may also struggle with negative images of God, fear of abandonment by God,
guilt and shame about sexuality, reduced capacity to love and serve, and dishonesty
(Richards et al., 1997).
Women with eating disorders may also pursue one or more of the 10 dysfunctional
beliefs listed in Table 1. For example, they may erroneously believe that their eating
disorder will give them a positive sense of identity, or that it will help them gain
Table 1
False Beliefs of Eating Disorder Patients and Therapeutic Goals
False belief

Therapeutic goal

My eating disorder will give me a sense of Help patients afrm other aspects of their identity, including
identity.
their spiritual identity as creations of God.
My eating disorder will give me approval Help patients understand the differences between approval
from others.
and love and to recognize and accept love from God and
others.
My eating disorder will give me control of Help patients give up unhealthy efforts to control and
my life and emotions.
develop their capacity to be vulnerable without giving up
their choices.
My eating disorder will effectively
Help patients more effectively communicate their pain and
communicate my pain and suffering.
suffering.
My eating disorder will make me
Help patients accept their inherent uniqueness.
exceptional.
My eating disorder will prove that I am
Help patients accept their goodness and worth.
bad and unworthy.
My eating disorder will make me perfect. Help patients accept their human limitations.
My eating disorder will give me comfort
Help patients seek comfort and safety from others and God.
and safety from pain.
My eating disorder will compensate or
Help patients seek forgiveness from others and God.
atone for my past.
My eating disorder will allow me to avoid Help patients accept responsibility for their lives.
personal responsibility for life.
From Spiritual Approaches in the Treatment of Women with Eating Disorders, by P. S. Richards, R. K.
Hardman, and M. E. Berrett, 2007. Washington, DC: American Psychological Association. Copyright
2007 by the American Psychological Association. Adapted with permission.
Journal of Clinical Psychology

DOI: 10.1002/jclp

A Theistic Spiritual Treatment for Women With Eating Disorders

175

approval from others, or that it will give them control over their emotions and life.
Such unhealthy beliefs become the objects of their faith and attention, contributing
to their feelings of alienation from Gods healing inuence and from the supportive
inuence of other people. In a spiritual sense, therefore, these beliefs become objects
of worship that undermine their spirituality and relationships (Hardman, Berrett, &
Richards, 2003).
A major goal of our theistic approach is to help women with eating disorders afrm
their spiritual identity and worth as creations of God. As patients learn to listen to and
discern spiritual feelings that can be accessed through their heart or spirit, they
discover or rediscover their sense of identity as spiritual beings. We refer to the heart
as a metaphor for the eternal spiritual identity (Richards & Bergin, 2005). Learning to
trust their heart, or their spiritual feelings, is a process of discovery for patients. When
patients are engaged in the false pursuits of an eating disorder, they have difculty
paying attention to spiritual feelings because the false pursuits consume all of their
thoughts, energy, and time. Helping patients challenge their false beliefs can free them
up to pay attention to and reconnect with their spirituality.
Table 1 summarizes the therapeutic goals we pursue when we encounter each false
belief. For example, when a patients whole sense of identity revolves around
maintaining her eating disorder, we afrm other aspects of her identity, including her
spiritual identity as a creation of God. When a patient believes that her eating
disorder will win her approval from others, we help her understand the differences
between approval and love and encourage her to recognize and accept love from
God and others. When a patient believes that an eating disorder will give her control
of her life and emotions, we help her give up unhealthy efforts to be in control and to
develop her capacity to be vulnerable without giving up her choices.
Case Illustration
Presenting Problem/Client Description
The patient, Amy was a 23-year-old, single, Caucasian woman from Arizona. Amy
was the youngest of four siblings in an intact marriage and indicated that all three
siblings were male. Amy reported that spirituality was important to her and that she
wanted it integrated into her treatment. She said that religion was also important to
her, stating that she was raised in, and afliated with, the Episcopal Church.
Amy struggled with signicant eating concerns since age 12. She presented for
inpatient and residential treatment with the following chief complaint: Ive
struggled with food, eating and horrible body image for over a decade and Im
sick of it. Amy indicated that she was tired of obsessing about food and body
image, and indicated that it has been difcult to progress in her life due to her eating
concerns.
During her childhood and early adolescence, Amy had a conicted relationship
with her mother, a distant relationship with her father, and contentious relationships
with her siblings. Amy denied any physical or sexual abuse within the family. She
reported witnessing screaming ghts between her father and siblings, and
indicated that this contributed to the distant and fearful relationship she had with
her father.
Amy also experienced difcult interpersonal interactions from an early age outside
the family environment. She had difculty making and maintaining friendships; she
Patient name and other identifying details have been changed to protect her condentiality.

Journal of Clinical Psychology

DOI: 10.1002/jclp

176

Journal of Clinical Psychology: In Session, February 2009

became known as a mean girl, and was typically impulsive and reactive. She also
reported repeated molestation by a same-age male friend between the ages of
57 years old.
Somewhat surprisingly, Amy described her religious community during her
childhood as a place where she felt belonged. According to Amy, her family was
actively involved with their religious community, participating in weekly religious
services, social activities, and educational programs. Amy said the experiences in her
religious community helped her feel like she belonged to a community of worshipers
in a common cause and to her Higher Power.
Between the ages of 1214, Amy engaged in several sexual encounters, which she
described as misguided attempts at receiving love, attention, and acceptance. One of
these was a sexually abusive experience in that it occurred with a 19-year-old high
school student, although Amy viewed it at the time as a consensual experience.
Rumors about Amys sexual encounters caused Amy to feel ostracized among her
peers within her religious community. The sexual abuse and ostracism increased
Amys feelings of alienation and worthlessness. In addition, Amy described a history
of major depression, which began during this time.
When she was 14, Amys family moved cross-country, and she experienced
signicant loss, including the loss of her social network, her religious community,
and the regular presence of her father due to his travels. These changes, coupled with
Amys sense that her body was betraying her with its pubertal changes seemed to
intensify Amys feelings that she did not belong and was not accepted.
Amy did feel some relief that with the move she would receive a second chance to
redeem herself from the sexually promiscuous reputation that had contributed to
the ostracism she had experienced in her prior community. Soon after moving, Amy
became actively involved in a Christian youth group and vowed to become a good
girl. Amy sought to put the past behind her by turning to her God and the youth
group as a source of strength and direction.
Unfortunately, Amy had difculty integrating with the Christian youth group and
eventually disengaged from it because the moral standards espoused by the group
intensied Amys feeling of shame about the sexual encounters in her past. Thus,
although Amy had turned to her Higher Power for acceptance, comfort, and
belonging, as a result of the youth group experience, she ended up feeling more
ostracizednot only socially, but also in her relationship with God.
During this time of increasing social and spiritual alienation, Amy also
became more deeply entrenched in several of the false beliefs of her eating
disorder. Amy felt her body was betraying her with its pubertal changes. Could
she trust her body? Could she trust her Higher Power, who was responsible
for creating her body? Could she trust her Higher Power who in her own
self-judgment had rejected her? Amy decided she could not. She came to believe
that she could only rely on the eating disorder for comfort and acceptance. Amys
binging and purging behavior increased signicantly as did her restricting behavior
and overexercising.
At age 16, Amy was date raped by an older male friend. Although Amy reported
that her brothers beat up the male who raped her, Amy still felt blamed because of
the incident and more ostracized from her family and alienated from her Higher
Power. The rape also intensied Amys eating disorder symptoms and she began
using illicit drugs as a weight control measure. Amys behaviors increasingly
became out of control, and according to Amy, her parents were at a total loss of how
to help her.
Journal of Clinical Psychology

DOI: 10.1002/jclp

177

A Theistic Spiritual Treatment for Women With Eating Disorders

During this time of her life, Amy reported ghting more and more with her
mother, and her father remained a distant and elusive character that Amy felt had
high, unrelenting standards. Amy also continued to struggle in her social
relationships. Perhaps Amys worst fears were realized when she was removed
entirely from her family and placed in several different treatment settings. It is sadly
ironic that although Amy pursued thinness as a way of connecting with and
belonging to her family, her pursuit of thinness ultimately led to a physical, and in
many ways, emotional removal from her family.
Prior to her admission to the Center for Change, a private inpatient facility in
Orem, Utah, Amy received residential treatment on several occasions for alcohol and
drug abuse. She reported that her eating disorder ared up again during the course
of her most recent substance abuse treatment and was disrupting her daily
functioning. Upon the recommendation of her treatment team at the substance
abuse treatment facility, and her own recognition that additional treatment was
necessary, Amy sought specialized residential treatment for her eating disorder.
Case Formulation
Amy was 5 feet 9 inches tall and weighed 172.2 lbs at admission (fully dressed). Amy
was engaging in severe caloric restriction, exercising approximately 2 hours per day,
abusing diet pills and laxatives on a daily basis, and binging and purging 78 times
per week. Further, she reported intense negative body image concerns, and
depressive and anxiety symptoms. The dietician estimated Amys Body Mass Index
(BMI) at 25.4, which was slightly above the normal BMI range. The dietician also
noted that Amy had dry and breaking hair, dry and blotchy skin, sore throat,
bloated stomach, gas and constipation, leg and neck cramps, and migraines and
dizziness.
Amys physical, cardiac, and neurologic exams were unremarkable, although a
urine drug screen was positive for cocaine metabolites. Her menstruation was
regular, but was sometimes heavy with cramps. Amy was taking 450 mg per day of

Table 2
Amys Scores on Psychosocial Measures at Admission and Discharge From the Center for
Change
Psychosocial test
EAT
BSQ
OQ-45.2
Total score
Symptom distress
Relationship distress
Social role conict
SWBS
Religious well-being
Existential well-being

Normal range

Admission score

Discharge score

78

15

o30

190

119

o110

107
59
28
20

74
41
16
17

o63
o39
o15
o13

56
40

53
46

447
443

Note. EAT 5 Eating Attitudes Test; BSQ 5 Body Shape Questionnaire; OQ-45.2 5 Outcome
Questionnaire; SWBS 5 Spiritual Well-Being Scale. The normal range score estimates are based on
normative data.
Journal of Clinical Psychology

DOI: 10.1002/jclp

178

Journal of Clinical Psychology: In Session, February 2009

Wellbutrin XLs (GlaxoSmithKline, Mississauga, Ontario, Canada) at the time of

admission. This dosage was continued throughout her inpatient stay.
Amy completed a battery of standardized psychosocial tests upon admission and
at discharge, including the Eating Attitudes Test (EAT; Garner & Garnkel, 1979),
Body Shape Questionnaire (BSQ; Cooper, Taylor, Cooper, & Fairburn, 1987),
Outcome Questionnaire (OQ-45.2; Lambert & Burlingame, 1996), and Spiritual
Well-Being Scale (SWBS; Paloutzian & Ellison, 1991). Amys score on these
instruments at admission and discharge are presented in Table 2. Amy was
experiencing clinically signicant levels of eating disorder symptoms and behaviors
(e.g., restricting, binging, purging, preoccupation with food; EAT); body image
concerns (BSQ); and symptoms of depression, anxiety, substance abuse, relationship
distress, and social role conict (OQ-45.2). Although Amys responses to the
religious well-being scale of the SWBS seemed to indicate that she perceived that
God cared about her and supported her, it became clear during her therapy sessions
that her feelings about her relationship with God were actually very conicted and
negative. Her existential well-being scores on the SWBS were below normal,
suggesting that she was also experiencing dissatisfaction with the direction and
purpose of her life.
Her diagnosis by her psychiatrist and psychologist according to the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American
Psychiatric Association, 1994) on Axis I were eating disorder NOS (not otherwise
specied), major depressive disorder (recurrent severe), cocaine abuse, and attentiondecit/hyperactivity disorder, predominantly inattentive type. Amys Axis II
diagnosis was deferred; her Axis III was recurrent migraine headaches. Her Axis
IV was stressors in primary support system and academic stressors; Amys global
assessment of functioning (GAF; Axis V) at time of admission was 40 (major
impairment in several areas, including work, school, family relations, judgment,
thinking, and mood).
Course of Treatment
Amy was treated for 24 weeks at the Center for Change, a private inpatient facility
that specializes in intensive treatment for women with eating disorders. The
multidisciplinary treatment staff includes physicians, psychiatrists, psychologists,
marriage and family therapists, clinical social workers, registered nurses, registered
dieticians, certied teachers, and chefs. Approximately 80% of the treatment staff is
women and about 50% of the staff is members of The Church of Jesus Christ of
Latter-day Saints (LDS or Mormon). The remaining staff members adhere to a
variety of spiritual traditions, including Protestant Christian, Jewish, and Muslim
perspectives and a variety of nonreligious spiritual viewpoints.
Like all patients at Center for Change, Amy was given permission to explore
spiritual issues related to her recovery during her individual psychotherapy sessions.
She was invited (but not required) to attend a weekly spirituality group and read a
self-help workbook, which included scriptural and other spiritual readings and
educational materials about topics such as faith in God, spiritual identity, grace,
forgiveness, repentance, and overcoming adversity.
Amys individual psychotherapist during her stay was Dr. Melissa H. Smith (a
psychologist) and her spirituality group therapist was Dr. Michael E. Berrett (a
psychologist). Amy received approximately 75 individual sessions with Dr. Smith
and approximately 20 spirituality group sessions with Dr. Berrett. Amy also
Journal of Clinical Psychology

DOI: 10.1002/jclp

A Theistic Spiritual Treatment for Women With Eating Disorders

179

participated in group psychotherapy, experiential and expressive activities (e.g.,

music, art, movement, and yoga therapies), family counseling, nutrition monitoring
and counseling, medical evaluations and treatment, and education classes (e.g., diet
and nutrition).
At the beginning of individual psychotherapy, Dr. Smith focused on building a
strong, secure, and trusting therapeutic alliance with Amy wherein she could safely
explore attachment concerns. Care was spent in understanding Amys history, her
perceptions of her past, and her insights about herself, her struggles, and her
strengths for recovery. Considerable time was also spent exploring Amys earliest
relationships, especially those within her family. Her history suggested enmeshment
with her mother, emotional removal from her father, and isolation from her siblings.
Through her therapy sessions, Amy also began exploring a family and cultural focus
on body image, weight loss, presenting as perfect, and receiving attention for ones
looks.
Direct invitations were given to Amy to look at particular segments of time in her
life, view those times as an unbiased observer and without judgment, and reect
on the learning, beliefs, and decisions she experienced, linking those to current life
patterns of thought, belief, and behavior. Amy came to recognize as she explored her
feelings during therapy sessions, and through journaling assignments, that once her
belief that she did not belong took root it grew and strengthened with time.
Everywhere she went, Amy had sought out and found evidence of how she was
different, how she did not belong, how she was unacceptable. In a dysfunctional
effort to feel more belonging, Amy increased her efforts to be thin, popular, and
attractive. As Amys efforts to be accepted became more extreme, she identied
herself as a bad girl and acted out sexually. Thus, already feeling unacceptable,
over the course of puberty Amy came to feel unworthy as well.
Over the course of her eating disorder, Amy had come to believe that the eating
disorder would give her approval from others. To challenge this mistaken belief,
Amys therapists helped her recognize and accept love from God and others. This
was done in several ways, including exploring the difference between worldly
approval for appearance and performance versus Godly acceptance and love, which
is unconditional. In addition, Amys therapists helped her understand that love and
connection changes lives, and that it is by turning to relationships that real healing is
found, whereas seeking approval for appearance or performance does not.
As Amy explored her life during her therapy sessions, she saw the correlation
between feeling increasingly disconnected from family and friends, on the one hand,
and the disconnection from her Higher Power, on the other. From an attachment
perspective, given that Amy felt rejected by her parents, it is not surprising that her
feelings of rejection and not belonging would extend to other relationships and to
other attachment gures, including her Higher Power (OGrady & Richards, 2007).
Amy openly shared her feelings of alienation, disconnection, and loneliness with
her parents during family sessions. This honest sharing helped her not only feel more
connected to them, but also helped her feel more connected to herself. During the
beginning stages of therapy, Dr. Smith continually pointed out the many ways Amy
made herself the exception. Although she could freely give love and care to others,
Amy believed that she was undeserving of such love and care, not only from others,
but from her Higher Power. Amy was afraid of seeking spiritual connection with her
Higher Power out of fear that her belief would be conrmed.
Amy also reported her belief that she was unworthy to engage in religious or
spiritual activities. During one session, Amy expressed her belief that she was
Journal of Clinical Psychology

DOI: 10.1002/jclp

180

Journal of Clinical Psychology: In Session, February 2009

unworthy to pray. She said that she felt that prayers should be reserved for other,
more worthy individuals. She stated that though all other humans on the earth had
worth and value, she was an exception, and that as such, she should not waste her
Higher Powers time with prayers and devotion. Amy was confronted gently and
regularly in session every time she verbalized that she was the exception. She was
asked to verbally correct her unhealthy view of herself as an exception to a view of
being of great worth and value.
Signicant therapeutic work was needed to help Amy overcome her feelings of
worthlessness and unlovability and her fears of reaching out to her Higher Power.
This work started with helping Amy understand that she was not an exception.
Cognitivebehavioral techniques assisted Amy in challenging illogical thinking, all
or nothing thinking, and exception-making thoughts. Over time, Amy came to know
that she is no better or worse than anyone else.
Dr. Smith helped her make a connecting link between her feelings of unworthiness
and the rejecting interactions from family and peers, the trauma of the date rape and
other sexual abuse she had experienced, and from her own cognitive distortions, and
worked to challenge Amys belief that she was unworthy. Dr. Smith pointed out the
potential ways Amy misunderstood her Higher Power, and taught Amy that,
consistent with her spiritual values, there was love and comfort to be experienced in a
relationship with God. Dr. Smith asked Amy questions such as the following:
Who is God? What do you believe about God? Given your beliefs about
God, how do you think you are perceived? Is God cold and rejecting? Is God
set on punishing you for past sins? Is God a potential source of comfort and
love? Given your spiritual beliefs, what do you understand about your worth?
These questions helped Amy to challenge her beliefs that she was her eating
disorder, that she had no spiritual identity, and that she was the exception to Gods
love and care.
As Amy challenged her beliefs about such questions, she began to make a
signicant shift in her perspective of her Higher Power. She began to challenge her
ingrained belief that her Higher Power had rejected her and found her unworthy.
Amy began to see how she had misunderstood her Higher Power, and that there was
love, comfort, and care to be experienced in a relationship with God. This increased
Amys desire to use spiritual practices as part of overcoming her eating disorder
behaviors. Amy began praying, meditating, reecting on Gods love, journaling
about spiritual experiences, and reading scriptures and other spiritual works. Amy
learned to treat herself as if she were worthy and worthwhile, even in those times
she did not feel the same. Over time as Amy engaged in these spiritual practices her
sense of spiritual connection with God, and her feelings of worthiness grew and
stabilized.
Dr. Smith and Dr. Berrett also sought to help Amy see how her identity
had become enmeshed with an eating disorder, and to assist Amy in
separating herself from this identity. As her therapists pointed out the emptiness
and sadness of life with the eating disorder, Amy gained a desire to change her
identity.
Dr. Smith and Dr. Berrett helped Amy afrm her spiritual identity by encouraging
Amy to seek spiritual conrmation of her worth as a creation of God. Both of her
therapists helped Amy see that the part of her that struggled with an eating disorder
was not her complete identitythere was so much more to Amy than her eating
disorder. Both of Amys therapists helped Amy to recognize that who she is more
important than what she does.
Journal of Clinical Psychology

DOI: 10.1002/jclp

A Theistic Spiritual Treatment for Women With Eating Disorders

181

Part of Amys progress came through helping her recognize spiritual promptings
and impressions. Dr. Smith gave specic attention during individual therapy sessions
to assisting Amy in developing more sensitivity to spiritual feelings, promptings, and
impressions as a way of afrming her worth and accepting love. Dr. Smith and Amy
discussed Amys beliefs about the nature of prayer. These discussions helped Amy
clarify her beliefs about the purpose of prayer and how prayers might be answered.
As Amy learned to discern spiritual feelings, she was given opportunities for solo
experiences where she had extended time to herself for spiritual exploration,
including prayer, use of spiritual imagery, and review of spiritual readings. She also
completed spiritually focused assignments, including writing about the nature of
God and individual worth, writing a letter from God to herself and from herself to
God, and writing a letter of forgiveness to herself.
On one of her solos, as she pondered and reected about her worth and
relationship with God, Amy experienced afrmation on a deep spiritual level that
she is loved by God. This experience became a touchstone of healing for Amy. She
was repeatedly able to recall and refer to it as she faced challenges and periodically
questioned her worth. During painful times during treatment, Amy reminded herself
of this and other spiritual experiences, of the times she felt spiritually connected, of
the times she felt deep peace and comfort.
As Amy matured spiritually, she was asked to identify and develop her spiritual
values and beliefs to be used as guideposts in recovery and her life. As she did so, she
realized that some of these beliefs were different from those held by her parents.
Although initially she feared being different from her familywhat would this mean
for her desire to be connectedshe eventually decided she must live by these values
even in the face of her fear of family rejection. Through consistent challenges to be
congruent and live with integrity, Amy found an increase in self-respect.
As Amys relationship with God grew, she also began cultivating other
relationshipsrelationships based on honesty, trust, and love. Amy no longer
wanted to reject others care, but rather desired to embrace it, accept it, and use it as
a foundation for shifting her perception of herself. These important relationships
included her parents, her therapist, and other patients. Through assigned and selfinitiated moments of asking for and accepting help, and expressing care through
word and deed to others, the maturity of her relationships increased.
Amy used her newfound connection with her Higher Power as a healing balm in
her relationship with her parents. Amy was asked to develop patience and
understanding for her father. Over time, she was able to recognize his efforts to
connect with her and the challenges he faced in this process. She continued to feel
sorrow for the losses in the relationship, but through learning patience, forgiveness,
and mindfulness, she was able to let go of her anger and resentment. Amy also
learned through therapy to set healthy boundaries with her mother, while afrming
and appreciating her mothers love and concern. She forgave and accepted the good
her parents offered, despite their imperfections.
Outcome and Prognosis
During the course of treatment, Amy continued to struggle at times with
reoccurrences of her eating disorder and substance abuse. Amys behavioral
relapses occurred at times of transition from dependence to more autonomy,
most notably during home passes from the treatment center, when Amys coping
skills would break down during sustained interactions with her parents. However,
Journal of Clinical Psychology

DOI: 10.1002/jclp

182

Journal of Clinical Psychology: In Session, February 2009

Amy found constant strength in her relationship with her Higher Power. As she
developed personal values founded on her spiritual beliefs, Amy made denite
progress.
At the time of her discharge from residential treatment to outpatient
psychotherapy, Amy had improved in many ways, but still had signicant behaviors
to address. Physically, Amy was functioning normally. She weighed 169 lbs and her
BMI was 24.7 (normal range). Amy was no longer engaging in binging, purging, or
the use of diet pills, laxatives, drugs, or alcohol. Consistent with this, Amys scores
on the EAT at discharge were in the normal range (Table 2). According to her
dietitian, Amy had expanded her choice of foods to meet her nutrient needs, felt
comfortable eating with family and friends, and overall, had developed a
controlled, healthful food intake.
The dietitian noted that Amy still had some tendencies to resort to over exercise
and using diet foods to control her weight. Dr. Smith concluded that Amy
continued to have signicant ruminations regarding weight loss and body image, but
she was able to manage them appropriately. Amys scores on the BSQ at discharge
had declined, but still fell within the abnormal range, which indicated signicant
concerns about her body weight and shape.
Amy made substantial progress in reducing depressive and anxiety symptoms,
although she still struggled with them. Her scores on the OQ-45.2 had declined
considerably, but they were still clinically elevated. Amys relationship with her
parents improved during treatment, but was still not without conict at times. Amys
scores on the SWBS indicate that she viewed her relationship with God positively
and these scores were now more consistent with what she reported during therapy
sessions. Her sense of life purpose and direction had also improved.
After much trepidationfor both Amy and her parentsshe transitioned to the
less-structured environment of outpatient therapy. Amy periodically checked in
with Dr. Smith through telephone calls and e-mails to give updates about her
postdischarge progress. Amy reported increasing condence in her ability to manage
eating disorder urges and reported that outpatient therapy continued to focus on her
underlying attachment concerns. In one e-mail, Amys excitement was palpable as
she described a successful home visit in which she fully connected with her parents
without sabotaging the relationships or feeling rejected. Amy reported that she
attended religious activities with her parents, engaged with them meaningfully, and
shared her spiritual beliefs with themthough they were different from her
parentswith condence that she could be an independent adult with safe,
meaningful, and secure relationships.
Clinical Issues and Summary
Amy struggled with a number of clinical and spiritual problems that we often
observe in women suffering from severe eating disorders. First, Amy experienced
feelings of rejection and alienation in her relationships with her parents, siblings, and
peers. In addition to her chronic feelings of rejection and alienation, Amy had
experienced several severe traumatic events in her adolescence (e.g., repeated sexual
abuse, the date rape). These contributed to Amys feelings of spiritual disconnection,
and unworthiness in her relationship with her Higher Power and religious
community. Furthermore, Amy came to believe that the pursuit of thinness through
her eating disorder was the only solution to her feelings of alienation and
unworthiness. As she placed her faith in the false promises of the eating disorder,
Journal of Clinical Psychology

DOI: 10.1002/jclp

A Theistic Spiritual Treatment for Women With Eating Disorders

183

Amy found that her relationships and physical, emotional, and spiritual functioning
further deteriorated.
We believe that patients physical, emotional, relational, and spiritual well-being
are all interconnected. As patients functioning declines in one dimension, their
functioning in other dimensions also tends to suffer. During treatment, as patients
functioning in one dimension improves, this also helps them begin to improve in
other dimensions. Thus, helping patients to heal spiritually can often help enhance
their improvement in the physical, emotional, and relational dimensions of their
lives. In fact, two research studies conducted at the Center for Change have provided
evidence that spiritual growth and healing during treatment is positively associated
with better patient outcomes (Richards, Hardman, Berrett, & Eggett, 2006; Smith,
Richards, Hardman, & Fischer, 2003).
We observed this in Amys treatment as the rediscovery of her spiritual
relationship with her Higher Power and the afrmation of her spiritual identity
and worth served as catalysts to healing. Of course, as in any multicomponent
treatment, we cannot conclusively determine that any single treatment method, such
as her spiritual work, was the primary contributor, but both our clinical experience
and research studies suggest that it was certainly a key to her recovery. In this sense,
we think that Amys case illustrates the value of understanding and using patients
faith as a resource in a comprehensive and multidimensional treatment.

References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2006). Practice guideline for the treatment of patients with
eating disorders (3rd ed.). Washington, DC: Author.
Bergin, A.E. (1980). Psychotherapy and religious values. Journal of Consulting and Clinical
Psychology, 48, 75105.
Cooper, P.J., Taylor, M., Cooper, Z., & Fairburn, C.G. (1987). The development and
validation of the Body Shape Questionnaire. International Journal of Eating Disorders, 6,
485494.
Garner, D.M., & Garnkel, P.E. (1979). The Eating Attitudes Test: An index of the symptoms
of anorexia nervosa. Psychological Medicine, 9, 273279.
Hardman, R.K., Berrett, M.E., & Richards, P.S. (2003). Spirituality and ten false pursuits of
eating disorders: Implications for counselors. Counseling and Values, 48, 6778.
Lambert, M.J., & Burlingame, G.M. (1996). The Outcome Questionnaire. Stevenson, MD:
American Professional Credentialing Services.
OGrady, K.A., & Richards, P.S. (2007). God image and theistic psychotherapy. Journal of
Spirituality and Mental Health, 9, 183209.
Paloutzian, R.F., & Ellison, C.W. (1991). Manual for the Spiritual Well-Being Scale. Nyack,
NY: Life Advances.
Richards, P.S., & Bergin, A.E. (2005). A spiritual strategy for counseling and psychotherapy
(2nd ed.). Washington, DC: American Psychological Association.
Richards, P.S., Berrett, M.E., Hardman, R.K., & Eggett, D.L. (2006). Comparative efcacy of
spirituality, cognitive, and emotional support groups for treating eating disorder inpatients.
Eating Disorders: Journal of Treatment and Prevention, 14, 401415.
Richards, P.S., Hardman, R.K., & Berrett, M.E. (2007). Spiritual approaches in the treatment
of women with eating disorders. Washington, DC: American Psychological Association.
Journal of Clinical Psychology

DOI: 10.1002/jclp

184

Journal of Clinical Psychology: In Session, February 2009

Richards, P.S., Hardman, R.K., Frost, H.A., Berrett, M.E., Clark-Sly, J.B., & Anderson,
D.K. (1997). Spiritual issues and interventions in the treatment of patients with eating
disorders. Eating Disorders: Journal of Treatment and Prevention, 5, 261279.
Richards, P.S., & OGrady, K.A. (2007). Theistic counselling and psychotherapy: Conceptual
framework and application to counselling practice. Counselling and Spirituality, 26,
79102.
Smith, T.B., Bartz, J.D., & Richards, P.S. (2007). Outcomes of religious and spiritual
adaptations to psychotherapy: A meta-analytic review. Psychotherapy Research, 17,
643655.
Smith, F.T., Richards, P.S., Hardman, R.K., & Fischer, L. (2003). Intrinsic religiosity and
spiritual well-being as predictors of treatment outcome among women with eating
disorders. Eating Disorders: Journal of Treatment and Prevention, 11, 1526.

Journal of Clinical Psychology

DOI: 10.1002/jclp