Spiritual Approaches in the Treatment of Women with Eating Disorders By P. Scott Richards, Randy K. Hardman, and Michael E. Berrett. Washington, DC: American Psychological Association 304 pages, $59.95 ©2006 American Psychological Assoc Order online at Bulimia.com

This book is one of the first I’ve seen that systematically, comprehensively and thoughtfully addresses the many connections between eating disorders and spiritual issues in treatment. The authors, including a professor of counseling psychology at Brigham Young University, are all associated with the Center for Change in Orem, UT. The Center for Change is an eating disorders center that uses a multimodal and multidisciplinary approach in the treatment of patients with severe eating disorders. This center and organization and several other well-known treatment centers across the country incorporate spiritual assessments and treatment methods alongside traditional “evidence-based” practices.

This book addresses the rationale for such practices within the medical-scientific paradigm, and examines how many patients with eating disorders experience their eating disorders from a spiritual and religious perspective. It outlines how the authors have integrated their spiritual interventions into patients’ treatment programs. The authors’ rationale is based on the fact that many patients strongly adhere to spiritual and religious beliefs, and a substantial literature exists that suggests that patients who are believers who receive treatment that addresses and incorporates these beliefs and traditions do better than others. Of note and importance, the authors clearly state that ethical guidelines of their profession preclude prosthelytizing patients during treatment and that each patient’s beliefs, including those beliefs of those who are agnostics or atheists, should be respected.

In the spirit of full disclosure, I’m an agnostic-deist-secular humanist—depending on my ego state—who fell away from an Orthodox Jewish tradition early in life. I fully understand and accept that faith and spirituality are important and helpful for many—but not all—of my patients, and very often in ways that are very, very different from how I see things.

The authors identify themselves as “Theists,” i.e., believers in God, without necessarily specifying exactly what that entails, and as ecumenical with regard to accepting others’ views. They present a substantial Theistic theoretical perspective on how religion and spiritual matters may contribute to eating disorders pathogenesis and treatment. These formulations, based on hearing patients’ religious and spiritual formulations and struggles, available literature, and consistent with the authors’ own world-views, are carefully laid side by side with conventional biological, psychological, interpersonal, and sociocultural perspectives.

The interventions they describe have evolved over the years, and in structure resemble many other cognitive, imaginal, journaling and other humanistic individual and group psychotherapy techniques, complete with workbooks. In addition, in accord with patient’s individual religious and spiritual beliefs, preferences and explicit permissions, the authors employ techniques involving connection with higher spiritual beliefs, including 12-Step practices and sometimes prayer on the part of patient and therapists as well that are clearly not part of conventional psychotherapies. They also present preliminary data from a modest study showing that patients in their program who participated in spiritually oriented groups had some general outcomes that were slightly better than patients in a control group that received nonspiritual emotional support.

What’s especially valuable here is the authors’ attempt to explain the bases for their activities within the scientific-clinical tradition to an audience they know will include many skeptics and nonbelievers. With respect to eating disorders, these issues have, for the large part, been talked about in the Academies of Medicine and Psychology only in hushed voices and quiet corners, or derisively, and with far more heat and smoke than careful reflection.

Since the ranks of patients and practitioners include many people of faith as well as many who see themselves as atheist or agnostic secular humanists or spiritual but nonreligious deists, to start, it’s important that we flush out inevitable issues of values and underlying assumptive world-views in psychiatric diagnosis, ideas about pathogenesis, and treatments. What’s clear is that no system of psychiatric practice is values-free. The virulent atheism of some early (and current) psychoanalysts, psychiatrists, psychologists and other mental health professionals may seem to rest not only on their fears that an “unscientific” world view will hamper medical truth and progress, but also on their need to build protective walls around their own belief systems.

Of importance, the authors’ own beliefs in God and prayer undoubtedly add to the enthusiastic beliefs they bring to their practices and convey to their patients. In line with Jerome and Julia Frank’s salient observations in their book, Persuasion and Healing: A Comparative Study of Psychotherapy (Johns Hopkins Press, 1991, when practitioners and their patients strongly share the same beliefs and attitudes about causation and treatment, treatment adherence and results are likely to be much better than when these things are discrepant. When clinicians really believe in what they’re doing and patients share their beliefs, outcomes benefit. That’s not bad, regardless of the belief system.

But, what gives me pause is that the primary beliefs of the Theistic worldview (to which I might subscribe as a private individual) inevitably fall outside of the scientific one, in that Theism’s fundamental assumptions cannot be tested. However, many of its practical clinical sequelae may be, and, in that spirit the authors offer a substantial set of researchable questions concerning beliefs, treatment and outcomes.

I recognize that some atheist-skeptical readers will immediately, out of hand, want to reject what these authors are talking about and trying to do, and that others, out of emotional allegiance, might uncritically cheerlead their efforts. My sense is that neither position would be correct. Rather, from the perspective of my scientific-humanist agnostic-deist world view, I think this book is worth a very serious reading.

In passing, a major research article by Zhong and Liljenquist in the September 8, 2006 issue of Science presents the results of laboratory experiments showing unexpected parallels between feelings of moral purity and physical cleanliness that the authors claim may help explain the ubiquity of religious cleansing rituals. I’m struck by the fact that these experiments may, with some extension, be pertinent to understanding aspects of eating disorders, too, in a direction compatible with spiritual as well as psychological formulations. What’s next?

— J.Y.