The Theological Language of Anorexia: An Argument for Greater Rapprochement between Chaplains and Physicians

Abstract

This article explores the theological themes prevalent in the language of anorexia nervosa by briefly exploring extant literature in the field before reporting on the author’s qualitative fieldwork with Christian women with anorexia nervosa. Sufferers, both those from religious and non-religious backgrounds, often convey their understanding of their illness in theological and moral language, using terms such as ‘sin’ and ‘sacrifice’. The use of theological frameworks on ‘Pro-Ana’ internet forums is also considered. The article concludes by considering the implications of this use of theological language for pastoral and chaplaincy care, and argues that highly skilled mental health chaplains would be of benefit to treatment models for anorexia nervosa and that community church leaders can pay a crucial role in long-lasting recovery, particularly for anorexic women who profess a Christian faith.

Introduction

Anorexia nervosa is a growing problem in the Western world, with the most recent figures concerning UK hospital admission rates for patients with either a primary or a secondary diagnosis of an eating disorder reaching 13,885 in the year 2016–2017, almost double that of 6 years earlier (7620) (NHS Digital, 2018). Of these, 6436 were patients with a diagnosis of anorexia nervosa, making up approximately half the hospital admissions, despite the BEAT (a UK national eating disorder charity) estimate that anorexia accounts for only approximately 10% of all eating disorders (BEAT Eating Disorders, 2018). BEAT statistics suggest that the total number of eating disorder sufferers in the United Kingdom amounts to approximately 1.25 million, a conservative estimate compared to the figures produced by some other organizations such as the Priory Group who put the figure at 1.6 million (Priory Group, 2018). Around 90% of these cases are women. Anorexia nervosa, though it makes up a small percentage of eating disorders, nonetheless accounts for the most deaths, with some estimations that as many as 20% of sufferers will die prematurely from their illness (Mental Health Foundation, 2018).

The causes of anorexia nervosa are unclear, although increased research over the past decades has improved understanding. The current position is that there is no one etiological factor behind anorexia, but rather a complex combination of biological, psychosocial and cultural risk factors (Agras, 2010). In recent years, there has been recognition of religious themes in eating disorders, with some researchers (Banks, 1997; Grenfell, 2006; Lelwica, 1999) calling for awareness of a ‘spiritual element’ in anorexia nervosa in particular.

It is perhaps not surprising that sufferers of anorexia, both religious and non-religious alike, are turning to theological tropes to express their understanding of their illness. Use of religious language (specifically that of the Judeo-Christian tradition) by the Western diet industry is widely acknowledged: Griffin and Berry (2003) point to the use of words such as ‘temptation’, ‘heaven’ and ‘purity’ used in the advertising of diet products in particular to suggest a connection between eating and moral values. Lelwica (2017) points to a wider ‘cult of physical improvement’ which promotes both diets and beauty regimes in a ritualistic religious-style framework. Popular UK weight loss group ‘Slimming World’ references treats as ‘syns’ and incorporates the confessional into their groups. With these cultural influences, it is easy to see why both dieters and anorexics might frame their habits in theological language. In this article, drawing on extant literature and my own fieldwork, I will outline four key areas in which sufferers of anorexia nervosa use the language of religion to express their illness: sin and idolatry, morality, demon possession and the use of ritualistic frameworks. The use of religious language and frameworks to describe their subjective understanding of and feelings concerning their illness, I will argue, adds to the existing case for the incorporation of chaplaincy and/or spiritual models into mainstream eating disorder treatment.

Anorexia Nervosa and Christianity: A Connection?

Research into the connections between Christianity and anorexia nervosa is an emerging field of interest among psychiatrists, sociologists and theologians. The results of these research endeavours strongly suggest that there is some such connection, but there is as yet no consensus as to the nature of that connection. Some researchers, as noted above, suggest an etiological link, with Christian faith either as a risk factor for developing an eating disorder or as a risk factor for becoming more severely ill. Wilbur and Colligan (1981) noted that the anorexic patients in their study were significantly more likely to be practicing Christians than the control groups. Joughin et al. (1992) noted that of their research subjects, Christian women (and in particular, Anglicans) were more likely to have the ‘lowest lowest ever BMI’ than non-Christians, suggesting that Christian faith could be a risk factor for the disease progressing to a more severe point. A causal link could be supported by a study by Bennett et al. (2004) among school girls in Ghana, which suggested that religious fasting could be a risk factor for developing anorexia nervosa. King et al. (2013) reported that people who are more ‘spiritual’ – and in particular those without a clear religious framework to support that spirituality – are more likely to develop eating difficulties. Some researchers have gone further and attempted to differentiate between denominations: both Banks (1997) and Grenfell (2006) argued that religious conservatism is a risk factor for developing anorexia; Sykes et al. (1986) suggested that Roman Catholicism is to blame, while Jacoby (1993) argued that Protestants are more susceptible to anorexia and Roman Catholics to bulimia. Ultimately, due to the complex etiological background to anorexia nervosa, it is difficult to draw firm conclusions, as any control group can never truly be a neutral ‘control’ without accounting for biological, cultural, psychological and social factors for every participant.

Several researchers, rather than attempting to generalize a definitive correlation, have instead turned to a consideration of how this connection, however hazy it might be, could be used practically in understanding and supporting Christian women with anorexia nervosa. Rider et al. (2014) note that it is possible to predict the severity of symptoms based on a patient’s religious ‘coping style’. Those with a positive coping style (belief that life has meaning and purpose; constructive application of religion) became less ill and had improved recovery outcomes than those with negative religious coping styles (images of a punitive God; insecurity). Thus, Rider et al. suggested that incorporating religion into a treatment model attempts to remedy such negative coping styles.

The recognition of Christian faith not only as a possible hindrance but also as an aid to recovery is well-documented in what literature there is on the topic. Marsden et al. (2007), Morgan et al. (2000), Rider et al. (2014) and Taylor Smith et al. (2003), among others, all come to similar conclusions as to the benefit of incorporating spiritual care into treatment.

The literature on anorexia nervosa and Christianity brings out many spiritual themes. Marsden et al. (2007) in their interviews with anorexic women noted themes of control (self-control and ecclesiastical authority), self-image (particularly in a moral sense), sacrifice (e.g. self-denial), salvation and maturation (coinciding spiritual and clinical journeys). These themes are echoed, and extrapolated on, by others: Grenfell (2006) notes the complicated struggle for Christian women when Western cultural ideals to do with the body and the role of women do not match those of the religious community, and the history of the woman’s body associated with shame, sex and impurity set in a dualism against the ‘male sacramental body’. Both Garrett (1998) and Lelwica (1999) recognize a ‘spiritual element’ to eating disorders: for Lelwica, this is a need for alternative images and rituals to empower women who she sees as ‘starving for salvation’; for Garrett, the spiritual element of anorexia comes in the form of an existential quest. Lisa Isherwood (2007) writes concerning the Biblical diet industry and also argues that it is Christian heritage that creates the link of sex, food and sin which is at the root of Western diet culture – and by extension eating disorders. This, she believes, has been compounded by the individualistic outlook of contemporary Protestantism. The way for women to break free from these boundaries is to embrace a fleshly Christ, and in doing so embrace ourselves in all our fleshliness.

Perhaps one of the most well-documented connections of anorexia and Christianity is to be found in their ascetic elements. Many authors have drawn parallels with the ascetic saints of the medieval era and contemporary anorexics. Rudolf Bell (1985), who dubbed the saints ‘holy anorexics’, analyses the data of 170 Italian female saints of the medieval era. Half of them, he summarizes, exhibit what we would now consider anorexic behaviour. Although he is wary of retrospective diagnosis, he suggests that there is continuity between ‘holy anorexics’ and contemporary anorexia, and as such, a study of their habits and motivations could be of benefit in understanding anorexia nervosa. Bynum (1987) and Vandereycken and Van Deth (1994) also note similarities, but are more cautious about drawing comparisons over several centuries based on limited evidence. However, ascetic ideals have also been noted in the behaviour of contemporary anorexic women. Banks (1992) writes up two case studies: the first, Jane, follows the pattern of the medieval saints by fasting above and beyond what is required by her church and prays to God for self-control of her ‘sinful’ desire to eat food. The second, Margaret, has strong connections of virginity and purity, and believed that she survived on no food by ‘a miracle’; those who died from their illness were ‘not proper Christians’. Both of these stories strongly reflect elements of the lives of the medieval ‘holy anorexics’.

Fieldwork Findings: Sin, Demons, Ritual and What Would Jesus Eat?

The reflections in this section are taken primarily from my own fieldwork. This Grounded Theory study (approved by the National Health Service Integrated Research Approval System (NHS IRAS) Ethics Committee) was carried out over the course of 2 years and consisted of two phases: Phase 1 took place in an NHS acute eating disorder inpatient unit, and Phase 2 took place in the community with recovered women. The inclusion criteria were that participants should be above 18 years of age, female, either identify as or have been brought up Christian (any denomination), and should have a diagnosis (current or historic) of any sub-type of anorexia nervosa. The final sample comprised nine women: one Quaker, four Roman Catholic, one Anglican, one Methodist and two independent evangelical. However, many of the participants had attended different churches at points in their lives. The research consisted of one in-depth semi-structured interview with each participant, either via Skype or in person, and follow-up either in the form of further email exchange or a second interview. In addition to reflections on my own fieldwork, I have also included references to extant autobiographical texts by Christian women writing about their experience of faith and anorexia nervosa. All names of participants in this article are pseudonyms.

Sin and Idolatry

One of the main themes that emerged from my research was the concept of ‘sin’ and ‘idolatry’. It became apparent that many of the participants had struggled with the question of what anorexia was: an illness or a sin? As something that is often seen to be something you ‘do to yourself’, anorexia (as with many other mental health difficulties), in the experiences of the participants, elicited unhelpful responses from those around them that they were in some way to ‘blame’ for their illness. In a secular context, this is unhelpful to say the least, but when placed in a church context the illness itself became a ‘sin’ in their understanding or even a form of ‘idolatry’ because they were putting their eating disorder at the forefront of their life. A pre-occupation with thoughts of food is typical for anorexia sufferers – and indeed a natural consequence of starvation – but in a theological context had come to be seen as idolatry. The extent to which these issues pervaded the minds of my participants was striking: although not all came to the same conclusion on ‘sickness or sin?’, every single one of them had at some point in their illness asked this question in some form. One participant, Deborah, described feeling like a ‘tainted being’ who was ‘innately sinful’. For her, food was a contaminant, and yet at the same time she spoke of how she had come to battle ‘the idea that being anorexic . . . Is sinful . . . that it’s something that you needed to repent of, and that’s the answer . . . Actually I still find that has quite a hold on me, and that scares me’. For Deborah, the idea of anorexia as a sin was a misunderstanding, but one that had a frightening grip on her, just as the illness itself gripped her. Another participant, Eloise, who had been explicitly told by church mentors that her illness was a sin, even after recovery was still unsure how she understood anorexia:

What’s the definition of a sin? A sin is anything that is opposite of following God. And it’s definitely not following God. But at the same time could I have helped it? Like I couldn’t help myself. So, I just don’t know.

Interestingly, on recovery, other than Eloise, every other participant had come to understand anorexia as an illness rather than a sin: although some had concerns that to describe it as entirely non-volitional might detract from the autonomy required for recovery.

The concept of anorexia as ‘sin’ is also found in Emma Scrivener’s (2012) autobiography in which she explicitly asks, ‘is this sickness – or is this sin?’ Scrivener concludes that it is both: and that Jesus, the healer, is the doctor for sinners. Jo Ind (1993), in her narrative of her recovery from binge-eating disorder, makes an explicit connection with idolatry as she described how she makes a ‘god of her belly’ and ‘submits to fleshly desires’. For anorexics, the idol is different – the idol becomes anorexia who, almost like a goddess, permeates waking thoughts and controls behaviour. However, the notion of sinfulness and fleshly desires is still apparent as the deadly sin of greed is pitted against the fruit of the spirit of self-control. As Isherwood (2007) writes, the concepts of flesh, sin, appetite and women have ever been linked in our consciousness since the Fall, when the sin of the world entered through a woman eating.

Demon Possession

One participant, Grace, put forward an interesting alternative to the concept of sin as a way of understanding her illness. She described anorexia as an ‘external force’ and ‘something that has its fingers round my throat’ that ‘attached itself to me’. She told the story of her ‘healing’: Grace described going to the pastor’s house where her best friend told him her story, as she was crying too much to do so herself. The pastor then gave her an image in the form of a story. He described two men walking down a road from opposite ends, towards each other. One carries blocks of gold, the other carries manure – that is his living, his identity, how he carries himself through life. They bump into each other in the middle, and the man with the gold says, ‘If you put down that manure, I’ll give you some of this gold. You will never have to carry manure again. You’ll be taken care of’. The man with the manure protested: this was his livelihood, how would he survive without it? The man with the gold replied, ‘If you just trust me, put down that manure and take this gold. You won’t need that manure any longer’. The image of trust spoke to Grace and she felt in that moment that she had to put down her burden, her eating disorder, and trust that she wouldn’t need it to cope with life any longer: ‘I’m either going to die, or I’m going to put this down’. The pastor asked whether she was ready to lay it down, and she was. Grace emphasized that it was not like she was being forgiven of a sin or like a conversion – she was already a Christian, and wouldn’t have got to this point if she wasn’t. It was a laying down of a burden by trusting in God. The pastor and her friends then laid hands on her and prayed. Grace described that she wasn’t really comfortable in settings like this:

But I do believe in healing and I do believe there is a demonic force in the world. And the guy, he laid hands on me and was praying, and he was pretty much calling things out . . . a kind of casting out. He was naming things I hadn’t even told him about my life. It was a kind of . . . a lot of it’s a blur because I was crying so much it was so intense.

She described herself as feeling ‘freed’ and having an incredible ‘sense of peace’, describing it like a spring clean – someone coming and sweeping your house out while you are out and setting it all back to order. Her friend described it as though a heavy dark cloud had lifted from her. From that day on, she never again restricted food with the aim of weight loss or made herself sick, nor wanted to. That night was 24 years ago at the time of interviewing.

Grace’s understanding of anorexia as demonic possession stemmed partly from her experience and partly seemed to be a backlash against the understanding of anorexia in Christian circles as a ‘sin’. However, other participants rejected this interpretation of their illness and reacted differently. Those who believed in demon possession as a literal concept were offended by the suggestion. Deborah, who did not believe in literal demon possession, welcomed the idea as a metaphor, speaking of the Biblical passage of the man healed of his demons by Jesus who ‘lived among the tombs’ (Mark 5:1–17). This, she felt, was ‘a profound way to speak of mental illness’. The concept of a metaphorical ‘demon’ or ‘voice in your head’ is paralleled in some mainstream therapies for anorexia nervosa: sufferers often recognize the voice as an external intruder into their consciousness and are encouraged by therapists to name it as a way of externalizing the illness and separating it from their own identity (Lock et al., 2001). Lask and Bryan Waugh (2000) describe how one of their patients imagines her eating disorder as a scaly green creature with a large beak. Tracy, though she did not explicitly call her illness a ‘demon’, described her illness as a battle between her ‘true’ self and anorexia. She felt that anorexia had exhumed her identity until she was 90% anorexia, 10% Tracy. For her, recovery was about winning back more of herself.

Morality

All of my participants in some way used the language of morality to talk about their relationship with food. As noted in the introduction, this is by no means surprising in the context of the diet industry’s use of moral language to sell their products. Isherwood (2007) describes in depth the growth of the ‘Christian diet’ industry in the United States since the 1950s, estimated to be worth US$77 billion by the turn of the millennium. These diets explicitly link dieting with Christian faith and hold titles such as ‘What Would Jesus Eat?’; ‘Help Lord, The Devil Wants Me Fat’; and ‘Diet: Discipline: Discipleship’. The message of these diets is quite clear: the thin are godly and endowed with the fruits of the spirit – with a particular emphasis on self-control. The fat are subject to the deadly sins: gluttony and laziness. Isherwood (2007: 73) quotes the perpetrator of one of these diets, Don Colbert, who says that food is ‘an instrument of the devil’, and those who succumb to it are far from salvation. With these cultural influences, it is easy to see why both dieters and anorexics might frame their habits in theological language.

Although Isherwood (2007) asserts that it is the individualistic nature of Protestantism that makes Western Christians vulnerable to both the Christian diet industry and by extension eating disorders, the demographic who used the language of morality the most in my fieldwork were the Roman Catholic participants. Brigid spoke of ‘good and bad foods’ and ‘good and bad bodies’. Clare understood her illness in terms of ‘winning grace’ by counting calories and ‘being good’. For her, ‘being good’ was the most important thing, and she equated this with self-denial, behaviour and following rules. She described her feelings on an occasion when she had binged as ‘I’m bad’. Every single participant spoke of the ‘guilt’ that they felt for not being able to live up to expectations – be they expectations of what it means to be a ‘good Christian’, expectations of the anorexia itself, or expectations they and others had of their recovery. It is well-documented that low self-esteem is a risk factor and feature of anorexia (National Centre for Eating Disorders, 2018b). What is interesting here is the way in which my participants framed lack of self-esteem and feature of guilt in the language of their religion.

The elements of guilt and feelings of being morally bad seem to be especially complex in Christian women with anorexia. They reported feeling guilty when they ate, because they were judged by the anorexia (as though it was a separate being) or by the anorexic ‘part’ of their own minds as ‘morally bad’. However, they also felt guilty when they did not eat, as they felt that they ‘should be able to fix this’ (Brigid and Eloise) and ‘the sense that it’s morally wrong that I starve myself, even though [I know] that it’s non-volitional’ (Mhairi). The feeling that they should be able to recover was for many compounded by the expectations they and others had of themselves as Christians: they were told they were ‘not praying hard enough’ and felt that if they were good enough Christians they would be able to ‘snap out of it’ and choose to follow God, rather than anorexia.

Many of the illustrations of morality ultimately came down to the image that participants had of what a good Christian woman should be. Both Mhairi and Clare spoke specifically of ‘models’ of Christian womanhood that they felt they did not, but should, fit into. Eloise described herself as ‘not worthy to be a Proverbs 31 woman’. Deborah went a step further and explicitly linked the lack of self-esteem at the root of eating disorders with the church’s insistence that women are subservient, ‘confining them to supporting roles’. This is a theme echoed by Ind (1993) and Scrivener (2012), who both wrote of the difficulty of being caught between secular culture and the expectations of their religious community of a submissive ‘good girl’ femininity. The models of Christian womanhood that are portrayed to young women incorporate both beauty expectations and moral expectations: these expectations are reflected in the way the participants spoke of their eating disorders (Stammers, 2017).

Ritualistic Frameworks

In our conversation, Brigid reflected on the role that rituals played in her life: the rituals of her religion in saying the rosary and taking Mass, the rituals that came with her obsessive-compulsive disorder (OCD) such as checking the office heater was switched off and the rituals of her eating disorder:

It’s difficult to say whether an affinity for ritual and a tendency to be comforted by routines and repeated behaviour came before or after my religious background, as both have been a reality for me for as long as I can remember. As with much of my history, I can only say that I can certainly see that the two could be related.

In her recovery, Brigid had to sift through which of her ‘rituals’ were comforting and harmless, and which were disordered and unhealthy, such as cutting food into tiny pieces.

Rituals surrounding food and eating such as this are a well-documented symptom of anorexia nervosa (National Centre for Eating Disorders, 2018a). These can be a part of anorexia nervosa alone or as part of a co-morbidity with OCD as for Brigid. The full ritualistic quasi-religious framework of anorexia nervosa is little researched, but clearly evident on ‘pro-ana’ websites. A search of ‘pro-ana’ online chat forums revealed common ‘rituals’ such as keeping the day’s allotted food in a special box, chewing 10 times before swallowing, using only teaspoons, disassembling foods, drinking a glass of water before eating, weighing and measuring all portions (to calculate calories), and eating at exactly the same time every day (My Pro Ana, 2015b).

For some anorexics, the quasi-religious ritualization of the disorder goes even further, to the extent of seeing anorexia as a ‘goddess’ to worship. One commenter on a pro-ana forum offering ‘tips and tricks’ to be anorexic said, ‘Have you prayed to Goddess Ana yet? Everyone knows that’s how you become a little light butterfly’ (My Pro Ana, 2018). Another forum sets out the tenets of the ‘Religion of the Goddess Ana’, with the blogger writing, ‘Pro-ana grew into a cult-like community, and for me, it was like a religion with Ana being the goddess. I worshipped my anorexia’ (Thin For Ana, 2018). She goes on to describe her mantras: ‘Salvation comes from starvation’, and the page offers a link to the ‘Ana Prayer’:

Beloved Ana,

I come before you tonight to beg your acceptance and forgiveness for my wretchedness and to ask you to accept me with the understanding that I want to be yours wholly and entirely,

My Ana, I need your strength when temptation comes my way, your love when my bones begin to protrude and my heart fails at the profound emptiness I feel.

Ana, I need your grace as I walk through this lonely life – forgive me when I falter and protect me from my own destructive desires when starving just isn’t enough to ease the pain – all I really want is for you to love me as I love you each day. Watch over me Ana, when others try to tear you down or prosecute me for your name’s sake. You alone are all I need and you alone fill me. I love you Ana and I give you my heart, my soul, my life.

Amen.

Another commenter writes below: ‘I love this prayer I’ve been using it daily. Thank you’. The page also links to the ‘Thin Commandments’ (e.g. ‘thou must do everything and anything to make yourself thinner’) and the ‘Ana Creed’ which begins each line with ‘I believe in . . .’. Both of these are consciously modelled on the Ten Commandments and the Apostles’ Creed. This is not one isolated example of one sufferer expressing her illness in the framework of religion: such pages are rife on the Internet and, as our blogger comments, only open again on the dark web once they are shut down by authorities. Another example can be found at ‘Pro Ana Mia Diary’ (2018), in which blog the writer offers a creed, commandments and a symbolic beaded bracelet in the style of a rosary. During the course of my research, this website was shut down and at the time of writing is not available. On ‘myproana.com’ there is even a chat room for ‘Ana: the religion’, in which one commentator has collated all the different versions of the Ana Psalm, the Ana Commandments, Ana Prayers and even Ana’s Seven Sacraments (‘be triggered’; ‘fast’; ‘find an ana buddy’). In addition, she explains the ‘symbols and figures’: the Goddess Ana, and the ‘thins’ whom she describes as the ‘People who die for anorexia. The daughters of Ana, like Jesus in Catholicism’ (My Pro Ana, 2015a). Commentators refer to a ritual in which ‘you can summon the goddess of anorexia’ for strength. Another website is entitled ‘Pro Ana Goddess’ (2016) and contains a page on ‘Ana Religion’.

The use of theological language in these posts is clear: they are self-consciously modelled on a Christian framework – specifically Roman Catholic in places, with an explicit mention of Roman Catholicism and the full seven sacraments. In the ‘prayer’, the language is that of ‘temptation’ and ‘grace’. Although it is impossible to know for sure the religion of the members of the pro-ana community, of those who did mention their religion, there was a good mixture of Christians and atheists. It was also clear from the thread that although some found this framework ‘inspiring’, many did not.

The Argument for Collaboration between Chaplains and Physicians

In Michelle Lelwica’s (1999) book Starving for Salvation (interestingly, the exact phrase of the mantra found on pro-ana pages), she suggests that one of the causes of anorexia nervosa is that women are entering a ‘spiritual crisis’. They express this through the symbols and rituals open to them: and in this age of secularization, what is open to them is the ‘salvation myth’ of diet culture. Ironically, this secular ‘myth’ has grown from the anti-body misogynistic legacy of religion itself. She suggests that what is needed is for women to find another means of fulfilling their spiritual and ritual needs: and the very existence of such ‘Ana Religion’ frameworks supports her argument (Lelwica, 2010). To fulfil these needs, she looks to religion; however, as Lelwica (2010) attempts to keep her work broad and inclusive, she does not go into the specifics concerning what this might look like in any one religion, although she does use Christianity as her predominant example in her self-help book.

Lelwica is by no means alone in her call for attention to be given to the spiritual element of the illness: many researchers support a treatment model which gives attention to the spiritual dimension of the sufferer and the importance they place on their religion within the context of their illness. Multiple studies have suggested that religion can be a factor in assisting recovery, although it is worth noting that all these studies looked predominantly at Christian faith, due to the demographics of the patients they were studying (Grenfell, 2006; Joughin et al., 1992; Marsden et al., 2007; Morgan et al., 2000; Rider et al., 2014; Taylor Smith et al., 2003, among others). These researchers found that aspects of faith, such as prayer, community support, motivation, self-worth and forgiveness, could all play a part in aiding recovery. Such conclusions also emerge from my research, summarized in the words of Eloise:

I just think if you have a faith and it’s strong, not bringing it into your recovery . . . it’s never going to work. Because if God’s the most important thing in your life, and your eating disorder’s the other most important thing in your life, then they have got to be married before you could ditch one. And I didn’t ever know which one I would ditch to be honest, both were so strong for me . . . probably in equal measure. And God . . . if I hadn’t brought him in to just completely take over I would never have got better.

As a result, many researchers are calling for greater liaison between chaplains and psychiatrists, although there is as yet no consensus on what this should look like. One of the particular needs for a specially trained mental health chaplain is highlighted in the confused religious beliefs held by many Christian anorexics. As noted above, concepts of sin, salvation and self-worth often need addressing in a religious context.

Some researchers advocate a model in which a psychiatrist or psychologist carefully and gently challenges such beliefs (Joughin et al., 1992) or for a model in which the psychologist or psychiatrist integrates spiritual counselling into treatment (Cumella et al., 2008; Richards et al., 2007). The latter two works are both handbooks intended for eating disorder practitioners, which offer guidelines and suggestions for incorporating spirituality into practice. Neither of the two is without fault – as indeed, Wall and Cumella (2007) note in their review of Richards et al. (2007), pointing out, among other issues, that the programme developed at the Center for Change was developed in a largely homogeneous religious population and that the majority of their patients were members of the Church of Jesus Christ of Latter-day Saints, and as a result the treatment programme was based on that belief framework and is not entirely generalizable. Similarly, Cumella et al. (2008) emphasize a particularly Protestant trichotomist understanding of the body, spirit and soul, and an unusual desire to support all their statements about eating disorders with not only evidence-based studies and medical and psychiatric texts, but also a Bible verse. This in itself is a peculiarly Protestant trait, and thus I would argue that they are no more ‘generalizable’ taken as a whole than the manual offered by Richards et al. (2007). Nonetheless, both works offer an evidence-based treatment model, supported with appropriate studies, which incorporates spirituality into conventional eating disorder treatment with success within the demographics which they cater for. Health care providers and chaplains taking advice from these books would inevitably need to select carefully for their own patients and may find some of the ideas and suggested activities less appropriate to a different religious demographic.

Thus, although the concept and basic framework of the models presented by these authors are sound, and the studies which they have undertaken as to the effectiveness of such models are extremely useful (Cumella et al., 2008; Richards et al., 2006, 2007; Taylor Smith et al., 2003), it is the very difficulty of transferring these treatment models to another facility that highlights my main concern: in both these models, and indeed in Joughin et al.’s (1992) suggestion, it is a psychologist or psychiatrist who carries out the spiritual element of treatment. There are multiple problems with this: first, as is shown by Wall and Cumella’s (2007) criticism of Richards et al. (2007) – and indeed, my subsequent critique of Cumella et al. (2008) – neither sets of authors see that their own work is not generalizable or transferable to a different population. They are not theologians, but psychologists and psychiatrists, and as such – quite understandably – do not have a broad view of the beliefs of different denominations. Although in such homogeneous populations this is of less importance, in a more ecumenical or multi-faith area, it is unrealistic – and indeed unreasonable – to expect psychologists and psychiatrists to have the necessary in-depth understanding of each patient’s belief system. Thus, it would be of far more sense to have a highly skilled mental health chaplain working alongside health professionals as part of the clinical team who could add their particular expertise to a multi-disciplinary treatment model, in the same way as dieticians and occupational therapists. This would also be of benefit in cases when, as Joughin et al. (1992) suggest, distorted beliefs need to be gently challenged and worked through: many devoutly religious sufferers would not accept such challenges to their faith from a medical professional, particularly in countries such as the United Kingdom where religion and science have been unhelpfully polarized.

A challenge to the idea of chaplains and physicians working together comes from this place of polarization, and some researchers are wary of collaborative models. Huline-Dickens (2000), a psychiatrist, suggests that, although she agrees that distorted religious concepts need to be looked at in cognitive therapy, ‘there are many difficulties with this collaboration and it is argued here that religious beliefs should be examined rationally’ (Huline-Dickens, 2000: 74–75). Her argument hinges on her belief that a chaplain or other religious leader could not possibly examine beliefs ‘rationally’. This is in my opinion a perfect example of why the spiritual dimension of anorexia nervosa has been neglected in treatment. As I have previously noted, it is unreasonable to expect psychologists and psychiatrists to undertake to study every religious tradition to the point that they are as deeply informed as the chaplain of that faith; indeed, Huline-Dicken’s own vast generalizations and ignorance of either religion or health care chaplaincy demonstrate that this is unlikely to work. If we are ever to move forward in this area, Huline-Dickens and many others will need to recognize that religion and medicine are not – and should not be – at a dichotomy.

However, in fairness to those professionals and researchers who hold such views, often they are views born of experience of religious leaders who similarly polarize science and religion and thus shun the advances of medical science. We would therefore do well to heed the note of caution with which Huline-Dickens writes: although those who reject medical knowledge are few and far between in mainstream churches today, an untrained and well-meaning chaplain could do much damage by not understanding the nature of the condition. Participants in my study spoke eloquently of their experiences of both good and bad chaplaincy care and were clear that the ‘bad’ chaplaincy care could be not only unhelpful but also isolate sufferers and hinder recovery. The most common example of this was a lack of understanding of mental health from fellow Christians, including church leaders and the ‘idea that you could just say a prayer, and it would pick you up’ (Eloise). However, this in itself is further argument for trained mental health chaplains to bring their expertise to a multi-disciplinary team, rather than leaving spiritual counselling to be stumbled through by well-meaning religious leaders and friends with little or no understanding of the illness. It is worth noting that a psychologist or psychiatrist attempting spiritual counselling without the necessary in-depth understanding of the faith in question could be equally damaging.

Although treatment models such as the one that I (and other researchers) propose are still a rarity, there is anecdotal evidence from conversations with mental health chaplains in the United Kingdom that in some hospitals skilled mental health chaplains work either as part of the clinical team or closely alongside them, attending case meetings and having access to clinical notes. In some hospitals, ‘spirituality groups’ have been set up alongside one-to-one chaplaincy care, in addition to standard therapeutic treatment (M. Parkes, personal communication, July 2015).

Programmes such as these and those of Richards et al. (2007) and Cumella et al. (2008) demonstrate the possibility, and indeed success, of a treatment model which integrates spiritual care into more traditional eating disorder treatments. It is clear from the existing research in this area, as discussed previously, and my own fieldwork that Christians who suffer from anorexia nervosa, and indeed many non-Christians, express their eating disorders in the framework and language of religion – predominantly Christianity (although this is of course skewed due to both the demographics of the studies and the prevalence of anorexia nervosa in the Western world). Furthermore, research suggests that Christians suffering from anorexia benefit greatly from the adoption of a bio-psycho-social-spiritual treatment model (Cumella et al. 2008) and that distorted religious ideas can hinder recovery unless they are resolved (Banks, 1996; Cumella et al., 2008; Richards et al., 2007; Rider et al., 2014, among others).

It is, therefore, essential that we should continue to build on existing work to understand further the relationship between faith and anorexia nervosa in sufferers. My research has focused on Christian women with anorexia and demonstrates the depth of the connection they feel between their faith and their illness, and the language they use to speak of their illness reflects the religious framework in which they understand their experiences. As a small qualitative study, this cannot be generalized far beyond the sample. However, it does provide enough evidence to support a call for further research in this area. Further areas to consider would be the framework in which Christian men with anorexia understand their illness and sufferers of other faiths. The emergence of online ‘Ana Religion’ forums also suggests that a religious framework for anorexia nervosa is not restricted to those who profess a faith, and this could also be an area for further investigation.

However, in the meantime, it is also necessary to develop some practical models to integrate spiritual care into mainstream treatment in order to address distorted ideas and religious concepts held by many sufferers – in particular to challenge the language of ‘sin’ and ‘good/bad’ surrounding disordered behaviours. This should, by necessity, be in two formats: first, a recommendation for and increased training of specialized mental health chaplains in hospitals building on the existing work in the area, and second, basic training in mental health, and resources available for understanding the spiritual dimension of eating disorders, for all religious leaders working in their communities. This is of particular importance for chaplains working with demographics with high risk of anorexia nervosa, such as school and university chaplains.

The participants in my study noted that their religious communities and leaders had the potential to be an essential tool in their recovery, and many were so simply by ‘being alongside’ (Deborah) the participants. However, my research and existing research in the area suggests that there is the potential for a far bigger role for chaplains to play in the battle against anorexia nervosa. In a time when, in the United Kingdom at least, eating disorders are on the rise and mental health services are stretched to crisis point, I would argue it is time to use this unique resource with far more efficacy than we have previously done, both in the community and alongside medical professionals.