Integrating Spirituality into Therapy--My Interview on "Breaking Down: The Podcast"

Hello all! I’m so excited to present a transcript of a wonderful podcast I did in San Diego last fall on spirituality in therapy. It is called Breaking Down: The Podcast with Edie Stark, LCSW, and Mia Najor, LMFT. I discussed my background and how I came to understand what integrating spirituality in therapy means, and how important it is to do it ethically. We also talked about the importance of following clients’ lead when attending to spirituality, as well as the unique needs of working with the LGBTQ+ population, as well as with eating disorders in this area. I had so much fun talking with these very deep women. Enjoy!

MIA: Hello everyone. Welcome to Breaking Down: The Podcast. My name is Mia and I’m here with my lovely co-host . . .

EDIE: Edie!

MIA: I want you guys to brace yourselves right now, as we have Dr. Marianne Miller. She’s a Licensed Marriage and Family Therapist, and she has a PhD in marriage and family therapy as well.

EDIE: She’s wicked smart.

MIA: We couldn’t be happier to have her on and are very fortunate because she’s an incredible wealth of knowledge. We are going to sort of open up the floodgates to hear, well I want to hear and I think Edie wants to hear, and the whole world wants to hear, sort of your journey, Dr. Marianne Miller and how you come to be where you are right now.

MARIANNE: Well it’s an interesting story because my undergraduate was in English literature. I wanted to be a writer at one point. I wanted to be a Professor of English Literature, but I think I was end of my junior, beginning of my senior year in undergrad. I was talking with some grad students in English, and they were arguing about different points of what Shakespeare meant when he said blah, blah, blah. I was just thinking, you know, I just want something more meaningful. It’s all good—I loved Shakespeare, loved all of that. But I wanted something more meaningful, but I wasn’t sure what. So, I took a job as a writer for a computer company, and I hated it, ended up getting laid off.

At the time, my church in Denver had done church plants in Tomsk, Siberia in ‘94. In ‘96, when I got laid off, they were looking for looking for some people who were single, just to go over there for a year and work at the church. So, I volunteered, was able to raise the money and went over there. I’ve never met so many people who were so depressed and affected by alcoholism especially in my life, and so I worked primarily with high school students, and college students. Basically, did pastoral counseling. That’s how I fell in love with mental health.

When I was there, I found out about the field of Marriage of Family Therapy and decided that’s what I wanted to go. I applied to grad programs, and went to Abilene Christian University in Abilene, Texas, and then decided I wanted to go into academia, so I went to get my PhD in Marriage of Family Therapy at Texas Tech University in Lubbock, Texas. During that whole time, I was very, very interested in the integration of spirituality and therapy. I did research, projects on it. My dissertation was on integrating spirituality into therapy training.

Since then, I started working in academia, and working full time in a marriage and family therapy program. I was a director for that program for four years. My biggest passion was intergrading spirituality into therapy. During this whole journey, I started working with eating disorders, it was a backdoor way, through chronic pain. Within weeks of defending my dissertation, I injured my back snowboarding, and developed a chronic back pain issue. I ended up having to quit my job, and just do a part-time private practice, and worked with a lot of chronic pain clients.  

When I came to San Diego, I started working for the university I started a chronic pain group, and I started a part-time private practice where I had chronic pain clients. I found a lot of those clients, not all of them but some of them, had eating disorder issues, body image issues, disorder eating. Someone asked me that. Why do you think that was the case? It might have been even you, Edie, who asked me in that meeting when we had lunch the other day. I said, that I think people who develop chronic pain tend to be driven people and they tend in general, again there’s always exceptions, but people who tend to be detached from their bodies, so they run themselves into the ground. It could be through career, or giving to their families, or whatever. Again, that’s not always the case with everyone, but that’s been my experience with many of my clients. So, there’s this sense of detachment from their bodies. I found through their characteristics to be very similar to people who have eating disorders too. This sense of detachment.

So, when I did run the chronic pain group, many of the chronic pain clients, they were looking for something outside of the physical to give themselves strength and found that spirituality was helpful for them. When I was in my worse chronic pain, thankfully it’s mostly resolved now, but when I was in my worst part, I remember my sister-in-law, she was just dating my brother at the time, and they came and visited my husband and I in Texas, and I was bedridden. She said, “How do you keep going. How do you do it?” I said, “It’s my spiritual belief, it’s my faith.”

When you are in so much pain, it’s prayer, listening to music, and sometimes it’s not overly spiritual music, sometimes it’s classical music. It’s connecting with the beauty and intricacy a piece of Beethoven, or Rachmaninoff has composed. So, I’ve really found that working with chronic pain clients, spirituality can be something that can help them keep going in the mist of tremendous amount of pain and, it also works with many of my clients with eating disorders.

A lot of my clients with eating disorders do experience pain. Whether it is that they are getting used to having food in their stomachs again, their digestive systems working again, or they develop some sort of chronic pain, or chronic illness in conjunction with having the eating disorder. It’s something that I was very passionate about in my academic work. I’ve taught classes on and trained therapists in integrating spirituality into therapy. I published papers on it, did studies on it. I could talk about it all day

EDIE: I have a question. You talked about, how music itself can be used in a spiritual way. So, if you could give a little background? I technically grew up in a Christian home, and I remember thinking, when I was about twelve years old, it just wasn’t something I resonated with. I’ve asked people just throughout my life are their people that are just less spiritually inclined then others? I just wondered that for a long time, it just didn’t resonate. I did have a father who, was a pastoral counselor for many years, funny enough, and just have friends with all walks of faith, so I guess my question is in terms with the way you see spirituality extending outside of that realm. I just wanted to have a little more education on that myself. Is that a question that makes sense? 

MARIANNE: It absolutely makes sense. My belief, and my background. I grew up in evangelical Christian faith, and through grad school I became a feminist, which didn’t really fit the evangelical faith that I grew up in and so, my husband and I ended up leaving that faith and joining different faiths and organization that was more liberal and more inclusive. Especially for women, the LBGTQ community, and groups like that. My view of spiritually became broad. I see it as many paths to the same summit. I had a former student who identified himself as both Catholic and Buddhist. He gave me this book living Buddha, Living Christ, which is about intergrading Christianity and Buddhism. The author explained there are many paths to the same summit, and I completely agree. So, yes to go back to your original question Edie, there are people, that it’s just not their natural way of thinking, to be spiritual. I’ve always had a very deep spiritual part of me since I was young, but not everybody, I just think everybody’s brains are not wired that way. 

EDIE: That’s what thought. I just never really had a deeper conversation about it.

MARIANNE: Yeah, I just think not everyone’s brains are wired that way. It can make things more complicated, it can cause a lot of pain, cause a lot of abuse, and discrimination in the name of different faiths. I think that it can also influence accessing people’s spirituality in therapy. I have clients who tell me outside of the paperwork, I don’t want to talk about spirituality or religion, which is totally fine. If they are comfortable, I then ask some questions, such as, “What brings you peace in your life? What gives you joy? What gives you a sense of being? Where is your safe place? Or safe person? Or safe pet? What gives you a sense of connection with the world around you and humanity?” Sometimes people feel better talking about the sense of energy in the world and the universe. I tap into that. I might ask, “When do you feel most connected with the sense of energy?”  

MIA: This brought it into my head, Dr. Miller had an incredible talk last week with Center for Discovery, in their speaker series

MARIANNE: Thank you

MIA: It was amazing, and she had us do this amazing exercise of having us basically do word association with the word religion and the word spirituality. It was so interesting to see the difference in which people have that connotation. People did start off nice on the religion side and then as one brief person said something on the less flattering pc side of things, and all just started to draw out. You couldn’t keep up with writing. So, I think it would be interesting to just touch on the judgements that people have around religion verses spirituality. 

MARIANNE: Yeah, one thing I mention in my talk, when I would teach my students, and btw I stopped being a full-time professor when into full-time private practice in January of this year [2018]. It’s because I LOVE my clinical work. When I was working with my students and teaching my class, I would say, “imagine you have a couple coming into your session and she is wearing a head scarf, she’s wearing a veil, and she’s covered from wrist to ankle and her husband may have beard and look kind of middle eastern. What sort of assumptions come up for you?” I had them write them down. So, some of the assumptions where she was very oppressed in her marriage, that their culture is very discriminatory toward women, she’s at home all the time, etc..

Okay, well what if you found out that she was a doctor and he was supportive of everything that she did? Just breaking down some of those stereotypes. A lot of information that we get from religion is from media, and what makes the news? It’s the extreme incidents. The religious people who can go out and kill people. People who start wars. Where not talking about the everyday mosque that does great things for the community.

I think it’s important for therapists for themselves and for them to help clients to realize where these stereotypes are coming from. I think there is a regional component to, I think in southern California, Spirituality is in general more excepting and of a framing more individual thing, verses religion. It’s not like it was like when I was in Texas, there was a mega church on every corner. There are mega churches in southern California, well-known ones, but it’s not as prevalent.

When we were living in Texas, if you didn’t go to church every Sunday, it was like, “what’s going on?!” People were surprised. I think religion in general is considered to be more collectivistic, more about external doctrine verses spirituality is assumed to be more individual. It could be about your personal relationship with a higher power, universe, or spirit, or God. Religion can be more of the organization or entity.

Another thing I talked about in the Center for Discovery speaker series is intrinsic verses extrinsic spirituality, faith, or religion, and that’s written a lot about in the literature. A lot of research on the psychology of religion and spirituality. There’s actually a division of the American Psychological AssociationThe Society for the Psychology of Religion and Spirituality, so a lot of people publish research on that, and they talk about extrinsic versus intrinsic spirituality. Extrinsic is going to church for my standing in my community and maybe the roles that I have with them, i.e., the external motivation and that’s what I feel like I need to be doing. Intrinsic is more internally motivated, it’s coming from your heart and your soul or your spirit. Now you can have both in your life, but what researchers have shown is that a faith that’s more resilient is more intrinsic faith verses the extrinsic. 

EDIE: Makes sense to me. 

MIA: I know that you started to talk about this when you first asked your question a little bit ago about music and spirituality and I think that I know your very passionate about. Music is a huge aspect of your life.

MARIANNE: Oh huge.

EDIE: Yes, not that I’m a musician or anything it’s just that I listen to a lot of it.

MIA: and has great taste and DJ’s and does all these amazing things.

MARIANNE: Oooh, I wanna hear (Laugh) Wanna get some tips!

EDIE: Laugh, so I think for people who are listening and thinking I’m not spiritually inclined, I’m not religiously inclined, what is a way for me to get a more sense of meaning, and a sense of peace, music seems like a really wonderful natural gateway into that.

MARIANNE: Absolutely, music, art, you know I have clients who are into drawing and painting and things like that, even quilting is a huge one, being out in nature of course this is San Diego going to the ocean. I mean I’ve had one woman and her daughter I worked with a few years ago that they would go every Sunday to the beach, and they would go to pray that would be like their sacred time at the beach. I’m from Colorado, so It would be mountains or hiking, seeing animals, flowers and things like that. I had a dachshund who died a couple years ago.

EDIE: You had a dachshund too? That’s my kind of dog! 

MARIANNE: I know I’ve seen that on your Instagram. Our dog’s name was Max, he was our baby; I’m still recovering from his loss, unfortunately. I definitely had a spiritual connection with him. I mean I wouldn’t say it was this big life transformative spiritual connection, but just petting him and the comfort that we would mutually give each other felt spiritual to me. I mean when I hear people talk about their animals, I have worked with a lot of people who interestingly enough who ride horses or work with horses, and horses are very spiritual animals from what my clients tells me—they are very intuitive—there’s a sense of something about them that just kind of greater than their physical bodies. So, all those questions that I explore with my clients. Music is a huge one. It was a comfort for me and my pain.

MIA: That’s interesting, because our guest a few weeks ago Nima talked about not having the ability to listen to most music but there is one song that she was able to use in her recovery process and being able to really resonate with that. It’s a connector of people. 

MARIANNE: It brings people together, which in my mind I see that as a spiritual thing, too. You can feel the energy of a crowd, it’s just powerful. With my literature background, going to a play, or a musical, Hamilton was such a huge, transformative, cultural phenomenon, the way that it brought people together in such a meaningful way. I consider that like a spiritual experience. I also wanted to mention poetry can be scared text for some. For people who are more religious, it can be the Bible, or whatever, but also poetry as an inspirational writing can be especially helpful. Writing their own poetry, or writing their own songs, or composing their own songs. I find writing, I just started a five-part blog series on finding the spiritual in eating disorders treatment that I think that can apply all kinds of people and all kinds of recovery. The first one is filling your spiritual cup. It’s talking to people from all different walks of faith, as well as people who don’t really identify themselves as spiritual.

My own process of writing is a very spiritual for me, I’ve been journaling since elementary school and that is a very spiritual thing. I think from a clinical perspective, I must make sure as a therapist that I’m attending to their emotional health, their psychological health, and relational health, and their spiritual health. So, in many ways, attending to that spiritual part of them. Asking: When do I feel most authentic? When do I feel most grounded, or centered? Obviously, those are the times whatever your doing to feel most grounded and centered can really help you access that spiritual part of yourself. 

MIA: Something else that I’m going to keep going back to talk, because it was so mind-opening.

MARIANNE: Yeah, that’s fine. 

MIA: Someone had a question at your talk—it might have been you Edie actually (Laugh). 

MARIANNE: (laugh)

MIA: I know, there was a whole conversation that happened after but when religion can be used in a way that can counter-indicate therapy. What to do in that situation where it’s like you want to be respectful of the faith what’s going but being able to explore how it could be a barrier in their ability to get well.

MARIANNE: Absolutely, I once was supervising a woman when I was a professor, and her internship was at a the counseling center at church. She had a client with an eating disorder who said well God is telling me not to eat. Well, we can’t argue with God, you know! It like that’s when someone says well God is telling me to do something, I can’t argue with that, and so, you shouldn’t as a therapist because it’s about knowing your scope of practice.

Your scope of practice is the emotional, psychological, relational well being of your client. [At the same time], if their spiritual and religious beliefs are impeding things and affecting those things, then you can address it. I mean you’re not a theologian, you don’t want to get into a theological debate with them, just don’t even go there, don’t start bringing up Bible verses. You’re not going to win. When they are saying well God says this and that, you can’t do anything with that because you’re not a biblical scholar, you’re not an Islamic scholar, whatever.

One thing you can be curious about is asking them, “well I’m just kind of curious because if God is telling you not to eat, what are the consequences of you not eating?” and they say, “you know I’m going to continue to get thin.” You reply, “Okay, yes but then what will continue to be the consequences of not eating?” “Well I’m going to end up probably dying.” “Yeah, you probably will. You think that’s what God’s plan is for you is for you to die?” And go from there.

Even if you don’t feel comfortable having those kinds of discussions you can just say, “As your therapist, I would not be doing my job if I didn’t tell you that you need to be eating. I don’t what kind of experience you’re having a belief that God is telling you not to eat but I wouldn’t be doing my job if I didn’t tell you, you need to see a dietitian. We need to get you into a place where you’re eating or get you into a higher level of care.”

Another example of that I had a student share that he was once behind a one-way mirror in a training situation and there was a trainee therapist working with a couple and there was a husband who was emotionally and physically abusing the wife and he was saying, “Well, look at these verses in the Bible. They were Christians and look at [such-and-such] verses, and this is my justification.” What just astounded me and dishearteedn me is the supervisor was sitting behind the one-way mirror with my student and said, “We can’t address that because we can’t bring religion in.” I’m like “What? No!” And again, it’s what your scope of practice is. Ethically, we need to make sure that our clients are not coming to harm. We want to do what’s best for our clients, and we don’t want them to be hurt. And in those situations, the wife was being hurt and as a therapist, whatever your belief or faith is you have to tell the client to stop hitting his wife. This violence must stop. And here are the psychological, emotional and relational consequences of that. You can outline those things.

Going back to that example to the woman who was said God is telling me not to eat. It’s not only the physiological consequences of that, but what are the psychological consequences, what are the emotional? “Do you think that not eating won’t affect your ability to pray to participate in your faith organization, or the energy to pray? You won’t be able to focus. Your brain will start shrinking, because you’re restricting.” Thinking about it that way. Asking, “What do you think God’s purpose is for your life? Continuing to restrict, will it help you fulfill that purpose?” It can be used with other things like cutting on oneself. “Well continue to cut, will it help you fulfill your purpose in life?” 

MIA: I think what’s coming into my mind not being a very religious person, the eating disorder things that I have heard before in this process that treating people across this spectrum is, especially in Christianity and I know for a fact, I was raised in Judaism they just practice around fasting food and that can get very complicated. Making sure you have awareness of the cultural implications of what’s going on for you just jump in and say you have to eat! 

MARIANNE: Absolutely, you know if you have a Muslim client during Ramadan, they fast from sunup to sundown and that get tricky. You have clients who are in the refeeding process and that may not be possible and so what kinds of compromises can we make with them. It’s about being respectful of their religious beliefs. It’s important not to assume that they are restricting because if their restricting is part of their eating disorder, as they could be not eating certain foods because of their religious beliefs. It’s important to assess for those things. 

MIA: You mentioned before about like the supervisor saying you can’t touch this because it’s religious. I’ve falling into that trap multiple times. I don’t want to offend, I don’t want to overstep, don’t want to go outside my lane of practice but then I think it can be more harmful if you’re totally ignoring this huge piece of a person. How you navigate it is so amazing. Hoping to seep some of this in so I can use it.

MARIANNE: Thanks, I mean 89 percent of Americans believe in God or some sort of higher power. So, statistically the chances of your clients having some sort of belief in a higher power is high. I think ethically we are doing a disservice if we don’t assess for that. Your experience is very common, [which I saw when] I did therapist training for almost twelve years. One thing I hammered so much [is the important of assessing for spirituality. Most training programs and most supervisors don’t know how to teach their therapy students how to assess for spiritually or religion.

It goes back to when Freud came to the United States for the first time in 1912, I think. He was visiting Clark College, and during that period the American mental health field was just brand new, and all the cool stuff was happening in Europe and with Freud and all that stuff. [The Americans] were like, we just some legitimacy. In United States at that time there was more integration of faith, psychology, and spiritually. There were more connections between faith organizations and trying to help people through counseling. But when Freud came over and gave the talk at Clark College, now Clark University, he said straight up that anyone who belief’s in religion has some sort of psychosis. So, the mental health community was like oh we must do what Freud says, and it affected and turned the tide.

Other things that were going on in the United States [during the time Freud came], like the Big Tent Revival Movement, were scary for some people. The Big Tent Revival was a movement for Christians trying to convert people to Christianity, and that was scary for some people. That was coupled with what Freud said okay we’re going to step away and not talk about religion and spirituality with therapy and consider it maladaptive.

I would say people started talking about [spirituality in therapy] more in the 1990’s, when people started talking about diversity and people started talking about diversity issues in therapy. Even when I did my dissertation in the early 2000’s, [spirituality in therapy] still was kind of a taboo topic. Not very many people were talking about it or researching it. In the last fifteen years it’s exploded, and so much more research has been done about it. The emphasis on integrative help has also opened the door for spirituality to be integrated into therapy.

As therapists, the way to do it is to we need to ask very broad questions like, “What brings peace in your life? Do you feel calm? What helps you feel connected to the world around you? And then ask questions like, “What is your religious background? What was helpful about it? What was harmful about it? How does it affect how you live your life?” I work with a lot of LBTQ clients who have come from faith organizations that have been very oppressive to them, but they still want to hold on their faith, and that’s one thing I work on by separating the two. Yes, you can still have a faith but be fully gay or fully transgender or whatever. Still, with therapy you have to eat with the drama and discrimination and I would say spiritual and religious abuse that can happen. Especially with the LBGTQ community. 

MIA: Yeah, I can certainly identify with that on a larger level not necessarily identify with that community myself but when I was twelve years old, I actually wanted to accept all types of people and it felt as though the doctrine that I was being taught at the school and the church I was coming from certainly did not support that. So, it was traumatic to feel separate from the people around me weather it be because I told a friend I identify this way and I wanted them to be accepted. I’m 37 now and still deal with the aftereffects of all this and so I don’t want it to affect my practice in anyway. So, I think I’ve been continuing to try to work some of this so I can be there for people in my life or for clients that do identify but obviously don’t want to go about in a way that I experienced.

I’m glad you brought it up because it’s very real thing. I don’t know if it was anyone’s [intention]. I think it was just people did what they thought was right at that time, and so that’s a very different perspective I’ve ever thought would come out of my mouth. Back then, it felt like I couldn’t exist and be different from everybody else. That really disconnected me very young from everything from having to do with Christianity. Now, I’ve been fortunate to have some people come into my life that do identify that way and then it’s a very corrective experience for me in a lot of ways. I can see that they have amazing hearts love for humanity just as I try to do and yet can very much still believe and I don’t have to automatically go to this dark place. I mean, it still comes up; I’m not going to lie. I’ve had people ask me to go to a gathering and things, and I have a reaction to it. I don’t know if that will ever change, I’m not going to lie, but it’s just interesting that it’s nice to start opening to it. So, I’m not trying to turn this into the Mia session 

EDIE: I think that’s one very insightful view to share. What I’m hearing in this dialectic (looking at it as a dialectical behavior therapist) and that’s coming through right now the ability to say “yeah I had a negative role in this experience and now I have the ability to see it.”

MIA: Absolutely, and I’m so glad because the last thing I want to be is not be dialectical, that’s what I’m trying to live and breath and teach. The “both-hand” view is that I can still come across people in my life who will say absolutely keep me away from all of that and it’s like okay. I hurt in away cause I know that feeling. But we can be more open to it. 

MARIANNE: Sure, and unfortunately in the United States, and also around the world, but especially in the United States, there is a big element of tribalism, this sense of, “what I believe is right and I have to be loyal to my particular faith.” What results from that is this other phenomenon where anyone who believes differently from me, the different tribes per se, “they are wrong and we are right and we can’t associate with those people.” If you don’t believe that way, you can psychologically internalize the differences and start thinking, “something wrong with me,” instead of realizing that there are maybe some beliefs in the tribe that are not psychologically healthy. From a therapeutic perspective, we must look at the psychological, emotional, and relational health of our clients. That’s our scope of practice. So, sometimes the doctrine that people grew up with is detrimental [in those areas]. That’s something [as therapists] we must look at and try to help clients unpack. 

EDIE: This has been informative for me and I hope for all of you guys. Are there any final words you want to part with? 

MARIANNE: I just encourage people to nurture the spiritual part of themselves, even when it doesn’t feel overly spiritual. Whatever they find themselves passionate about, where they feel very authentic, whatever is grounding to them. I see plants around this room, it could be gardening, it could be hiking or nature, swimming, or the ocean, or swimming in a pool. Whatever feels grounding. It could be going to a religious organization and going to their faith community and participating in rituals or whatever is meaningful for you—that’s what will help you overcome the ups and downs and challenges [of life].

MIA: Thank you so much for your time and your wisdom.

MARIANNE:  Thanks for letting me come

MIA: Where can people find you? 

MARIANNE: They can find me at www.drmariannemiller.com, and they can find my blog and can see what things I’ve been writing, and they can find me on Instagram at @drmariannemiller.

EDIE: Thank you for gracing us with your presence. 

MARIANNE: You are sweet. 

MIA: Thank you for all you guys listening. This has been the 6th episode of breaking down the podcast, bye guys.

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Hey everyone, I really appreciate you reading my blog!  Have a wonderful day. :)  

Marianne 

If you are struggling to find eating disorder treatment in San Diego, give me a call for your free 15-minute phone consultation at (858) 699-3754, and I will help you get where you need to be! 

You can find more information about me on Instagram @drmariannemiller or on my Facebook page.