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Family-Owned, Patient-Focused: The Renfrew Center Difference

Podcast Transcript

Episode 13: Eating Disorders in Muslim Populations: A conversation with Fatema Jivanjee-Shakir, LMSW

[Bouncy theme music plays.]

Sam: Hey, I’m Sam!

Ashley: Hi, I’m Ashley and you’re listening to All Bodies. All Foods. presented by The Renfrew Center for Eating Disorders. We want to create a space for all bodies to come together authentically and purposefully to discuss various areas that impact us on a cultural and relational level.

Sam: We believe that all bodies and all foods are welcome, we would love for you to join us on this journey. Let’s learn together.

Ashley: Alright. Hello, everybody! Welcome back to another episode of All Bodies. All Foods. We’ve got Ashley and Sam here today and we are so excited to share with you, we have a special guest with us today. We’ve got Fatema Jivanjee-Shakir, LMSW joining us to talk about the intersection of eating disorder and the Muslim populations. So, Fatema is an eating disorder and body image therapist, speaker, and writer. Her work is strongly informed by the Health at Every Size perspective and intersectional approaches to healing. Fatema has a special interest in working with BIPOC clients, especially those of Muslim and South Asian backgrounds. Fatema is a therapist in private practice at the Conason Psychological Services where she offers individual and couples therapy, and board member of the International Association of Eating Disorder Professionals in the New York chapter. Fatema was most recently a primary therapist at The Renfrew Center. So, thank you so much for joining us today! We’re so excited that you’re here.

Fatema: Thank you for having me, I’m excited as well.

Sam: Welcome. Fatema, it’s been a while since I’ve seen you. We’ve done IG Lives together, we were on TikTok together, so it’s so great to have you here on our podcast. I was wondering, would you be able to tell us a little bit about yourself and what got you interested in the mental health field? What got you interested in eating disorders specifically? We just want to hear your story.

Fatema: Yeah! So, I think for me it’s always been eating disorders in particular. The reason I say that is because when I was growing up, I was really fortunate that I was a part of a lot of different multicultural communities. I grew up in a— my hometown was predominantly Hispanic. I identify as South Asian and Muslim, and on the weekends, I would spend a lot of time at my Muslim community, around other people who are also South Asian and Muslim. And I remember when we were going into high school, seeing a lot of friends who were white struggling with disordered eating, getting diagnosed, getting treatment, but noticing that my friends who identified as Hispanic or identified as South Asian and Muslim, their behaviors not necessarily being noticed as being disordered eating, and therefore them not always getting help. And I think there was also a lot of stigma as well. So, that was kind of the first touch point for me where I was like, “Oh, this is interesting, like, this person doesn’t seem okay, like, why aren’t they getting help?” And then during my, I think it was my junior or senior year in high school, I had a sociology teacher who had us do a research project. So, she was like you could do anything you want. And my friend and I decided to look at like body image and body satisfaction. And so, we administered these surveys during all these lunch hours at school and collected the data and analyzed it and everything, and it was really interesting to kind of look at the demographics and how people of different races, like, internalized different body ideals and their experiences with food and their family. And then for me, I think after that it kind of just felt like a calling, of like, “I want to go in this field and make a difference, especially for people whose eating disorders are really under recognized.”

Sam: Yeah. Oh, wow. So you are doing research on this as early as high school!

Fatema: Yeah, yeah. I’m very fortunate to have had that sociology teacher because she starts this whole like interest in me that I didn’t really know existed prior to that.

Sam: Yeah, shoutout to them for that because here you are. You know, Fatema, I have watched so many of your trainings and I recently watched the training you gave for The Renfrew Conference in 2022. And I learned so much, and one of the things that stood out to me, you had a slide talking about, you know, eating disorder recovery in Muslim populations and you had mentioned that eating disorders are 2.3x higher in Muslim teens, and body image dissatisfaction is 1.8x higher in Muslim teens compared to their Christian classmates.

Ashley: Wow!

Sam: Which is similar to the research you were doing early on in high school. Why do you think this is? Why do you think it’s higher?

Fatema: Yeah, it’s a good question. So, there’s two things that really come to mind. And the first thing that comes to mind for me is the fasting rituals in Islam. So, a lot of different religions have fasting as part of their religious practice, but I think that in Islam there’s a lot more fasting practices that happen. So, we have Ramzan which is the 30 days of fasting that we do. And then there’s also Youme Arafa, there’s Ashura for people who identify as Shia Muslim. And then there are other months where people can fast, it’s not a requirement of the religion, but it’s considered sunnah, so it’s something that’s recommended or suggested. And so, there’s two other months of fasting, and in fact, some Muslims believe that the Prophet Muhammad would fast for a one third of the month, every single month of the year, aside from Ramzan when it was 30 days of fasting. And so, there’s a lot of fasting rituals and practices that are part of the religion. And so, what research has shown is that fasting serves as a risk factor for disordered eating. And I don’t think it’s the religion itself, but I think it’s diet culture that’s kind of intertwined with that idea of fasting, right? Which tells you that controlling your food consumption is going to allow you to lose weight and therefore be thin and being thin is often seen as being really valuable.

Sam/Ashley: Mhm.

Fatema: And I think if you’re thinking also about Muslims who maybe are not living in Islamic countries, have migrated to Western places, a lot of times, their families really want them to succeed and to have good lives and to be able to fit in with other people. And so, if you’re a Muslim person who’s surrounded by a lot of Caucasian people, for example, people whose body shapes and sizes might be different from your genetics, your family might also encourage that weight loss because they want you to fit in, they want you to have your best chance. And it might be really well intentioned, but I think it kind of fuels into that disordered eating. And I think that it can also be exacerbated by the community around you. So I remember growing up, you know, I was one of the few Muslim people in my school, and so people would often make comments like, “Oh, like, I wish I had the self-control to go all day without fasting,” or like, “Wow, like, you know, it’s so amazing that that you can go without food and water all day.” And so, when you’re already feeling other and different and people are making comments that make it seem like you’re valuable and there’s something special about you because you can engage in this restriction and this refrain, it can really perpetuate that because you don’t want to lose that feeling of, like, “I’m special” or “People are looking up to me,” which can also bring on this kind of moral superiority and that pressure to really continue engaging in these practices that are harmful when taken out of the context and the safety gears that are kind of in place within Islam of how to practice fasting.

Ashley: Right, I’m just thinking—

Sam: That makes a lot of sense.

Ashley: Yeah, and I was thinking that that sense of feeling, you know, of somebody kind of congratulating you and feeling that way instead of feeling like the other, that’s got to be so, kind of, motivating, right?

Fatema: Yeah, exactly.

Sam: Yeah. And, you know, these religious practices, there’s a purpose behind them and they just—it just so happens that it aligns with diet culture where there are so many folks who—it sort of like provides that false sense of accomplishment and discipline, and the morality and all of that tied in, I could really see how that would be so reinforcing to hear that from your peers. And I think this is so helpful for anyone listening, just to know what not to say to someone who it is fasting for religious reasons, how those things can be really sort of reinforcing and can feed into someone who has, maybe, a vulnerability to have an eating disorder. You know, we don’t know who, you know, has the genetic vulnerabilities, the psychological vulnerabilities. This could be someone who is struggling and we don’t know.

Ashley: So, kind of thinking about that, Sam and Fatema, thinking about the Muslim populations, what might be some unique challenges that they might experience with eating disorder treatment specifically, and/or eating disorder recovery, you know?

Fatema: Yeah! So, I think kind of bouncing off of that idea of fasting, right? I think if someone’s in recovery, it can be really hard to decide, like, “Am I going too fast when there’s a holiday,” right? There can be a lot of social pressures coming from family and friends because there’s a lot of community around the different fasting holidays. And so, you know, if you’re making that decision of like, “Do I engage in fasting or do I not?”, you might be scared that, like, people are going to judge you, they’re going to ask questions, maybe you’re worried they’re not going to understand that you’re experiencing an eating disorder. You might also not want to feel left out, right? You might want to do what all your friends and family are doing. And so, what I’ve seen some people do in recovery is, you know, understanding that, like, “Okay, I might not be in a place to fast right now, but I’m going to pretend to fast when I’m in public spaces, like at the mosque, because I don’t want people to ask me questions.”

Ashley: Mhm.

Fatema: And while that might be done with a really good intention of like, “Okay, I’m going to try to protect my recovery,” it can still really trigger the eating disorder, because that person might refrain from eating for a couple of hours while they’re at the mosque. And I think, you know, in treatment especially, I think the lack of access to Halal foods is a huge thing. Because many Muslims who do eat Halal diets, often when they’re going to treatment centers, will adopt a pescatarian diet or vegetarian diet while they’re in a program. And so, in many ways this can actually reinforce the eating disorder because they’re restricting, right? They might be restricting meat that they would normally eat. And so, this can make the idea of really implementing recovery difficult, especially outside of a programmatic setting.

Ashley: Yeah.

Fatema: And in addition to that, the eating styles and eating cultures within programs are often not reflective of what’s happening at home. So, in a lot of Islamic communities, there’s a lot of communal eating, like everyone’s sitting around, like a really—it’s like a round, large plate, oftentimes it’s called a thali, there’s different versions of it depending on the culture, but there’s communal eating and everyone kind of, sharing from the same plate. When that isn’t reflected within a program, it can bring up this idea of, like, “Well, how do I do this when I’m not in this very controlled setting,” right? So, I think that can really increase the risk of relapse as well.

Ashley: That is so interesting, and I’m so appreciative of you even sharing this. I think, just even in my own journey, as I’ve learned and grown, you know, as a person, as a therapist, as someone that’s really trying to better understand different cultures—I identify as a cis gendered white female, you know? Often I do feel like programs are set up for cis gendered white females, right? And so, and I’m even thinking about some of the food that we’ve offered and served before, and I would not have thought about this idea of providing a Halal meal, or that communal bowl or plate for all of us to kind of eat from. I mean, that makes so much sense, what you’re saying.

Fatema: Yeah. And I think it can also make the person question the validity of the eating disorder, right? Like, “if treatment isn’t set up in a way that mirrors my life, is what I’m going through, like, real?” It can bring up questions like, “Am I making this up,” you know, which can be really hard because someone might already be facing that from family, from friends, from society of, like, “Is your eating disorder real?” And so that can really get reinforced, and I think it can also fuel that sense of disconnection, right? So, if your culture around food is based on connecting with others and community, and in your recovery process, that—the way that that’s implemented looks different, you know, I think it can fuel disconnection which can also then continue fueling the eating disorder,

Sam: Right! I mean, if someone comes into treatment and they’re not seeing the foods that they’re used to, they’re not eating in the ways they’re used to, it’s going to probably create some pretty strong emotions. And that would, in turn, make them possibly turn to the eating disorder for comfort. So, it really makes a lot of sense that, you know, really how important it is to have cultural humility in eating disorder treatment. So, I’m curious, you know, I think also, I’ve seen videos where you’ve talked about diet culture’s role in sort of demonizing cultural foods. And I was wondering if you could say more about that, because I think that can play into the eating disorder as well.

Fatema: Yeah, I think that’s a really good point, Sam. And, you know, I often think about it from the treatment lens in terms of the meal plans that we create for clients, right? So, I think different cultures, first of all, have different styles of eating. Some cultures might include more carbohydrates as compared to protein, or more vegetables as compared to a carbohydrate, etcetera, right? Like, the kind of quantities that are considered normative in different cultures and different religions is really going to vary place to place. And I think the meal plans that are often used by dieticians, both eating disorder dieticians and otherwise, are often reflective of Western standards of what it means to have a “balanced diet.” So, if you’re prescribing a meal plan to a client that maybe says, “Okay, you need this much protein in a day,” but maybe the client’s never grown up eating that much protein in a day in their whole life.

Sam/Ashley: Right!

Fatema: That meal plan becomes really difficult to implement again outside of a very controlled setting. And so, then I think what it does is it kind of reinforces the demonizing that diet culture does of, for example, like, carbohydrates, right? Diet culture often tells us, like, “Carbs are bad! Carbs are gonna make you gain weight!” All those great things. And then if you’re receiving a meal plan, as well intentioned as it might be, that says, “Okay, well this is how many carbs we’re recommending that you eat in a day,” the client might feel like, “Oh, wait. Okay, like, maybe eating more carbs than this is actually bad, it’s not good for me.” And so, it can kind of create that separation of like, “Okay, well now I need to disassociate and disconnect a bit from my culture so that I can be what western culture deems as being healthy or being valuable.”

Sam: Wow. And so that can really create a lot of shame around the way your family does things, and the way your culture does things, and again, intense emotions. Shame fuels eating disorders. So, I’m wondering what would your suggestion be, for maybe dietitians who are working with a Muslim client, and their client is telling them, “I usually eat more carbs than this.” How do you think the dieticians should navigate that conversation?

Fatema: That’s a good point, or a good question. And I think the first thing is to ask an open ended question, because when we think about the culture of respect and what is considered appropriate or not appropriate to say to someone of authority, a Muslim client may potentially not even feel comfortable—and I don’t say this to speak for all Muslims because obviously people have different personalities—but culturally, you know, they may not be comfortable being up front with you and telling you, like, “Hey, this isn’t really reflective of the way that I eat, or that my family eats.” And so, I think, you know, if a provider can really approach it with a sense of curiosity of, like, “Hey, let’s understand, like, what did meals look like when you were growing up? What does your family eat? Help me understand the different components of that, the style of eating.” Then you are, you’re really inviting a bigger picture, right? Of, you know—you’re not asking about, like, “Okay, well, how many meals and snacks were there?” You’re leaving it open. Maybe there’s more than three meals, maybe there’s fewer meal but a lot more snacks. And so, when you ask it in an open ended way, then you open the door for you and the client to really understand, like, “What is the culture of food in my family and in my community?” And then, “How can we build a meal plan that is really reflective of that? That allows me to participate in my life in a sustainable way.”

Sam: Well, I think it just goes to show how important it is that you’re really gathering so much information from your client about their culture, and understanding every detail about, you know, the norms around eating and, you know, family. And that’s another thing I would love to ask you more about, is the family work. But yeah, how important it is to really start from a place of curiosity and creating that safe space for your clients to really open up about the way that, you know, they culturally do things.

Ashley: Mhm. I’m even thinking about, like, food rituals at this point, Fatema. And for our listeners out there, a “food ritual” is something that our clients might engage in, to maybe soothe or settle some anxiety that they’re experiencing when a food is placed in front of them. So, they might cut things up really small, they might push things around, you know, on their plate. But I’m thinking about food rituals and maybe some behaviors that someone might engage in just on a normal capacity in the Muslim population, and/or how that might affect their eating disorder recovery. Any thoughts about food rituals and kind of that impact on eating disorder recovery?

Sam: Yeah, and just to go off what you’re asking, Ashley, like, I’m wondering, specifically in treatment centers, are there behaviors that are pathologized when it’s actually just part of client’s culture?

Ashley: The normal—Yeah, cultural behavior, yeah.

Fatema: Yeah. So, even the first thing that’s worth recognizing is that, depending on the Islamic sect that somebody is a part of, there can be certain food rituals that are actually like a part of the culture. So, for me and for the sect that I identify with, we start every meal with, like, a little taste of salt. And that’s regardless of whether it’s breakfast, lunch, or dinner,. It’s a part of the practice. And in some Muslim sects, there’s also an order of eating, right? So, especially if you’re eating communally, where food is kind of set out, like you might start with a sweet, then move to a savory dish, back to a sweet, back to a savory dish, and potentially ending with rice as the last part of that meal. And so, there can actually be an order to the way that we eat that I think, in my experiences working with an eating disorder, sometimes if we’re seeing clients who are eating in a specific order, we might see that as being a disordered practice, but it can actually be a cultural norm.

Sam: Right, absolutely. It’s sort of like, you know, you have sometimes counselors who are monitoring meals, and their job is to look out for food rituals because, you know, food rituals sort of keep an eating disorder alive. And if they’re not aware that this client has these cultural practices they could be marking down that this client is engaging in eating disorder behaviors during the meal, and they’re not!

Ashley: Or maybe challenging them, even. Like, I’m thinking about–

Sam: Or redirect—

Ashley: Right, yeah, redirecting.

Sam: Redirecting!

Ashley: Because I have sat across so many people, kind of coaching and trying to help them consume their food, and I’m just—my mind is racing right now, truly. Like, “Oh my goodness, have I redirected someone when they were experiencing something or engaging in something that was just culturally appropriate,” right? Like that— I’m so happy you’re on here today, Fatema, I feel like I’m learning so much.

Fatema: I’m glad to hear that!

Sam: Oh, I’ve learned so much from your trainings, it’s been amazing. You know, I’m thinking about, you know, excessive use of condiments as a ritual and if, you know, if a counselor would see someone eating salt before the meal, they might immediately think, “Oh, this is someone who is either using a condiment to mask the taste of the food, or they’re using salt maybe to water load, or you know, some of those more extreme eating disorder behaviors.” And it really shows how important it is for the team to communicate with each other. Where, you know, to be aware that this client might engage in these behaviors, but it’s not part of the eating disorder at all.

Ashley: Right. I think it begs us—I mean, you said this already, Fatema—it begs us to be curious about the whole picture. I mean, just continually as their providers and really as the people that are providing that safe space, you know, or wanting to provide that safe space for them. We have got to be curious about where our clients and people are coming from. I mean, we have to, right? And we can’t assume. We can’t assume that they’re a part of our culture or that we have done things the same way, you know, growing up and things like that.

Fatema: And I think one exercise, actually Maggie Hartman at Renfrew introduced exercise to me, but it’s called the Family Table, right? Where you ask the client to really just like draw out, like, “What did your family meals look like when you were growing up?” And what I loved about that exercise when I would implement it, I would try to change it from Family Table to Family Meal, because it allows clients to really think about, “Well, did we eat at a table? Did we sit on the floor? Did we eat on the couch?” You know, like, in Islam, especially the sect that I’m a part of, we will typically eat meals on the floor in this communal setting. And so, an activity like that I think really invites that curiosity of, like, “Let’s understand what it looks like for you.” And yeah, I think it’s just a really beautiful exercise to kind of remove our blind spots as clinicians, to invite new information that might just never have been privy to.

Sam: Well, I think it’s an example of— that’s like an open ended question. You know, “Here’s a blank piece of paper, you tell me what mealtime was like for you.” And really it’s our job as clinicians to just learn in the beginning about our clients and, you know, just really sit back and really try to understand. So, speaking of families, I’m wondering, you know, on this podcast we talk a lot about the importance of family work in eating disorder recovery, and I’m curious what you think providers need to understand when working with Muslim families who have a loved one in eating disorder recovery. What do you think are the most important things that, whether it’s a therapist or a dietician or a psychiatrist, really anyone, what do they need to know?

Fatema: So, I think the first thing to recognize is that Islam typically operates from a very collectivistic point of view. And so, what that means is that a client’s family may want and need to be heavily involved in the recovery process regardless of the client’s age. And I think often times we use the legal standard of, “18 years old means that you’re an adult.” And so, we might not provide, like, family sessions to a client, whether that’s therapy, psychiatry, or even dietetic sessions, once they’re 18 or above. But the idea of family and, you know, the idea of us versus you looks very different in an Islamic religion, and who is considered part of the family is also going to look really different. So oftentimes in Islam, people who are not even blood related to you are seen as like your Muslim brothers and sisters, right? So, when we then think about the context of, like, “Well, who is family,” you might see grandparents, you might see aunts, uncles, cousins, want to be involved in the treatment process. And that’s largely because they’re considered part of the immediate family, right? I think in Western cultures, we think of your immediate family as being like your parents and your siblings, but that’s often not the case in a lot of collectivistic cultures. And so, you know, one, we should always check with the client. Like, “Are you comfortable with these individuals being part of your treatment? Who do you want to be a part of your treatment?” And recognizing that, you know, there might be a little bit more that we provide, and some things that we provide that are different from Muslim clients, than we might for other people who are of the same— of a similar age range.

Sam: Mhm. I think that’s so important for therapist to know, because I think sometimes maybe with greener clinicians, you know, maybe ones who don’t have much experience or they’re not culturally informed, they might even pathologize if there are multiple family members that want to be— or friends and family that want to be a part of the process. I mean, I’m thinking about, you know, the term enmeshment, you know, it’s sort of like— I think, you know, some clinicians are at risk of maybe even using those terms, like it’s a negative thing that your family is so involved. Or your family must have collapsed boundaries if, you know, if they’re too involved. And the reality is, like, this is how many cultures feel, you know, many populations, this is how they feel supported in a collectivist culture. It’s wanting and needing that support from their family and friends and loved ones, and the family is really extended.

Fatema: Yeah. And who we perceive that enmeshment to happen with might actually be that clients greatest supporter in recovery. It’s when you think about family roles and gender dynamics that can show up in a lot of Muslim communities, oftentimes, like, a client’s mom might have the most sway with a client’s dad, right? Or like if a client, for example, is female and has a brother, the brother might be that client’s greatest ally in communicating to the family and helping them understand what’s going on because of the gender and power dynamics that are often given to males. Now, I’m not saying that, like, that is something that the client wants to ascribe to or really wants to participate in. But, you know, I think what we can do is we can work with a client to understand, “Okay, what are the things that you’re wanting to work on, and how do you want to rank them?” So, maybe the client isn’t comfortable with these gender dynamics that exist in their family, but perhaps what’s more important to them in this moment is making sure the family understands the eating disorder and is a part of that recovery. In which case, like, if they’re wanting to play into those gender dynamics to support their recovery right now, it’s okay for us to do that and to then later work on this issue, right? But again, I think it goes back to that idea of, like, we might perceive the client and these other loved ones as being enmeshed, and at the same time, those people might be the client’s biggest advocates and allies in the process.

Ashley: Right, right.

Sam: Exactly.

Ashley: And just again, that term enmeshment, I think even as a, you know, as a therapist, I feel like we have kind of a negative connotation with it, right? And that truly may not be the experience of our client, kind of what we’re thinking. So really, yeah, really kind of understanding that for each individual client that walks in, that family can look very different than what we have perceived it as.

Fatema: And I think that boundaries can also look different depending on the culture, right? I think in the U.S. and other Western places, we look a lot towards individualism and this idea that, “It’s about me.” And in other cultures that operate a little bit more collectivistically, it is often about the “US,” right? The boundaries between individuals are lesser so. And, you know, I think a lot of times that’s pathologized, when really we can look at it as a way of, like, “Well, this person may have a lot of community for healing, a huge support system because of the level of closeness that they have to other people.”

Ashley: You know, I was thinking about boundaries too, as you were kind of talking even about the enmeshment. Just like— I mean, just even thinking about, you know, my own self as a therapist, how you can be like, “Okay we’re gonna work on boundaries today, we’re gonna work on this.” And it’s like, wow, that truly someone might have a different experience and that, right, might really be changing or shifting a perspective that they have always lived under, which isn’t necessarily harmful for them, you know?

Fatema: Which also, you know, now that you say that, Ashley, is making me think about, like, the dynamics between providers and clients in the recovery process, right? Where I think, you know, I don’t know about the two of your trainings, but in my training, you’re taught a lot about, like, having boundaries as a clinician, right?

Ashley: Right.

Fatema: So, if the boundaries that you are kind of ascribing to a situation are conflicting with the boundaries that a client has been taught based on their culture, I wonder how that’s going to impact the therapeutic relationship as well.

Ashley: It’s just really helpful reminders. Even, you know, I know all three of us practice, we all do different things, but we also all have practices, and so this is just really incredible information to be reminded of.

Sam: Yeah, it’s— this is so helpful. And, you know, as we talk about these different terms that can be really pathologizing, I remember from one of your trainings, you helped clinicians understand the ways in which certain therapeutic modalities, even evidence based ones— It’s like, you know, in this field, it’s, you know, the evidence based modalities are really pushed, and you’re— you can really be made to believe that these modalities can be helpful for anyone, across the board. And in one of your trainings, I remember you talking about how there’s certain modalities and certain approaches that can actually be harmful to Muslim clients. And I was wondering if you could say more about that because it might surprise a lot of the clinicians out there who maybe rigidly sort of stick to a certain approach.

Fatema: Yeah, for sure. So, one of the things I often think about is informed consent when we’re going to utilize a therapeutic modality with a client. So, if we think about, like, modern day mindfulness and meditation practices and the way that they’re really implemented in Western societies, those practices have a lot of roots in Buddhism and Hinduism, right? And oftentimes clinicians aren’t informed of those roots, and then also aren’t informing clients about it. So, it’s not that a client can’t engage in those practices, it’s that as clinicians, I think we hold an ethical responsibility to inform a client that these practices are rooted in these belief systems. And, “Are you okay with that? Do you want to move forward with trying out this tool? And if not, do you want to think about a way that we could potentially adapt it that’s more religiously or culturally aligned for you?” So, I think about with Muslim clients who maybe aren’t comfortable with traditional meditation practices that often include music that has tones of Hinduism in it, they might be like, “Okay, I’m not okay with that, but I’m okay with, perhaps like, grand recitation or prayer as being my form of meditation.” And that might work for them, and that is completely okay. It’s okay for us to adopt practices according to client’s belief systems. And I think about that also with Dialectical Behavioral Therapy, right?

Ashley: Okay.

Fatema: That’s often used for the treatment of eating disorders, or we at least pull on skills from DBT to help people with eating disorders. And, you know, I think an approach like that is really rooted in individualistic ideals. The idea that you need to be able to self-regulate, have the skills to take care of yourself. But again, if you’re coming from a collectivistic background where the idea is that, “We rely on each other, that we co-regulate,” that can really conflict with what someone’s culture and religion has taught them. And so, it doesn’t mean that we can’t teach the client DBT skills, but maybe we involve a caregiver or supportive person in that to be like, “Okay, let’s all learn these together so that when the individual is in distress, you can co-regulate using the skills together.”

Ashley: Yes. You’re blowing my mind!

Sam: How would you, how— if you had a client and you brought in a caregiver, how would you sort of work through that, the co-regulation.

Fatema: So, I think I would reframe the idea of, like, “Who’s the client here,” right? Oftentimes you see the person as the eating disorder with the client, but if we think about it as like, okay, this unit, right? Like, perhaps it’s the child and the parent, or the client and their partner, are the unit, are the client together that we’re working with, then we can walk them through the psycho education of, like, “Okay, this is what this skill looks like. This is why we practice it. This is when we can implement it.” And then we can all practice that skill together, right? So, maybe the supportive person who’s participating in treatment practices the skill thinking about the time that they’re in distress, right? “How do I tolerate that distress?” And really what they’re doing then, is they’re showing the person with the eating disorder, “Okay, here’s an example of how we can regulate. And now how do we apply that to the problem that you’re facing? And let’s do this together, right? If what you need in this moment is to hold ice, right? To really feel that temperature difference in your body, lets each hold a piece of ice and make observations about what that feels like for us.”

Sam: Mhm, I love that.

Ashley: I do too, that’s beautiful.

Sam: We need more of that in therapy, more co-regulation.

Ashley: Yes.

Sam: Absolutely, I love the sound of it. Yeah, so, I think also I remember you talking about CBT. I mean we hear about CBT all the time in this field, sort of like the— I’ve heard it referred to as the “gold standard,” you know, before in different, you know, settings. And I’m curious what your thoughts are about CBT and Muslim populations.

Fatema: Yeah! So, I think a Cognitive Behavioral Therapy can be effective for a lot of people, and when we’re not conscientious about how we implement it as clinicians, it can also perpetuate trauma. So, one of the common ones I think about is cognitive reframing, right? Which is where, you know, we might think about a thought that we’re having and then think about, like, “Okay, what alternatives could be true? Are there other ways of looking at the situation that might also be accurate?” Right? And I think we often implement that with really good intentions, but when clients, especially Muslim clients, are often facing discrimination, Islamophobia, racism as well, I think if we’re not cautious about how we’re implementing a tool like that we can actually invalidate their experience, right?

Sam: Oh, absolutely.

Fatema: And say like, “The discrimination that are facing, maybe that wasn’t discrimination,” right? Which can kind of— I think for a client it can feel like we might be gaslighting them, and then they might also feel like they’re gaslighting themselves by trying to convince themselves that what they experienced isn’t really accurate or real, right?

Sam: Or even worse, the therapist saying, “That’s a distorted thought,” right? And calling them cognitive distortions, like, “There’s something wrong with that thought and we have to change it because that thoughts is making you feel bad.” When in reality, that could— that is the client’s experience in life. And their fears are valid and their anxieties are valid, and it’s more about maybe, you know, putting those emotions into action with advocacy and social justice work rather than trying to change the thought in some way.

Ashley: I mean, a lot of the thoughts that we have, we have because of the experiences we’ve been through, right? And so, if we’ve been through something similar and then another thing happens, well, it makes sense that we’re going to think, “Oh, that’s racism. I’ve experienced that before. Absolutely.” Right, I mean, that— I’m saying this is somebody who loves a good reframe. That, oh my goodness, like it’s just more— this is more food for thought.

Fatema: Well, I think cultural dynamics and family dynamics are another one, right? Because based on your culture, different actions and interactions can hold different meanings, right? And so, when we interpret those same behaviors and interactions through a Western lens, they might mean very different things. And so, what a client might see as like, “Well, this behavior meant that my mom was upset at me,” another person might say, like, “Well, can we refrain that in another way, right?” Like Sam said, the distortion in that thought. But the clients perception might actually be really spot on based on the cultural norms that they’ve observed.

Ashley: Right, right.

Sam: But really the clinician’s job in that moment is just to validate. Empathy, validation. And, you know, if you’re really heavily reliant on CBT, it can go wrong pretty quick.

Ashley: Yeah.

Sam: And it could really impact, I think, the relationship between the client and the therapist.

Ashley: Well, if you’re not feeling validated, you know, at all…

Sam: Of course! Right!

Ashley: I mean, that— you’re gonna leave therapy feeling pretty down on yourself, truly. Like, “Am I even living life right? Like, what is going on here?

Sam: Right, or just to feel so misunderstood?

Ashley: Yeah, yeah. So, I’m curious, Fatema, at your training at the Renfrew Conference in 2022, you talk about the intersection of Islam, gender identity, and gender expression. What do clinicians need to understand about the intersection of these two? And how can we best support our Muslim clients who are exploring their gender identity or identify as non-binary or trans?

Fatema: Yeah. So, in Islam things tend to operate in a gender binary, right? So, depending on the gender that you ascribe to or that has been ascribed to you, there can be different kinds of clothing that people wear, different areas of the mosque that you might sit in, that you might pray in, even the way that you pray, depending on the Islamic sect that you’re in, can be different based on the gender that has been ascribed to you. And so this binary can be especially exacerbated when someone is exploring their gender identity or doesn’t identify within that binary. It can bring up questions like, “Where do I fit in? What should I wear? Where am I allowed to be when I’m in the mosque?” Right? And really open the door for that person to be bullied more, and judged more, and feel like they don’t have a place where they belong, either in the mosque, in their community, or even within Islam. And I think sexual orientation can, you know, play a role in this as well. A lot of people in Islam will see heterosexualism as being a sin. And I’ve met a lot of people who have been told, “Well, you know, it’s a sin to be heterosexual, but it’s even more sinful to act on it.” So, you shouldn’t act on what brings you pleasure, right? And so, it can really send that message that, like, you need to hide who you are, you need to control this aspect of your life. And so, someone might engage in the eating disorder as a way to control their life and control their gender identity or their sexuality, or even to escape or dissociate, right?

Ashley: Mhm.

Fatema: They might be seeking safety from what feels harmful or dangerous to them. And so, I think as clinicians, what we can best do to support clients is to create a space where they can be their authentic selves, right? So, I think this goes back to what we talked about earlier, of asking open ended and really exploratory questions rather than asking yes or no questions, because when we ask a yes or no question, we’re putting the client back into the binary that they might already feel really trapped in. So, I think about that a lot. And then, you know, I also think about helping the client find ways of engaging in the religion, if they want to engage in the religion, in ways that feel really safe for them. So, are there places in communities where there isn’t segregation, in terms of how people sit at the mosque or how they pray, and would the client feel a lot more welcome there? Are there communities that they could be a part of where there’s other non-binary, trans, LGBTQ folks, where they can feel that sense of safety and community. A lot of times that will come online, right? Because if they’re going to the physical space, they might feel like that poses a threat, that people might find out. But there might be online communities where they can feel that sense of connection and community.

Ashley: Yeah. I know we’re kind of, like, coming down to time here.

Sam: Oh, I wish we had more time.

Ashley: I know! Are there just in general— first of all, I feel like we could have you on for another hour and just keep going and talking about stuff. Are there resources? I know you do talks and you do trainings, what can we leave with our listeners today? How can they listen to you? How can they connect with you? Or what resources can we offer them today?

Fatema: Yeah! So, if they’d like to connect with me, I’m on Instagram. My Instagram handle is @YourSouthAsianTherapist. I post about things related to South Asian clients, related to Muslim clients on there, and I’m accepting clients for therapy as well. I think some other places that are great resources is the Institute of Muslim Mental Health, there’s the Khalil Center which has all Muslim providers, so if you’re looking for someone who really has that religious understanding, I know they have sites in New York and Chicago, I think LA and Texas are other locations that they’re a part of as well. And then I also offer a lot of different trainings on these topics. So, if people are wanting to bring, you know, any of these topics into organizations, schools, mosques, etc., I’m always happy to be contacted.

Ashley: Awesome, thank you so much.

Sam: Thank you. Fatema, will you come back for next season? We need to talk more!

Fatema: Absolutely, yes!

Sam: I love it! Thank you so much for this conversation, and thank you to our listeners for another episode of All Bodies. All Foods. This was really informative, for those of you out there who are wondering more about eating disorders in the Muslim community. If you like this episode and learned from us, you can support us by subscribing, rating, leaving a review, sharing with others. And if you want more, you can follow us on Facebook, Instagram, Twitter and TikTok, our handle is @RenfrewCenter. For free education, events, trainings, webinars, resources and blogs, go over to our website www.RenfrewCenter.com. And if you have any questions you’d like us to answer in a future episode, be sure to email them to [email protected]. See you next time.

Ashley: Thank you for listening with us today on All Bodies. All Foods. presented by The Renfrew Center for Eating Disorders.

Sam: We’re looking forward to you joining us next time as we continue these conversations.

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