Download a free accompanying Power Point presentation from Dr. Barnett here: Integrating_Religion_and_Spirituality.ppt
It may be easy for psychotherapists to overlook or avoid addressing our clients’ spirituality and religion in psychotherapy. Such issues may not have been addressed in our training and thus may not be seen as relevant to our clinical work with clients. After all, we are mental health professionals, not members of the clergy.
Those who seek out psychotherapy under our care may also not view a focus on spirituality and religious issues as a part of what occurs in psychotherapy and what psychotherapists do. Other than those who seek out faith-based counseling, it is common for psychotherapy clients to perceive that psychotherapists address mental health issues and that members of the clergy are the ones to address religious and spiritual issues.
Some Definitions
Religion has been defined by Dew and colleagues (2008) as an “organized system of beliefs, rituals, practices, and community, oriented toward the sacred” (p. 382). Religion tends to focus on formal organizations with specifically defined and widely accepted beliefs, practices, and traditions.
Spirituality, in contrast, can be thought of as a “search for the sacred, a process through which people seek to discover, hold on to, and, when necessary, transform whatever they hold sacred in their lives” (Hill & Pargament, 2008, p. 4). This can be a very private experience and need not be part of experiences in organized religion. But, one can be religious but not spiritual, spiritual but not religious, neither religious nor spiritual, or both spiritual and religious.
The APA Ethics Code
Yet, the Ethical Principles of Psychologists and Code of Conduct (APA Ethics Code, APA, 2010) very clearly addresses these issues in its discussion of diversity and individual differences in Principle E, Respect for People’s Rights and Dignity. It states “Psychologists are aware of and respect cultural, individual and role differences, including those based on … religion … and consider these factors when working with members of such groups” (p. 3). Further, in Standard 3.01, Unfair Discrimination, the Ethics Code states “In their work-related activities, psychologists do not engage in unfair discrimination based on … religion … or any basis proscribed by law” (p. 6).
How is This Relevant to Me as a Psychotherapist?
If you are not a faith-based psychotherapist it is possible that the above discussion seems of little relevance to you professionally. After all, you know you are not prejudiced and you would never hold clients’ religious or spiritual beliefs and practices against them. But, prejudice and bias are not the only relevant issues to consider. There are abundant data that highlight the need for psychotherapists to be knowledgeable about these issues, to be sensitive to their possible role and meaning in our clients’ lives, and to be proactive about addressing them.
The Pew Forum on Religion and Public Life (2008) found the following:
- More than nine-in-ten Americans (92%) believe in the existence of God or a universal spirit.
- Sixty three percent of American women and 44% of American men say that religion is very important to their lives.
- Americans are nearly unanimous in saying they believe in God (92%), and large majorities believe in life after death (74%) and believe that Scripture is the word of God (63%).
- Most Americans (54%) say they attend religious services fairly regularly (at least once or twice per month), with about four-in-ten (39%) saying they attend worship services every week.
- Americans also engage in a wide variety of private devotional activities. Nearly six-in-ten (58%), for instance, say they pray every day.
- People who are not affiliated with a particular religious tradition do not necessarily lack religious beliefs or practices. In fact, a large portion (41%) of the unaffiliated population says religion is at least somewhat important in their lives, seven-in-ten say they believe in God, and more than a quarter (27%) say they attend religious services at least a few times a year. (Pew Research)
Thus, it can reasonably be assumed that religion and spirituality are of relevance to the lives of a large portion of the clients every psychotherapist will come in contact with. While religious and spiritual issues may not be a primary focus of treatment, these are likely to be relevant aspects of each client’s life, helping to define their values, beliefs, lifestyle choices, and decision making. Thus, as Principle E of the APA Ethics Code (APA, 2010) addressed, psychologists should be sensitive to, aware of, and respect all individual differences, to include religious and spiritual beliefs, values, and practices.
Relevance to the Practice of Psychotherapy
Two major reasons why this is so important for every psychotherapist are:
- Religious and spiritual issues may be relevant to the underlying issues that prompt clients to seek treatment. These can include conflicts over religious values, crises of faith, feelings of alienation from one’s religion, and distortion of religious beliefs and practices, among others.
- The client’s religious and spiritual beliefs and faith community may be sources of strength and support that may be accessed in the course of psychotherapy to assist clients to achieve their treatment goals.
Thus, to overlook or to intentionally ignore or avoid addressing each client’s religious and spiritual beliefs and practices may be doing them a great disservice. It is important to note that it is not the psychotherapist’s beliefs, values, and practices that are of greatest importance here; it is the client’s.
Implications for Clinical Practice
Accordingly, it is recommended that during the initial intake or assessment phase of treatment that every client be asked about these issues. This does not mean that addressing religious and spiritual issues will be a focus of psychotherapy. Rather, asking these questions and raising these issues for the client to respond to helps to promote each client’s autonomous decision making about treatment planning. If we never raise these issues or ask these questions clients may naturally assume that these are not issues to be discussed with psychotherapists. Thus, it falls on us to let clients know that these are issues that may appropriately be addressed in psychotherapy if the client so chooses.
Specific questions that can be asked include asking about the client’s religious and spiritual background, current practices, their role in the client’s life in the past and at present, how important these are to the client, and the influence they may have on the client’s values and beliefs, if issues relevant to their religion or spirituality are relevant to the reasons for seeking treatment, if they wish to discuss these issues with the psychotherapist, if the psychotherapist may consult with their clergy, and other related questions. Interestingly, authors such as Frazer and Hansen (2009) and Hathaway, Scott, and Garver (2004) found that many psychotherapists neglect to ask these questions or raise these issues with their clients. [See also PowerPoint slides 9-13].
Key Ethics Issues for Psychotherapists to Consider
A number of ethics issues are relevant to thoughtfully and appropriately addressing religious and spiritual issues, beliefs, and practices in psychotherapy. These include informed consent, clinical competence, consultation and collaboration with other professionals, boundaries and multiple relationships, imposition of one’s values on clients, integrating religious and spiritual themes into ongoing psychotherapy, and the use of a thoughtful decision-making approach to making decisions about each of these issues. While much has been written elsewhere about these important ethics issues, each will be highlighted briefly here [See also PowerPoint slides 15-19]:
Informed consent
Clients have the right to be presented with all information that might reasonably be expected to influence or impact their decision to participate in psychotherapy. Informed consent should also address all reasonably available treatment options and their relative risks and benefits. Based on the discussion above it is hoped that mention of religious and spiritual issues and their possible relevance to treatment will be seen as essential.
Clinical competence
To be able to provide competent psychotherapy to their clients, psychotherapists must educate themselves about the major religions and spiritual beliefs and practices. Psychotherapists also should know the limits of their knowledge and clinical expertise, seeking consultation from expert colleagues and from members of the clergy when unsure of what knowledge they should have and when facing clinical situations outside their competence. Psychotherapists should ensure they receive comprehensive training and clinical supervision before attempting to integrate religious or spiritual practices into psychotherapy.
Consultation and collaboration with other professionals
In general when faced with challenges and dilemmas, and with the client’s consent when sharing specific information about a client, psychotherapists should consult with knowledgeable colleagues and members of the clergy on an ongoing basis. At times it may be appropriate to collaborate with members of the clergy in a client’s treatment. Again, this should only be done with the client’s informed consent, but at times such collaboration may be in the client’s best interest and thus, should be considered.
Boundaries and multiple relationships
When addressing religious and spiritual issues in psychotherapy with clients, psychotherapists should be cognizant of the potential to move from the role of psychotherapist to the role of the clergy. This is especially relevant when integrating religious and spiritual practices into psychotherapy. Psychotherapists should also be cautious about imposing their values on clients and taking on a prescriptive approach in treatment.
Integrating Religion and Spirituality into Psychotherapy and Ethical Decision-Making
Integrating religious and spiritual themes into psychotherapy may range from asking the questions about a client’s beliefs, values, and practices to making specific values based recommendations and recommendations for engaging in particular religious activities and practices such as meditation or prayer. The integration of spiritual and religious interventions into psychotherapy may include activities such as reading selected passages of scripture with the client in session and praying together with the client in session. Thus, a wide range of interventions exist, some of which may be appropriate with some clients (if informed consent was engaged in appropriately and the psychotherapist possesses the necessary clinical competence), while others may be inappropriate and even harmful.
A number of decision-making models exist that may be helpful to the psychotherapist in making thoughtful and informed decisions about how and when to address religious and spiritual issues with clients and how and when, and when not to integrate religious and spiritual interventions into psychotherapy. One comprehensive decision-making model that may be of use to psychotherapists in this regard is the one developed by Barnett and Johnson (2011). Each step in their decision-making process includes a number of details and factors to consider [See PowerPoint slides 20-29 for the complete model], however the basic steps of this model are provided:
- Respectfully assess the client’s religious or spiritual beliefs and preferences.
- Carefully assess any connection between the presenting problem and religious or spiritual beliefs and commitments.
- Weave results of this assessment into the informed consent process.
- Honestly consider your countertransference to the client’s religiousness.
- Honestly evaluate your competence in this case.
- Consult with experts in the area of religion and psychotherapy.
- If appropriate, clinically indicated, and client gives consent, consult with client’s own clergy or other religious professional.
- Make a decision about treating the client or making a referral.
- Assess outcomes and adjust plan accordingly. (pp. 159-161)
Recommendations
It hopefully can be seen that this brief article merely provides an introduction to this topic and that all psychotherapists should seek ongoing education about religion and spirituality; how they may impact individuals’ mental health; how they may be relevant to clients’ psychotherapy; and how they may be addressed and integrated into ongoing psychotherapy when the ethics issues mentioned above have been thoughtfully considered and addressed.
Becoming educated and informed about religious and spiritual issues, using ongoing consultation and collaboration with other professionals, maintaining appropriate boundaries, possessing and practicing within one’s clinical competence and scope of practice, and utilizing a thoughtful decision-making process when making decisions about these issues, are each highly recommended.
