Integrating Spirituality and Religion into Psychotherapy: Decision Making in Challenging Situations

1. Integrating Spirituality and Religion into Psychotherapy: Decision Making in Challenging Situations Jeffrey E. Barnett, Psy.D., ABPP Baylor University Nov. 09, 2012

2. Disclaimer • The opinions expressed in this presentation are those of the presenter alone and not those of any organizations or institutions with which he is associated.

3. Why is this Topic Relevant? • Prevalence of religion and spirituality in American population • 71-90% of individuals surveyed reported a firm belief in God • 56 - 85% of individuals reported that religion is important in their daily lives • 79% described themselves as spiritual, while 64% described themselves as religious • The most recent (2008) large scale survey of religion in America, found that 56% reported religion to be very important in their daily life. • Sources: Barna, 1992; Gallup and Castelli, 1989; Brawer, Handal, Fabricatore, Roberts, & Wajda-Johnston, 2002; Kelly, 1994; Kosman & Lachman, 2001; Pew Forum on Religion and Public Life, 2008; Russell & Yarhouse, 2006; Shafranske & Malony, 1990.

4. Who are we and who are our clients? • Gap in religiosity of clients and clinicians • “my whole life is based on my religion” • 72% of participants agreed • 33% of psychologists agreed • Sources: Barna, 1992; Brawer, Handal, Fabricatore, Roberts, & Wajda-Johnston, 2002; Gallup and Castelli, 1989; Kelly, 1994; Kosman & Lachman, 2001; Pew Forum on Religion and Public Life, 2008; Russell & Yarhouse, 2006; Shafranske & Malony, 1990.

5. Training Issues • Spirituality and religion are integrated into the training of psychotherapists in a very sporadic and inconsistent manner • As of 1994, only 25% of graduate training programs included religious and spiritual issues as a course component • Sources: Brawer, Handal, Fabricatore, Roberts, & Wajda-Johnston, 2002; Russell & Yarhouse, 2006; Shafranske & Malony, 1990.

6. Potential risks and consequences of not assessing a client’s religious and spiritual beliefs • May overlook or minimize the significance of these influences in a client’s life to include conflicts, struggles, and maladaptive beliefs and behaviors • May lead to over pathologizing spirituality and religion • May lead to mismanagement of counter-transference reactions

7. Potential benefits and opportunities of including an religious and spiritual issues in psychotherapy • May find religion or spirituality to be a source of strength • May increase client’s comfort in sharing other aspects of the personal life with clinician • Some research suggests that positive religious practices can lead to improved well being

8. Religion/Spirituality and Psychological Health • Research shows: • Positive associations between religious commitment and overall well-being • Negative associations between religious commitment and psychopathology • Sources: Astrow, Puchalski, Sulmasy, 2001; Beckman & Houser, 1982; Decker & Schultz, 1985; Guy, 1982; Levin & Vanderpool, 1987; Lindenthal, Myers, Pepper & Stern, 1970; Stark 1971; Moberg, 1965; Paloutzian & Ellison, 1982; Rogalski & Paisey, 1987;

9. Primary health care and the integration of spiritual and religious issues • A majority of patients receiving health care report that they would like their caregivers to ask about and discuss spiritual aspects of their illness • In a recent poll, 79% of respondents believed that spiritual faith can help people recover from disease • 63% believed that health professionals should talk to patients about faith • Source: Miller & Thoresen, 2003

10. Assessment • Current Practice • 42% of psychologists asked clients about religion or spirituality at least half the time • 12% never asked about beliefs, experiences, practices • 18% never asked about spirituality. • Sources: Barnes, Powell-Griner, McFann, & Nahin, 2004; Hathaway, Scott, and Garver, 2004; Pew Forum on Religion and Public Life, 2008; Pargament, Koenig, & Perez, 2004; Savdah & Eberhardt, 2006.

11. Assessment (cont.) • What to ask • Get specifics about what that means to the client • Also specifics about beliefs and practices • Why it is useful • Demonstrates relevance to the psychotherapy process • Widely applicable to many clients • 39% of Americans surveyed reported attending a religious service at least once each week • 58% reported praying at least once each day.

12. Religious-Spiritual Client Intake Assessment Questions-Revised • Are religious issues important in your life? • Are spiritual issues important in your life? • Do you wish to discuss them in counseling when relevant? • Do you believe in God or a Supreme Being? • Do you believe you can experience spiritual guidance? • What is your current religious affiliation (if any)?

13. Religious-Spiritual Intake (cont.) • Are you committed to it and actively involved? • What was your childhood religious affiliation (if any)? • How important was religion or spiritual beliefs to you as a child and adolescent? • Are you aware of any religious or spiritual resources in your life that could e used to help you overcome your problems?

14. Religious-Spiritual Intake (cont.) • Do you believe that religious or spiritual influences have hurt you or contributed to some of your problems? • Would you like your counselor to consult with your religious leader if it appears this could be helpful to you? • Are you willing to consider trying religious or spiritual suggestions from your counselor if it appears that they could be helpful to you?

15. Multicultural Competence • Diversity Factors • Client’s own definitions of religiosity or spirituality • Client’s faith experience • Mental Health Factors • Healthy practice vs. unhealthy practice • Religious experiences vs. pathology

16. Clinical Competence • Essential Elements of Competence • Awareness of client factors and knowledge of faith traditions • Knowledge about healthy and unhealthy beliefs and behaviors • Training and practice integrating religious and spiritual treatment goals • Familiarity with community resources • Consultation as appropriate

17. Informed Consent • Ethical and legal requirement • Basics of Consent • What would you want to know? • Additional Information to disclose prior to working on issues of religion and spirituality • Advertising and Public Statements

18. Boundaries and Multiple Relationships • How to handle multiple relationships • Attending the same church (incidental contacts vs. multiple relationships • Serving as a clergy AND a psychotherapist. • How to integrate religion and spirituality as a therapist vs. serving in the role of clergy

19. Self-Disclosure • When – if ever- is it appropriate to self-disclose when working with clients around issues of religion and spirituality? • Disclosure of personal beliefs and practices? • Providing support, normalizing beliefs, or exerting influence?

20. An Ethical Decision-Making Model Model developed by Barnett and Johnson (2011)

21. Stage 1: Respectfully assess the client’s religious or spiritual beliefs and preferences • Continued respect and dignity • Include rationale for asking such questions in informed consent process

22. Stage 2: Carefully assess any connection between the presenting problem and religious or spiritual beliefs and commitments • Where is the line between disorder and diversity? • Seek consultation if this line is unclear

23. Stage 3: Weave results of this assessment into the informed consent process • Discuss findings openly in the initial phase of psychotherapy • Disclose any elements of your own beliefs and values that may facilitate or impede the therapeutic alliance • Develop a treatment plan incorporating religion and spirituality if relevant and appropriate • Review this plan in an informed consent process

24. Stage 4: Honestly consider your countertransference to the client’s religiousness • Could your reactions be harmful to the client in any way? • Seek consultation or referral if your reactions will potentially reduce the efficacy of treatment

25. Stage 5: Honestly evaluate your clinical competence in this case • Consider your education, training, knowledge, and experience • Review relevant literature, practice guidelines, and ethical standards

26. Stage 6: Consult with experts in the area of religion and psychotherapy • Self-assessment of competence may not always be accurate • Consult with colleagues to process countertransference reactions

27. Stage 7: If appropriate, clinically indicated, and client gives consent, consult with client’s own clergy or other religious professional • Consult clergy regarding appropriateness of: • Client’s beliefs and practices • Integrating religious and/or spiritual interventions into treatment • Find out what role clergy can and will play in supporting the client or collaborating throughout the treatment process

28. Stage 8: Make a decision about treating the client or making a referral • Evaluate risks and benefits of integrating religion/spirituality into treatment • To include a review of literature regarding the efficacy of such interventions • Consider expert consultations (e.g. clergy, etc.)

29. Stage 9: Assess outcomes and adjust plan accordingly • Monitor results of implemented plan • Impact on client and their family • Impact on the client’s relationships within their religious community • Repeat decision-making steps as needed • From: Barnett, J. E., & Johnson, W. B. (2011). Integrating spirituality and religion into psychotherapy: Persistent dilemmas, ethical issues, and a proposed decision-making process. Ethics & Behavior, 21(2), 147-164.

30. Vignettes: An application of the decision-making model

31. Should Dr. Smith continue to see this client? Is it ethical for him to integrate prayer into their treatment? Why or why not? What other options should Dr. Smith consider? What other elements of the decision-making model are important here? • Dr. Smith begins psychotherapy with 72-year-old client Ms. B. During their first session, Ms. B explains that her spirituality and faith in God and the Catholic Church are some of her most important sources of support. Towards the end of the session, Ms. B asks Dr. Smith to pray with her, explaining how important the healing power of prayer is. She expresses that it will be important to her to spend a few minutes praying at the end of each psychotherapy session with Dr. Smith. Dr. Smith is trained in clinical psychology and does not typically integrate religion and spirituality into his work. He is, however, a member of a Catholic church and feels that it would be beneficial to Ms. B to include prayer in treatment, since it seems to have benefitted her in the past. He is not sure how to proceed with this case (adapted from Barnett & Johnson, 2011, p. 156). Scenario # 1

32. Is competence an issue here? Were Dr. Hernandez’s actions in this session ethical? Why or why not? What other courses of action could or should Dr. Hernandez take with regards to this situation? What other elements of the decision-making model are important here? • Dr. Hernandez completed a graduate-level course in psychotherapy with religious clients and received supervised experience working with religious issues in psychotherapy. Although she does not often share her clients’ religious or spiritual beliefs and practices, she recognizes their value in enhancing well-being and treatment gains with some clients. She feels that most of her clients would benefit in some way from integration of religion and spirituality in treatment, but does not explicitly describe these practices to clients since she feels they are more effective when they are casually included in sessions without introduction. She has had three sessions with Mr. C so far, and feels strongly that reading a specific section of scripture with him will benefit him greatly. During their fourth session, Dr. Hernandez takes out a Bible, says to Mr. C, “Listen to these words. I think they can really help put your thoughts and feelings in perspective,” and begins to read a section to him. Mr. C appears surprised by the actions of Dr. Hernandez, but allows her to continue with the reading, thinking, “She’s the doctor. I guess I just have to trust her to know the right way to treat me” (adapted from Barnett & Johnson, 2011, p. 153). Scenario # 2

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34. Resources (cont.) Barnett, J. E., & Johnson, W. B. (2011) Integrating spirituality and religion into psychotherapy: Persistent dilemmas, ethical issues, and a proposed decision-making process. Ethics & Behavior, 21(2), 147-164. Bergin, A. E., Payne, I. R., & Richards, P. S. (1996). Values in psychotherapy. In E. P. Shafranske (Ed.), Religion and the clinical practice of psychology (pp. 297-326). Washington, DC: American Psychological Association. Brawer, P. A., Handal, P. J., Fabricatore, A. N., Roberts, R., & Wajda-Johnston, V. A.(2002). Training and education in religion/ spirituality within APA-accredited clinical psychology programs. Professional Psychology: Research and Practice, 33, 203-206. Ellis, A. (1973). My philosophy of psychotherapy. Journal of Contemporary Psychotherapy, 6, 13-18. Fisher, C. B., & Oransky, M. (2008). Informed consent to psychotherapy: Protecting the dignity and respecting the autonomy of clients. Journal of Clinical Psychology, 64, 576- 588

35. Resources (cont.) Frazier, R. E., & Hansen, N. D. (2009). Religious/spiritual psychotherapy behaviors: Do we do what we believe to be important? Professional Psychology: Research and Practice, 40, 81-87. Gallup, G., & Castelli, J. (1989). The people’s religion. New York: Macmillan. Gartner, J. Religious commitment, mental health, and prosocial Behavior: A review of the empirical literature. In E. P. Shafranske (Ed.), Religion and the clinical practice of psychology (pp. 297-326). Washington, DC: American Psychological Association. Hawkins, I., & Bullock, S. (1995). Informed consent and religious values: A neglected area of diversity. Psychotherapy: Theory, Research, Practice, Training, 32, 293-300. Miller, W. R., & Thoresen, C. E. Spirituality, religion and health care: An emerging field. American Psychologist, 58(1), 24-35. National Academy of Sciences. (1984). Science and creationism: A view from the National Academy of Sciences. Washington, DC: author.

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