Spirituality and Psychotherapy

SPIRITUALITY AND PSYCHOTHERAPY

No thanks, we’re Psychologists!

Spirituality: A Definition

A person’s thoughts, feelings and behaviors related to, concern about, a search or a striving for understanding and relatedness to the transcendent ( Hill et al. 2000)

Includes religious and non-religious strivings

Saunders et al., 2010

Religion: A Definition

A particular system of beliefs and behaviors formally sanctioned by an external entity such as a church body.

Narrower than spirituality

Saunders et al., 2010

Themes of Spirituality

Sense of purpose Sense of connectedness- to self, others,

nature/God/Divine Quest for wholeness Search for harmony or hope Belief is a higher being or beings Some level of transcendence or sense that

there is more to life than the material/practical Those activities give meaning and value to

people’s lives(Cornah, 2006)

Vaillant, 2008

Spirituality is 8 positive emotions:AweLove ( attachment)Trust (faith)CompassionGratitudeForgivenessJoyHope

Spirituality is the vehicle through which meaning is sought. Religion is that vehicle for some.

Sometimes people get the mistaken notion that spirituality is a separate department of life, the penthouse of existence. But rightly understood, it is a vital awareness that pervades all realms of our being.

Brother David Steindl-Rast.

PSYCHOLOGY

PSYCHE – meaning “soul”

LOGY – from logos – “the study of “

What is the soul?

The soul is the infinite depth of a person comprising all the many mysterious aspects that go together and make up our identity. The soul is the point of connection between the individual and God. (Moore , 1992)

What is the soul?

The soul is the essential animating dimension of living things, and as the overarching force that links and reconciles disparate aspects of our lives, thoughts, feelings, mind and matter, inner and outer, dark and light. (Hillman, 1975)

What is the soul?

Ten times a day something happens to me like this-Some strengthening throb of amazement-Some good empathic ping and swell.This is the first, the wildest and the wisest thing I know:That the souls exists and is built entirely out of attentiveness.

Mary Oliver

The History of Psychology

Founding fathers had no need to separate psychology and spirituality; roots in philosophy and theology

For exampleWilliam James G. Stanley Hall

The History of Psychology

Change in early 20th century to side more with natural sciences

Distancing from mesmerism, spiritualism, etc.

Began to see religion with more suspicion and hostility

Religion as an impediment to the scientific study and rational efforts to improve the human condition

The History of Psychology

Psychology began to attract young people who were disaffected from their religious upbringing

Emergence of models of personality and psychotherapy that depicted spirit in oversimplified, stereotypical terms.

The History of Psychology

BF Skinner: Fundamentalist background which he rejected

“God is the archetype pattern of an explanatory fiction”

“Religious faith becomes irrelevant when the fears which nourish it are allayed and hopes fulfilled – here on earth”

The History of Psychology

Freud: rejected traditional beliefs and practices of his Judaism Saw religion as rooted in the child’s sense

of helplessness in a world of dangerous forces

“ Surely this infantalism is destined to be surmounted”

Religion is “the universal obsessional neurosis of humanity”

The times they are a-changing

Moving from a Psychology of control- trying to maximize the control people have in their lives ( e.g. CBT, behavioral, psychodynamic, etc.)

Pargament, 2007

The times they are a-changing

More recent movements to a psychology that helps people come to terms with their human limitations- a different way to seeing the world with a broader transcendent perspective (e.g. positive psychology, ACT, mindfulness, MBSRP, etc.)

Pargament, 2007

Growing Recognition of S/R issues in the Psychology

Recognition of the positive association between measures of Religion/Spirituality and health (spurred by health and sliding over to mental health)

Post and Wade, 2009; Saunders et al., 2010

Growing Recognition of S/R issues in the Psychology

Realization that S/R issues are essential aspects of individual and cultural diversity (provoked by the multicultural competence movement)

Post and Wade, 2009; Saunders et al., 2010

Growing Recognition of S/R issues in the Psychology

The majority of the general public in America identifies as religious or spiritual.

Plante, 2009

Gallup Poll95% of Americans believe in God

40% of Americans attend religious services on a weekly basis

Martinez et al. 2007

Over 80% of Americans consider themselves affiliated with a religion

Over 75% of Americans affirm the existence of God and pray at least weekly

The question is no longer “whether” to address the sacred in psychotherapy but rather the questions are “when” and “how” to address the sacred. Post and Wade,

2009.

APA code of ethics- Principle E

“Psychologists are aware of and respect cultural, individual, and role differences and consider these factors when working with such groups.” 2002

Saunders et al., 2010

APA 2010

We understand diversity to include religion and spirituality as important dimensions of human diversity, and practitioners are expected to attend to religious and spiritual variables when assessing and treating clients.

Aten at al., 2011.

APA (2002)

APA Ethics code states that psychologists must be aware of, respect, and understand individuals’ religious backgrounds (with the term religion appearing four times in lists along with attributes such as gender identity, race and ethnicity).

(as quoted in Crook-Lyon et al., 2012)

Clinicians’ concerns about addressing SRBPs

APA surveys suggest that we are hesitant and uncertain

We recognize that SRBPs are beneficial to mental health and treatment

Saunders et al., 2010

Clinicians’ concerns about addressing SRBPs

Psychologists report discussing SRBPs with only about 30% of clients

Concern about competence, undue influence and other potential ethical issues

Saunders et al., 2010

Delaney et al., 2007

Relative to the general population, psychologists were: more than twice as likely to claim no religion three times more likely to describe religion as

being unimportant in their lives five times more likely to deny belief in God less likely to attend religious services, be a

member of a congregation or engage in prayer

Shafranske, 2001

90% of US population report a belief in a personal God

24% of clinical and counseling psychologists report a belief in a personal God

Shafranske, 2001

58% of a national sample report that religion is very important to them

26% of clinical and counseling psychologists report that religion is important to them

Delaney et al., 2007

Psychologists today are more likely than the general population to describe themselves as “spiritual but not religious.

Spirituality was very important – 52%

Spirituality was fairly important – 28%

Rose et al., 2001

People expressly desire to discuss S/R issues with care providers 63% of clients felt it was appropriate to

discuss religious/spiritual concerns 55% of clients expressed an interest in

addressing religious/spiritual concerns 18% preferred not to discuss such

topics

Cornah 2006

Interviews with clients indicated that many felt their religious and spiritual beliefs are not understood or explored in psychotherapy

Found that clinicians either ignore their spiritual life completely or treat their spiritual life as a manifestation of psychopatholgy

Pargament, 2007

Many clients are reluctant to inform their therapist about their SRBPs.

“They already think I’m crazy”

You have to be very cautious about what you say because being not main stream, a little off track, you have to be very careful you are not condemned for what you believe by the professionals”

O’Connor and Vanderberg, 2005

Found a bias among mental health professional against less familiar religious traditions.

Given vignettes of beliefs and practices of Roman Catholics, Mormons and Moslems and asked to rate for psychotic pathology.

The members of the less familiar religions were rated as more pathologized than Catholics.

The differences held even when the beliefs & practices in all 3 sets were described as harmful.

McVittie and Tiliopoulos, 2007

Practicing therapists tended to underestimate the significance of religious beliefs, to stereotype religious clients as intransigent and to marginalize and exclude the religious dimension in the context of therapy.

Ethical Issues

Martinez et al. 2007

Informed consentReligious and spirituality identity

Dual relationshipsCollaboration with religious leaders

Ethical Issues

Respect for client’s values/fear of imposing

Discomfort with subjectLack of interest or awareness

Therapist competence

Competence

Surveys of APA accredited clinical programs and internships ( 2006) 13% of clinical programs had a course on

religion and spirituality 17% of clinical programs reported that the

topic is covered systematically Few addressed Religion and Spirituality

systematically and some not at all. Tended to be addressed only in

supervision and only if the client brought it up.

Crook-Lyon et al. 2012

82% of counseling psychology training directors report that, in their programs, R/S issues are not regularly discussed as issues of diversity and not considered as important as other kinds of diversity ( as quoted from Schulte et al., 2002)

Crook-Lyon et al. 2012

In their survey of 340 psychologists in related APA divisions found that

65% said that R/S issues should be included in graduate training

Clinical & Training Implications

Understanding and effectively addressing issues related to individual and cultural diversity including: Respectful attention to spiritual issues Being aware of one’s own attitudes,

assumptions and biases on issues of spirituality, religion and faith.

Ability to work with other professions including clergy.

Saunders et al., 2010

Clinical & Training Implications

More advanced but general competencies Openness and tolerance Self-awareness Authenticity (openly embrace our own SRBPs

to reduce likelihood of undue influence)

Saunders et al., 2010

Clinical & Training Implications

Specific Competencies Demonstrate similar respect and sensitivity to

SRBPs ( don’t assume- we don’t assume re: race or sexual orientation, etc.)

Competence in SRBPs: various spiritual/religious beliefs and immense diversity

Training: ongoing professional development on relevance of SRBPs to our lives

Saunders et al., 2010

Religious and spiritual competency includes familiarity with differences between spirituality and religion, ability to differentiate between a healthy and pathological religious or spiritual experience, and an understanding of how spirituality can be both a problem and a helpful dimension.

Serlin, 2004 (quoted in Delaney et al., 2007)

Significance of Self-Awareness

3 main reasons: More inclined to be spiritual not religious Unlikely to have explored

religious/spiritual bias in graduate school May have poorer judgment regarding

religious beliefs than are unfamiliar

Post and Wade, 2009

Post and Wade, 2009

Wisdom of Experienced clinicians who work with religious/spiritual issuesPluralistic approach/Appreciation

of diversityCareful not to imposeUsed a developmental lens or saw

religious/spiritual issues as intertwined with psychological issues

Post and Wade, 2009

Techniques typically used: meditation, scripture, prayer

Most important intervention –

An explicit statement or discussion communicating openness to explore religion/spirituality with the client.

Spiritually Oriented Interventions ( SOIs)

Overall research has shown that SOIs can serve as powerful healing resources for clients during treatment.

Aten et al., 2011; Post and Wade, 2009

Spiritually Oriented Interventions ( SOIs)

Making meaning and life calling Addressing value conflicts Addressing problematic

spirituality Sacredness of life Working with prayer

Spiritually Oriented Interventions ( SOIs)

Role of forgiveness Meditation Mindfulness Yoga and yoga techniques Sacred writings and texts Spiritual journaling

Smith et al., 2007

Results of a meta-analytic review found that spiritual or religious adaptions to psychotherapy effectively benefit clients.

31 studies between 1984 and 2005

Overall effect size of 0.56 ( moderately strong magnitude) – higher than the average value of 0.48 typical of psychotherapy outcomes when compared to control groups.

Smith et al., 2007

Interesting finding:

Spiritual therapeutic approaches appeared to have a greater impact of measures of well-being than on other measures of mental health symptoms.

Importance of clients learning to apply their own SRBPs to their mental health or well-being concerns.

Wachholtz & Pargament, 2005

Compared spiritual meditation to secular meditation and to relaxation

All subjects told how to relax physically and how to create a relaxing atmosphere

Measure impact on affect, spirituality, pain perception and tolerance, cardiac reactivity

Wachholtz & Pargament, 2005

Spiritual meditation group reported Lower anxiety More positive mood Greater spirituality Able to withstand pain for longer periods of time

Secular meditation group and relaxation group were not significantly different from each other.

Wachholtz & Pargament, 2005

Pain Perception No difference among the groups in perception

of pain

Pain ToleranceSpiritual meditation group endured pain level

almost twice as long as other 2 groups.

Cardiac reactivityNo group differences but all groups showed

decreased heart rate when practicing their techniques

Margolin et al., 2007; Avants et al., 2005

Examined a “spiritual “self-schema therapy for the treatment of addiction and HIV risk behavior ( versus an “addict” self –schema)

3-S ( www.3-Sus)

An 8 week manual guided intervention

Margolin et al., 2007; Avants et al., 2005

T he treatment program consists of meditation, mindfulness as well as cognitive behavioral therapy techniques evolved from the self-schema theory.

The goal is to decrease automaticity of “addict” self-scheme and construct a “spiritual” self-schema powerful enough to supplant “addict” self-schema.

Margolin et al., 2007; Avants et al., 2005

Found drug use and other HIV risk behaviors decreased

Evidence of a shift from “addict” to “spiritual” self-schema

A shift in self-schema was correlated with changes in drug use and other HIV risk behaviors.

Daily spiritual experiences and practices and the perceived influence of spirituality on behavior increased

Emmons and McCullough, 2003

Examined the influence of grateful thinking on psychological well-being in daily life in 65 adults with a chronic disease ( Neuromuscular Diseases)

Randomly assigned to 2 GROUPS: Gratitude and control

Emmons and McCullough, 2003

Gratitude condition: “There are many things in our lives, both large and small, that we might be grateful about. Think back over the day and write down on the lines below up to five things in your life that you are grateful for.”

Control group only completed questionnaires each day.

Emmons and McCullough, 2003

Daily records of:

Positive and negative affect, Activities of Daily living,Health behaviorPhysical symptomsOverall life appraisal

for 3 weeks

Emmons and McCullough, 2003

Observational reports of well being by spouse or significant other at the end of the study-

Positive and negative affectSatisfaction with Life Scale

Emmons and McCullough, 2003

Gratitude condition elicited more gratitude than control condition

Gratitude condition elicited significantly more positive affect and less negative affect than control condition

Gratitude Ss had a significantly more positive appraisal of life as a whole and their future

Emmons and McCullough, 2003

Physical Well Being: Gratitude Ss had significantly more hours of

sleep and felt more refreshed on awaking No differences in terms of physical pain,

exercise and functional status

Observer Effects:Gratitude Ss were seen as having more positive affect and life satisfaction than the control Ss .No difference on the negative affect.

Emmons and McCullough, 2003

Conscious focus on blessings may have emotional and interpersonal benefits.

The benefits of being grateful go beyond self-perception.

Delaney at al., 2007

Religion is an aspect of culture which psychologists may be especially predisposed to unfamiliarity, and one for which stereotypic biases have been present and tolerated in our discipline’s past. We therefore have a particular responsibility to ensure that we are well prepared to understand, honor, and competently address religious diversity.

No need to say No Thanks anymore

Pargament (2007) Spirituality is a natural and normal

part of life. The yearning for the sacred is a primary irreducible aspect of human nature.

Spirituality is a therapeutic fact of life. The question is not “whether” to address it but “how”

A spiritual person tries less to be godly than to be deeply human.

Rev William Sloane Coffin, Jr.

All people have a spiritual life and most are happy to talk about it - if you can just discover their language for it. Let them teach you their language.

Gerald May, 1992.