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Christian psychologist William Hathaway, PhD, of Regent University in Virginia, found himself the latest in a long line of therapists to work with a family in crisis over the son's uncontrolled attention-deficit hyperactivity disorder (ADHD). Hathaway asked the family members about their religious beliefs and, finding that they were Jewish and that the boy's behavior in temple was preventing them from attending services, encouraged them to go back to their religious rituals.

"They had made the decision not to and were tearful about it when asked, especially because none of their mental health providers had considered it before," says Hathaway. Discussing the ramifications of spirituality in family life broadened the family's experience in the therapy room and allowed them to address religious issues as a serious component of their well-being, he says. And, he adds, their religious practices might well have strengthened the family's ability to deal with their son's ADHD.

"Just being sensitive to a possible role of religion in a client's life can broaden your evaluation and provide different solutions," he explains. "Being able to help a person connect with the variable of spirituality in their lives can be a beneficial and important therapeutic accommodation."

That heightened awareness of spirituality, or even taking it a step further by directly incorporating religion and spirituality--different but not mutually exclusive concepts--into therapeutic practices, is common for some psychologists. Moreover, the expansion of its use is leading to efficacy research, specific training and even tacit specialization.

Spirituality as a therapeutic strategy

"Using religion as a therapeutic tool is a little controversial and still emerging," Hathaway says. "Techniques include use of prayer during a session, ways to direct clients to pray, spiritual journaling, forgiveness protocols, using biblical texts to reinforce healthy mental and emotional habits and working to change punitive God images."

For example, Hathaway uses spiritually guided forgiveness protocols to help clients deal with emotional problems that resulted from harm inflicted by friends or family members. Using religious teachings on forgiveness can direct clients to let go of unhealthy anger and move past an abusive situation without justifying the abuse, he says.

In the context of implementing these techniques, however, the possibility that religion may have a negative influence on a client's life--believing in an angry God, for example--should be assessed carefully so that therapy doesn't make emotional crises worse, says Carrie Doehring, PhD, a psychologist at the Iliff School of Theology in Denver who studies how people use religion to deal with experiences of violence.

"During assessment, I ask about religious and spiritual backgrounds, ask the client if they pray and if it helps or not. And if they do have a belief in a personal God, I ask them what they think God wants from them right now, and that leads them to talk about their experience with God," Doehring says. "It's the sum of that conversation that helps me to understand what religion's impact is on their life."

With religious or spiritual clients, that sensitivity and willingness to interact in a religious way helps them to trust the therapist and, Doehring says, can bring a beautiful aspect of the human experience into the therapy room.

"Some people describe the beauty of spiritually guided therapy as experiencing a third presence in the room--a spiritual presence or a God presence," she says. "There's a mystery being revealed to the patient in that presence; it's a sort of an epiphany that can be extremely useful in therapy."

Precautions to ponder

Although potentially effective, use of religiously guided treatments needs to be considered carefully, especially when a therapist is new to using them, Doehring says.

"I think it's important for all psychologists to understand how spirituality and religious faith are important to them personally, both as a tool and as a way to prevent personal roadblocks, but there are pitfalls to incorporating religious practices into therapy," she says.

A primary concern for those promoting the field is ensuring there's proper supervision for therapists learning to use religious tools or help clients deal with religious issues while in their postdoctoral training. For that reason, specific training programs should be available for psychologists looking into developing practices that include religious therapies, Doehring says.

Psychologists who do work with clients on religious issues need to be particularly careful of their personal ideas about religion and the possibility of countertransference problems. They also need to guide their clients to healthy views of religion in their lives--without allowing religious practices to get in the way of pursuing traditional markers of psychological improvement, Doehring says.

And finally, the practice as a whole needs to rely on more than anecdotal treatment strategies, instead turning to evidence-based practices, she says.

Building the research base

Although anecdotal evidence of the impact of spiritually inclined therapy is strong, most in the field agree that psychologists must develop both research and theoretical models to understand the connection between religion and spirituality in practice, says Edward Shafranske, PhD, a psychology professor at Pepperdine University.

The field has recently reached a point where there's a substantial body of high-quality literature that discusses the connection between mental health and spirituality, says Shafranske.

"But until we have good, solid empirical evidence and studies about how to integrate religion into practice, it may be premature to encourage widespread use," Shafranske says.

Psychologist Kenneth Pargament, PhD, of Bowling Green State University says research evaluating the efficacy of specific therapeutic techniques, such as forgiveness interventions, spiritual meditation, rituals and religious coping resources, is under way. Some of the graduate students he supervises have created spiritual interventions for people who've struggled with significant problems, including cancer, incest and serious mental illness.

The evidence indicates that the sense of hope, meaning and spiritual support that clients gain from discussing religious issues and drawing upon spiritual resources helps them cope better with their situation, Pargament says (see page 44).

"The research is showing that spiritual dimensions brought into therapy can add something distinctive to health and well-being," he says. "People ask, 'Is religion just another version of a healthy social support or a positive system of meaning?' We're finding that there's something special about the religious dimension that cannot be easily reduced to traditional psychological constructs."

For example, Pargament cites research done at the University of Minnesota by psychologists Patricia Frazier, PhD, and Andrew Tix, PhD, that demonstrates that patients undergoing kidney transplants who turn to God or a higher power for transcendent support had greater life satisfaction following their surgery, even after taking into account their general secular coping methods.

Building the expertise

With that growing body of evidence, some in the field are working to develop ways to teach religious sensitivity and spiritual practice to psychologists.

"Right now, we're not certain we know that most clinicians use religion or spirituality at all," Shafranske says. "Most do consider it in assessment, but have very little training in how to do it, what models to use, and there's almost no supervision in it.

"The use of scripture, the use of prayer, is very low--which might be good because very few are trained," he adds.

Only about 10 percent of new psychology PhDs report moderate to high levels of exposure to religious sensitivity or guided practices in their training, and most of that goes on at religiously affiliated training programs at schools like Brigham Young University and the Fuller Theological Seminary, Shafranske says.

Making sure religious diversity is presented as a key issue in training programs is an important first step, Shafranske says, and that could, in turn, open doors to postdoctoral emphasis on using religious techniques in practice.

By incorporating spirituality into therapy, practitioners can add richness and depth to the treatment of their clients, Pargament says, and it's incumbent upon training programs to at least teach students an openness to it.

"Some of the most basic questions and problems people face in life have a spiritual dimension to them," he says. "These kinds of questions can be viewed in purely psychological terms, but, for many people, they have a profound, existential, spiritual meaning--one that shouldn't be ignored."

Further Reading

  • Richards, P.S., & Bergin, A.E. (Eds.). (2003). Casebook for a spiritual strategy in counseling and psychotherapy.Washington, DC: American Psychological Association.

  • Richards, P.S., & Bergin, A.E. (Eds.). (2000). Handbook of psychotherapy and religious diversity. Washington, DC: American Psychological Association.

  • Shafranske, E. (Ed.). (1996). Religion and the clinical practice of psychology. Washington, DC: American Psychological Association.