Addressing Religion and Spirituality in Psychotherapy: Ethical and Clinical Perspectives
Clinical Impact Statement: This article addresses the clinical and ethical imperative for psychotherapists to competently and effectively assess and treat each client with a focus on their religious and spiritual beliefs and practices. Key issues addressed include how religion and spirituality should be addressed as aspects of diversity that may be essential aspects of each client’s identity, and the steps to take to provide clients with effective treatment.
Psychotherapists strive to provide their clients with the best treatment possible, something highly dependent on our ability to achieve high standards of competence. An important aspect of one’s clinical competence that has received increasing attention in recent years is multicultural competence. It is recognized that a psychotherapist cannot be clinically competent without being multicultural competent (Rodolfa et al., 2005; Sue et al., 1992). Applying our knowledge and skills with sensitivity to each client’s individual differences is essential for providing them with a meaningful relationship that provides the foundation for the individualized application of various psychotherapeutic interventions (Norcross & Wampold, 2018).
The Ethical Principles of Psychologists and Code of Conduct (Ethics Code; APA, 2017a) make clear the need for awareness of, sensitivity to, and respect for all individual differences in the aspirational General Principle E, Respect for People’s Rights and Dignity. Within this guidance on diversity in psychotherapy it states that “Psychologists are aware of and respect cultural, individual, and role differences, including those based on … religion…” Beyond this aspirational guidance, minimal enforceable expectations that must be met or exceeded are found in Ethical Standard 2.01, Boundaries of Competence, which acknowledges that to provide competent professional services psychologists must possess and be able to effectively apply sufficient knowledge and skills relevant to individual differences, to include religion. This is further emphasized in the Multicultural Guidelines: An Ecological Approach to Context, Identity, and Intersectionality (APA, 2017b) which identify religion and spirituality as among the many potentially important aspects of each individual’s identity that may be relevant to how each person is conceptualized, understood, interacted with, and treated.
Although psychotherapists are expected to demonstrate and maintain multicultural competence, issues relevant to religion and spirituality and their potential roles in clients’ lives are often overlooked both in training and in clinical practice. Yet, as will be explained, the ability to address religion and spirituality ethically, effectively, and competently with clients is a necessity for providing clients with culturally sensitive and effective psychotherapy.
A Brief History of the Mental Health Professions’ Views on Religion and Spirituality
The mental health professions have a long history of overlooking, and even rejecting, a focus on religion and spirituality as relevant aspects of clients’ lives that are worthy of psychotherapists’ attention. Freud (1961) described religious belief as “an obsessional neurosis” (p. 43). Albert Ellis (1973) stated that psychotherapy should have “no truck whatever with any kind of …god or devil, or any kind of sacredness” (p. 16) and described religion as being “directly opposed to the goals of mental health,” (1962, p. 12). Additionally, there is a history of pathologizing religion during diagnosis and treatment, as illustrated by how it is addressed in early editions of the DSM (Allmon, 2013).
A “religiosity gap” is described between mental health professionals and the general public (Lukoff et al., 1995, p. 468). Studies have found psychologists to be much less religious than the general population (e.g., Delaney et al., 2007) and to frequently hold negative biases about religion and spirituality as well as about religious and spiritual clients in particular (O’Connor & Vandenberg, 2005). Further, most psychologists do not receive education and training relevant to addressing religion and spirituality in psychotherapy (Vieten et al., 2016), and what exists often relies on “informal and unsystematic sources of learning” (Vieten & Lukoff, 2021, p. 30), leaving many psychotherapists frequently reluctant to address such diversity issues with their clients (Hathaway et al., 2004).
Evidence in Support of Religion and Spirituality’s Positive Role
Research into religion and spirituality has increased significantly in recent years, including examining how they impact psychological wellbeing and mental health. A majority of these studies have found that religion and spirituality have a positive relationship with wellbeing/happiness, social support, and the experience of positive emotions (Koenig, 2012). Individuals who utilize support systems through their religion have demonstrated lower levels of depression and greater life satisfaction (Fiala et al., 2000). Many spiritual and religious behaviors and practices are found to promote mental health and wellness (Hathaway et al., 2004) and offer resources that promote better coping and resilience (Ano & Vasconcelles, 2005). Overall, individuals who are religious and/or spiritual are often found to experience enhanced emotional and physical health (Newport et al., 2014).
Are Religion and Spirituality of Relevance to Our Clients?
National surveys have repeatedly found religion and spirituality to be important to Americans and that such beliefs play a significant role in many individuals’ lives, including influencing their views, values, coping, and important life decisions. A recent Gallup survey (2022) found that in 2021, 49% of Americans reported religion to be very important in their lives, with another 27% describing it as fairly important. Eighty-one percent of the population reports believing in God, with 58% acknowledging praying to God often, and an additional 17% praying to God sometimes. Further, approximately one-half of all adults in the U.S. report attending religious services at least weekly.
Similarly, reporting on findings from 2014, the Pew Religious Landscape Survey (2022) found that 63% of U.S. adults report being absolutely certain in their belief in God, with an additional 20% being fairly certain in their belief in God. Pew also found 53% of U.S. adults reported religion as important in their life, and 24% reported it as fairly important in their life. Thirty-six percent report attending religious services at least weekly, and an additional 33% attending once or twice each month. Fifty-five percent of those surveyed were found to pray at least daily, and an additional 16% prayed at least weekly. Thirty-three percent reported believing that there are absolute standards of right and wrong and that religion is their source of this guidance. With regard more specifically to spirituality, 40% of respondents report meditating at least once each week, and an additional 8% once or twice each month; 59% report feeling spiritual peace and wellbeing at least once each week, with 15% reporting experiencing this once or twice each month; and 46% report feeling wonder about the universe at least once each week, with 16% reporting experiencing this once or twice each month (Pew, 2022).
Oxhandler et al. (2021a) conducted a national survey of mental health clients and found that a significant portion of them report that religion and spirituality are of relevance to their mental health and that engaging in religious or spiritual behaviors and practices enhances their mental health. Furthermore, in another national survey, these authors found that the majority of clients in the United States currently receiving mental health treatment are open to discussing their religious and spiritual beliefs with their psychotherapist, hold positive attitudes toward integrating their religion and spirituality into the treatment process, and have the expectation that their psychotherapist will have the knowledge and skills to competently do so (Oxhandler et al., 2021b).
Why Address Religion and Spirituality with Clients?
Numerous reasons exist that support the need to address issues relevant to religion and spirituality with all clients. Despite the fact that religion and spirituality play important roles in many individuals’ lives (Gallup, 2022; Pew, 2022), many clients may assume that such issues are not of interest or relevance to their psychotherapist. If psychotherapists do not directly inquire about such issues in their initial assessment of each client, clients may perceive that such issues are not appropriate for attention in psychotherapy and perhaps are better left to attention by members of the clergy. Failure to broach the topic of how religion and spirituality may be of relevance in clients’ lives may result in these important issues not being addressed and their role in the client’s life being overlooked, thus possibly limiting the effectiveness of treatment. This also goes against the guidance on multicultural competence and the assessment and treatment of the whole person articulated in the APA Ethics Code (APA, 2017a) and the APA Multicultural Guidelines (APA, 2017b).
Consistent with the wide range of potential benefits many individuals receive from their religious and spiritual beliefs and practices, these may be sources of strength and support that the psychotherapist may help the client access and utilize during the course of treatment and beyond. Many individuals find strength and support in their faith, find prayer to provide great solace and find a strong sense of community and support from their congregation (Koenig, 2012).
Additionally, not all individuals receive benefits from their religious and spiritual beliefs and practices, with some actually being negatively impacted by them. Religious and spiritual struggles have been linked to increased psychological distress and problems in psychosocial functioning (Exline, 2013). Thus, issues relevant to religion and spirituality may be of great relevance to the reasons a client is seeking psychotherapy. Clients may experience a loss or questioning of their faith (Lukoff et al., 1999), they may be experiencing conflicts between religious teachings and their sexual orientation or gender identity (Sowe et al., 2017), and may experience many other difficulties that impact their mental health and emotional functioning that are secondary to religious or spiritual issues or practices.
In addition to religious and spiritual issues of being of potential relevance to psychotherapy for the reasons mentioned above (a source of strength and support and possible sources of distress and conflict in a client’s life), other reasons exist for psychotherapists inquiring about these issues. Without this ‘permission,’ clients may assume that these are not issues to bring up and address in psychotherapy doing so may increase the client’s comfort in sharing other aspects of their personal life with the psychotherapist and may promote a more effective treatment alliance (Griffith & Griffith, 2002; Plante, 2007).
Assessing Religious and Spiritual Beliefs and Practices
As all multiculturally aware psychotherapists understand, not all dimensions of diversity are readily apparent and must be inquired about to develop a full understanding of all issues relevant to the client and their treatment needs. Obtaining information about each client’s religious and spiritual beliefs and practices should be included as part of their intake assessment at the outset of treatment. Much like how other potentially relevant aspects of a client’s presenting issues and history are investigated (e.g., family and medical history, trauma history), a spiritual and religious history is relevant to the client’s care and background (Koenig, 2012). Psychotherapists need to find out about the role of religious and spiritual beliefs and practices in the client’s life, if any, and if present, how they may be sources of distress or used for coping, and any other needs that the client may have relevant to these issues.
Assessment of religious and spiritual beliefs and practices with a client can be as simple as a few “yes” or “no” questions about their beliefs or as exhaustive as an extensive examination of their religious and spiritual history, beliefs, values, coping, conflicts, and functioning. Rather than asking the client questions specifically related to religion and spirituality, clinicians may choose to use an implicit assessment method instead. This can be demonstrated by using open-ended questions that indirectly attempt to reveal any religious and spiritual dimensions that are present in the client’s life, such as by asking the client, “From what sources do you draw the strength to go on?” which can result in the client disclosing religious and spiritual beliefs and behaviors they may rely on (such as praying) or involvement in a religious or spiritual community (Pargament, 2007, p. 218). One may also utilize structured interviews, questionnaires, and rating forms in addition to the clinical interview (e.g., Griffith & Griffith, 2002; Hill & Pargament, 2003).
Addressing Religion and Spirituality in Psychotherapy
In order to competently address and integrate religion and spirituality into psychotherapy, psychotherapists must possess the competence necessary to do so. Vieten et al. (2016) propose 16 basic competencies in the areas of attitudes and beliefs, knowledge, and skills that each psychotherapist should possess to be able to effectively address religious and spiritual beliefs and practices in psychotherapy. A careful review of these competencies is recommended by all psychotherapists, and focused education and training are recommended so that all psychotherapists will be able to competently and effectively meet their clients’ treatment needs.
Beyond assessing each client’s religious and spiritual history, beliefs, and practices, and in addition to the requirement to possess adequate competence to effectively address these issues with clients, other important ethical issues to consider and address include accuracy in how psychotherapists represent their treatment focus to members of the public (e.g., faith-based psychotherapy or Christian counseling), the use of a comprehensive informed consent process that addresses the use of any religious or spiritual interventions in treatment, attention to boundaries and multiple relationships, including staying consistent with the psychotherapist role and not taking on the role of the clergy (e.g., providing spiritual guidance), and cooperation with other professionals such as consultation and possible collaboration with religious leaders (Barnett & Johnson, 2011).
It is hoped that all psychotherapists will embrace religion and spirituality as essential aspects of diversity that are deserving of our understanding and attention in treatment. It is recommended that graduate programs and clinical training settings integrate a focus on religion and spirituality into the education and training provided to all future psychotherapists. Additionally, clinical supervisors should ensure that these important aspects of many clients’ lives are addressed in both treatment and supervision, with supervisors taking the lead in ensuring that these issues receive sufficient focus and attention. Psychotherapists should engage in ongoing learning and skill development throughout their careers so that clients may receive the most competent and effective care possible. Ethics training should integrate attention to religious and spiritual issues into education and training on topics such as competence, advertising and public statements, informed consent, boundaries and multiple relationships, and interprofessional practice. By embracing each of the above, psychotherapists may achieve the aspirational ideals of our profession and provide clients with the competent, ethical, and effective assessment and treatment services they need and deserve.
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