Jeffrey E. Barnett, Psy.D., ABPP

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.

◦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.

◦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.

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.

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

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

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;

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

◦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.

◦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.

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)?

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?

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?

◦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

◦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

◦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

◦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

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?

Model developed by Barnett and Johnson (2011)

Continued respect and dignity

Include rationale for asking such questions in informed consent process

Where is the line between disorder and diversity?

Seek consultation if this line is unclear

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

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

Consider your education, training, knowledge, and experience

Review relevant literature, practice guidelines, and ethical standards

Self-assessment of competence may not always be accurate

Consult with colleagues to process countertransference reactions

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

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.)

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.

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).

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?

Scenario # 1

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).

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?

Scenario # 2

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