Can religion and spirituality have a place in therapy? Experts say yes - APA Monitor on Psychology

More than 70% of U.S. adults say religion is important in their lives, and most patients want the chance to discuss religion or spirituality during therapy (Religion, Gallup Historical Trends, 2023; Oxhandler, H. K., et al., Religions, Vol. 12, No. 6, 2021). But when surveyed about their expertise, up to 80% of practicing psychologists say they received little to no training on addressing spiritual and religious issues during therapy (Vieten, C., et al., Spirituality in Clinical Practice, Vol. 3, No. 2, 2016).

"Most people in the United States find religion either very important or somewhat important in their lives. This is a foundational part of how people view the world," said psychologist Cassandra Vieten, PhD, a clinical professor of family medicine and director of the Center for Mindfulness at the University of California, San Diego, who has developed guidance for enhancing spiritual and religious competencies among therapists. "But, in general, clinicians don't tend to bring it up with patients."

Psychologists say it's time for that to change, pointing to compelling ways that discussions of faith can enhance therapeutic outcomes. Myriad studies show that religious or spiritual involvement improves mental health and can be useful for coping with trauma. By centering the patient and their existing beliefs, psychologists can help people leverage their religious and spiritual resources as a source of strength during challenging times (Oman, D., & Syme, S. L., in Why Religion and Spirituality Matter for Public Health, Springer, 2018; Park, C. L., et al., Trauma, Meaning, and Spirituality, APA, 2016).

On the other hand, religion can cause harm that patients may need to address in therapy, such as abuses toward the LGBTQ+ community or a legacy of oppression or colonization based on religious affiliation. People of faith also face day-to-day conflicts and questions relating to their beliefs and communities that they may wish to explore in a secular space. And just as therapy affords the space for patients to explore how they approach their work, health, and relationships, it can also offer opportunities to answer deeper questions about the meaning of life and their place in the world.

"We're not only biological, social, and psychological beings, but spiritual beings as well. We have a yearning to connect with something larger than ourselves, something sacred," said Kenneth Pargament, PhD, an emeritus professor at Bowling Green State University in Ohio who has led efforts to integrate spirituality into mental health care and to help patients navigate spiritual and religious struggles. "But traditional behavioral models of psychology often do not fully capture what it means to be human."

To start, many mental health practitioners simply need more thorough training on how to ethically and effectively make space for spirituality and religion in therapy. That should include an exploration of their own biases, experts say, such as why they may hesitate to engage with patients on spiritual topics and assumptions or microaggressions they may unknowingly make. It's also time to start asking about religion and spirituality during intake interviews and to look for signs that a patient may want to explore further.

Spirituality and religion are two distinct but overlapping concepts. While religion involves organized or shared practices and beliefs, spirituality is the process of seeking out something sacred. That can involve a higher power or other aspects of life—such as loving relationships, nature, or work—and may occur either inside or outside of a religious tradition. More than a quarter of U.S. adults say they are spiritual but not religious ("More Americans Now Say They're Spiritual but Not Religious," Pew Research Center, 2017).

"If a large part of the way that people see themselves, make meaning, and understand and approach their challenges is connected to their faith, traditions, and beliefs, it is against our ethical guidelines to ignore that," said APA 2023 President Thema S. Bryant, PhD.

Mixing faith and science?

Psychology, as a field, has historically not been particularly interested in—or friendly toward—religious and spiritual issues, Pargament said. With the 20th-century rise of psychoanalysis and behaviorism, that divergence peaked.

"Leaders like Sigmund Freud and B. F. Skinner wanted to establish psychology as a science, and thought religion was largely a way of protecting people from confronting reality," Pargament said. "That orientation shaped and shaded the field for many years."

In the United States, cultural taboos around discussing religion and politics likely also contribute to discomfort among mental health practitioners, said Stephanie Winkeljohn Black, PhD, an associate professor of psychology at Penn State Harrisburg who studies multicultural psychotherapy. On top of that, many simply lack exposure to religious life. Surveys show that psychologists are considerably less religious than the general public (Shafranske, E. P., & Cummings, J. P., in APA Handbook of Psychology, Religion, and Spirituality (Vol. 2): An Applied Psychology of Religion and Spirituality, 2013). If they also received little training on the subject, they may view it as unprofessional to discuss spiritual matters with patients, Bryant said.

Others may have negative experiences of their own with religion or feel concerned about discussing the topic with groups who face outsize harm from religious establishments, such as people who identify as LGBTQ+.

"Some frame it as almost a moral or ethical imperative to protect their clients from religion," said Winkeljohn Black, who is studying perspectives on religion and spirituality among trainees.

The lack of attention to religion isn't just a missed opportunity. In some cases, psychologists cause or compound harm by dismissing patients' attempts to discuss their beliefs; assuming that a patient's religion is racist, sexist, or shame-based; or pathologizing someone as "hyper-religious" because they attend services several times a week (Trusty, W. T., et al., Psychotherapy, Vol. 59, No. 3, 2022).

"Often there is a silencing on the topic, but there have also been mental health providers who are disrespectful, shaming, and dismissive of people's faith traditions," said Bryant, who is an ordained elder in the African Methodist Episcopal Church.

That silence and dismissal may contribute to disparities in mental health service use by Black and Brown communities in the United States, Vieten said. Black Americans are more likely than the general public to believe in God or a higher power and to say that religion is very important to them ("Faith Among Black Americans," Pew Research Center, 2021). Among Muslims in America, two-thirds say religion is very important and 6 in 10 pray daily ("U.S. Muslims Concerned About Their Place in Society, but Continue to Believe in the American Dream," Pew Research Center, 2017). An unwillingness or inability to address religious strengths and struggles with those populations in therapy could discourage them from seeking help.

Research also suggests that psychologists may have a distorted view of their preparedness to discuss religion and spirituality. Though the large majority report getting little or no training on religious and spiritual issues, most still say they are fully or mostly competent to handle them when they arise (Vieten, C., et al., Spirituality in Clinical Practice, Vol. 3, No. 2, 2016).

Now, a growing cadre of psychologists say it's time for a change. For one, religion should be a standard part of the intake—just as we ask about family, work, and relationships, we should ask what patients hold sacred and where they find meaning. That information offers insight into their psychological functioning, Vieten said, but it's also a component of their diversity. In addition, asking about religious or spiritual engagement sends the message to patients that it is a welcome subject in therapy.

"Some therapists might be hesitant to even start the conversation," said Cynthia Eriksson, PhD, dean of the School of Psychology & Marriage and Family Therapy at Fuller Theological Seminary. "Unfortunately, that leads to clients feeling like it's not safe or appropriate to talk about their religious beliefs, which is a huge loss."

How to effectively incorporate spirituality and religion

To support psychologists in beginning to effectively and ethically weave spirituality and religion into clinical practice, Vieten and her colleagues, including David Lukoff, PhD, of the Spiritual Competency Academy and co-investigators on the Spiritual and Religious Competencies Project, have developed a set of spiritual and religious competencies (American Psychologist, Vol. 77, No. 1, 2022). They are now drafting a series of formal religion and spirituality guidelines as part of APA's Division 36 (Society for the Psychology of Religion and Spirituality) that will soon undergo review by other divisions. Experts offer the following advice grounded in the spiritual and religious competencies:

Routinely ask about spiritual and religious background, beliefs, and practices

It all starts with asking the questions. During intake, Mark Yarhouse, PsyD, director of the Sexual & Gender Identity Institute at Wheaton College in Illinois and chair of the Division 36 Task Force on LGBT Issues, suggests asking about a patient's religious tradition growing up. How were beliefs and values expressed? To what degree does that background influence how you view things today? Would you like to integrate spirituality and religion into clinical care as we work toward your goals?

As therapy progresses, Bryant suggests finding opportunities to learn more about a patient's religious practices and beliefs—including how their own beliefs may differ from those of their community. It's important to ask questions about both strengths and challenges related to a person's faith.

Know how religion and spirituality can shape identity, diversity, and psychology

Psychologists should enter those conversations with a basic conceptualization of both religion and spirituality, including practical points such as how major religious traditions view gender roles and expectations, said Sandra Dixon, PhD, an associate professor of counseling psychology at the University of Lethbridge in Alberta, Canada. They should also understand the multidimensional nature of spirituality and religion, which can involve beliefs, practices, relationships, and experiences that may differ significantly, even among individuals from the same tradition.

"A psychologist doesn't have to be an expert on all world religions, but they do need to understand how religion and spirituality function in a person's life," Yarhouse said.

Beyond foundational knowledge, approaching conversations with cultural humility and healthy self-disclosure, when appropriate and beneficial to a patient, can show that even if a practitioner does not share the same faith, they are genuinely curious about and comfortable with discussing it, Dixon said. That means having the willingness to say, "I don't understand, but I'm willing to learn alongside of you."

Practice with an awareness of your own spiritual and religious background and beliefs, including any biases

Just as therapists hold biases around race, gender, sexuality, age, culture, and other characteristics, they also have biases around religion and spirituality. A deeply religious clinician, for example, might encounter an atheistic patient and worry that the person is lonely or unfulfilled; a secular therapist might assume their religious or spiritual patient is anti-intellectual or naive. Bias and countertransference can also be an issue when a provider and patient come from the same religious tradition if the provider makes judgments about how to observe or participate correctly.

"Even though you might share the same faith as your client, your client might have a different understanding of that faith, belief system, and worldview," Dixon said.

Probing those assumptions and reactions, then recentering on the patient's lived experience, is a key part of becoming competent and confident as culturally humble clinicians.

Understand that spirituality and religion can bring strengths to support treatment

Religious and spiritual beliefs and practices can be a powerful resource for patients who are working through challenges, including traumatic experiences.

"One of the important things psychologists do is to help people regain their footing when trouble hits and draw on the resources that have sustained them in the past," Pargament said. "That applies to spiritual as well as physical, psychological, and social resources."

In some cases, that may simply mean encouraging a patient to reconnect with a religious or spiritual community that previously has provided support. When one of Pargament's patients was suffering from post-traumatic stress disorder after witnessing a fatal car accident, he withdrew from his church community because he feared burdening or frightening other members. Pargament encouraged him to reach out, suggesting that others may see it as a gift to support him after he had enriched their lives (Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred, Guilford Press, 2007).

"When he finally reached out, it was really a key moment in his healing, something that helped him regain his emotional footing," Pargament said.

For trauma survivors, Bryant recommends paying attention to how religious and spiritual beliefs may relate to shame and self-blame, self-forgiveness, and the possibility of change.

Be aware of spiritual struggles that might influence patients' faith

When patients experience challenges related to their spirituality or religion, practitioners can provide support by encouraging discussion and reflection, as well as by helping patients find ways to use those struggles as a springboard to growth. For example, a patient may feel anger for being punished by God, worried about being tormented by evil spirits, guilt about not living up to moral standards, or concerned that life may not really matter. Interpersonal struggles can also occur in a religious community, including conflict with others relating to one's beliefs (Pargament, K. I., & Exline, J. J., Working with Spiritual Struggles in Psychotherapy: From Research to Practice, Guilford Press, 2022).

"Therapy is a place where people can say, 'I'm not sure what I believe,' and where they can explore behaviors that their faith tradition may not support," Bryant said, such as living with a partner without being married.

Some populations may be more likely to face religious struggles than others. In Canada, Dixon and a graduate student assistant, Juliane Bell, recently completed a study exploring immigrant patients' experiences of faith and faith practices in the context of counseling. One key finding revealed the intersectionality between religiosity and colonization, including intergenerational trauma that has resulted from certain Christian and Eurocentric worldviews and traditions (Cultural and Pedagogical Inquiry, Vol. 12, No. 1, 2021). While many Indigenous, Black, and racialized people (including immigrants) have faced direct and indirect harms from organized religion, many still draw strength from their religious involvement to cope with life's challenges, Dixon said.

LGBTQ+ patients also experience fewer benefits from religion than the general population, according to a meta-analysis led by Tyler Lefevor, PhD, an associate professor of clinical/counseling psychology at Utah State University (Psychological Bulletin, Vol. 147, No. 7, 2021). But religion can also provide these individuals meaning, values, and community, just as it does for other people of faith. Lefevor cocreated the religious/spiritual stress and resilience model to help providers understand and probe the range of harms, benefits, and questions LGBTQ+ patients may face with religion and spirituality (Perspectives on Psychological Science, online first publication, 2023).

"Religion can be both damaging and life-giving for LGBTQ people, but it's a real shame when they can't access it," he said.

Know when to consult with colleagues or spiritual or religious leaders

Being competent on matters of religion and spirituality also means knowing when to seek support. Practitioners should be willing and able to refer to, consult with, or collaborate with other clinicians who have expertise at the intersection of spirituality and psychology. Look for training directors at clinics that offer spiritually integrated care, or contact a member of APA's Division 36 for a referral, Vieten suggested.

It can also help to connect with a spiritual guide or leader from the patient's tradition (Milstein, G., et al., Professional Psychology: Research and Practice, Vol. 41, No. 5, 2010). A patient who is struggling with questions about theology and morality, for example, could benefit from the dual support of a psychologist and a religious adviser.

Vieten once worked with a patient who was protesting weekly at abortion clinics because of his religious beliefs but was also experiencing nightmares and distress linked to that behavior. She consulted with other psychologists and guides from his religious tradition to help gain clarity on the situation and to separate her assessment from any personal feelings on the subject.

"It's a good idea to seek outside support if you find yourself having a strong reaction, or if you are not sure what to do," she said.

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