Integrating Religion and Spirituality into Clinical Practice Objectives

Integrating Religion and Spirituality into Clinical Practice

Objectives Ø To become familiar with empirical data that connects religion and spirituality in clinical practice Ø To gain understanding on how people grow and develop from a religious and spiritual perspective

Book Information Ø Marsha Wiggins Frame (2003). Integrating Religion and Spirituality into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole

Objectives Ø To develop skills on specific strategies for working with patients’ religious and spiritual issues Ø To acquire expertise in using spiritual interventions that promote healing and transformation

Objectives Ø To refine skills in applying religious and spiritual counseling strategies with families Ø To explore ethical concerns related to religious and spiritual interventions in clinical practice

Definitions: Spirituality and Religion Ø Spirituality involves: ØAnimating life force ØImages: wind, breath, vigor, courage ØInnate capacity that moves people toward love, meaning, hope transcendence, connectedness & compassion

Definitions: Spirituality and Religion Capacity for growth, creativity, values Ø Encompasses religion Ø May or may not involve God or a Higher Power Ø Less a method than an attitude Ø

Definitions: Spirituality and Religion ØSet of beliefs and practices of an organized institution ØDenominational ØExternal ØPublic

Definitions: Spirituality and Religion ØCognitive ØBehavioral ØRitualistic ØDoctrine and dogma ØCommunity ØPolity

Relationships Between Spirituality and Religion Ø Spiritual, but not religious Ø Religious, but not spiritual Ø Spiritual and religious Ø Neither religious nor spiritual

Pelikan’s Paradigm: Spirit vs. Structure Pelikan (1968) used paradigm to describe Luther’s role in the Protestant Reformation Ø Institutional structures squelching God’ spirit Ø Free-floating spirituality needs structure to mediate its power Ø

Clinical Implications Avoid making assumptions about patients’ worldviews, spirituality, or religion Ø Inquire about how patients’ make meaning in their lives—especially the meaning about illness, trauma and death Ø

Clinical Implications Ø Ask how you may best serve patients’ religious or spiritual needs given your professional role Ø Actively invest in learning about patients’ religious or spiritual perspectives

Empirical Data on Religion, Spirituality & Health Extensive empirical studies reveal that acitvely religious people have lower rates of many physical disorders ranging from cancer to heart disease. Ø Mortality rates are lower. Ø Coping with death and other stressors is better Ø

Empirical Data on Religion, Spirituality & Health Recovery rates from almost everything, including surgery are better for religiously active individuals (Larson & Larson, 1994) Ø A TIME survey in 1996 revealed that over 70% of patients polled believed that spiritual faith and prayer help in illness recover Ø

Empirical Data on Religion, Spirituality & Health Ø 64% of those surveyed believed physicians should talk to patients about spiritual issues as part of their care and pray with patients if they request it

Empirical Data on Religion, Spirituality & Health Ø One of the strongest predictors of survival after heart surgery is the degree to which patients draw strength from religion or spirituality, and the more religious they are the greater their protection from death (Oxman, Freeman, & Manheimer, 1995).

Empirical Data on Religion, Spirituality & Health Ø Weekly church attendees have been found to have 50% fewer deaths from coronary artery disease, 56% fewer deaths from emphysema, 74% fewer deaths from cirrhosis and 53% fewer suicides (Comstock, & Partridge, 1972)

Why? Levin (1995) suggested: Ø Religiously affiliated people have a secure sense of identity which lowers their anxiety level and facilitates resiliency under stress Ø Religion & spirituality provide meaning and purpose that allow for rational interpretations of life problems

Why? Positive emotions of hope, faith, optmism, and catharsis emerge from beliefs and ritualis, including the process of forgiveness and the hope of healing and redemption. Ø Religious people experience social support through community Ø

Why? Ø Religion and spirituality that offer prayer, ritual, worship provide experiences of communion between the individual and the Higher Power Ø Many beliefs lead to a healthy and responsible lifestyle

Empirical Data on Religion, Spirituality and Mental Health There is a favorable association between religiousness and suicide risk, drug use, alcohol abuse, delinquent behavior, and criminal behavior (Gartner, Larson & Allen, 1991) Ø Couples who attend church regularly as less likely to divorce—of course they may stay unhappily married! Ø

Empirical Data on Religion, Spirituality and Mental Health However, further research revealed religious folk were more satisfied in their marriages than were the less religious. (Gartner, et. al, 1991) Ø In fact, church attendance predicted marital satisfaction better than any of 8 other variables (Glen & Weaver, 1978) Ø

Empirical Data on Religion, Spirituality and Mental Health There is a positive relationship between religion & spirituality and overall well-being. Ø Religious persons reported lower levels of depression than did those who were not so religious (Gartner, et. al, 1991) Ø Conclusion: Religion & spirituality are integral to clinical work Ø

Models of Religious and Spiritual Development Ø Why they are useful: ØProvide framework for understanding how patients incorporate their faith ØAssist in assessing patients’ religious and spiritual growth

Models of Religious and Spiritual Development Ø Why they are useful ØExternalize religious and spiritual perspectives and reduce practitioner reactivity ØProvide tools for practitioners to make sense of their own religious and spiritual journeys

Models of Religious and Spiritual Development ØMake practitioners more open to a variety of religious and spiritual beliefs and expressions ØMay be useful in helping patients or clients understand their own perspectives vis a vis these frameworks

Models of Religious and Spiritual Development Ø CAVEATS: ØThese models are linear and hierarchical. As such they imply that higher stages are “better. ” They do not allow for circularity or movement between stages

Models of Religious and Spiritual Development ØThese models are all based on western world views. That is, they are more focused on individualism rather than collectivism. As such, they are not particularly useful with patients who hold eastern worldviews.

Models of Religious and Spiritual Development Ø GORDON ALLPORT: The development of religious sentiments (1950) Ø Three stages: Raw Credulity, Satisfying Rationalism, Religious Maturity

Models of Religious and Spiritual Development Ø STAGE 1: RAW CREDULITY ØChildren believe everything they hear about religion and spirituality ØChildren cling to their beliefs because of the bond with their parents Ø“Authority based” approach ØSometimes continues to adulthood

Models of Religious and Spiritual Development Ø STAGE 2: SATISFYING RATIONALISM ØBegins in adolescence ØQuestioning previously held beliefs ØRebellion/rejection of parental values ØSome youth retain their childhood values & beliefs

Models of Religious and Spiritual Development Ø STAGE 3: RELIGIOUS MATURITY ØOccurs after adolescence ØAbility to remain connected to a tradition but approach it critically ØKeep meaningful beliefs; reject those that do not make sense ØReligion & spirituality are positive

Models of Religious and Spiritual Development Some adults retain childhood faith Ø Other adults have more faith than doubt Ø Other adults have equal amounts of doubt and faith Ø Some never reach “religious maturity” Ø Some have meaningful life without religion or spirituality Ø

Models of Religious and Spiritual Development JAMES FOWLER: Faith Development Ø Influenced by Piaget’s theory of cognitive development Ø Influenced by Kohlberg’s theory of moral development Ø Also influenced by Erik Erickson and John Dewey Ø

Models of Religious and Spiritual Development Based on an empirical study of 359 individuals Ø For Fowler faith has more to do with a dynamic, trusting orientation toward life, others, and God, than with the more static notion of faith as believing beliefs Ø

Models of Religious and Spiritual Development Ø About the stages: ØThere are 7 ØThey are invariant, sequential, hierarchical ØIt is not possible to skip stages ØSome people stay in one stage for long period of their lives

Models of Religious and Spiritual Development Ø About the stages: ØSometimes they overlap as people transition to the next stage ØThey are not content specific ØFowler claims that lower stages are not inferior, but he has been challenged on this point

Models of Religious and Spiritual Development Ø STAGE 1: PRIMAL FAITH (Infancy) ØTrust in caregivers is developed in infancy ØThey learn that caregivers are reliable ØCorresponds to Erikson’s stage of trust vs. mistrust

Models of Religious and Spiritual Development Ø STAGE 2: INTUITIVE PROJECTIVE FAITH (Early Childhood) ØImages of God and faith are reflections of children’s relationships with parents and other significant adults ØChildren in this stage do not have the capacity for logical thinking

Models of Religious and Spiritual Development Ø STAGE 3: MYTHIC-LITERAL (Middle Childhood and Beyond) ØConcrete thinking ØPeople appropriate the myths, stories, beliefs, symbols of their traditions ØGod’s characteristics are anthropomorphic

Models of Religious and Spiritual Development Ø Stage 3: Mythic-Literal continued… ØGod rewards good, punishes evil ØMany people in this stage get disillusions when they discover that “bad things happen to good people. ” ØAdults can also remain in this stage ØSome entire congregations (often fundamentalist) are in this stage

Models of Religious and Spiritual Development Ø STAGE 4: SYNTHETIC-CONVENTIONAL (Puberty to Adulthood) ØAbility to think abstractly ØFaith is constructed in terms of conformity to a set of values and beliefs with deference to authority ØFaith stabilizes identity & worldview

Models of Religious and Spiritual Development Ø Synthetic Conventional continued… ØBeliefs and values are typically unexamined ØYearning for a personal relationship with God or Higher Power

Models of Religious and Spiritual Development Ø STAGE 5: INDIVIDUATIVE=REFLECTIVE Faith (Young Adulthood) ØCritical examination of faith ØTake responsibility for their worldview ØCommit through conscious choice rather than unexamined acceptance

Models of Religious and Spiritual Development Ø STAGE 6: CONJUNCTIVE FAITH ØUsually emerges in midlife and beyond ØPeople acknowledge multiple perspectives as valid ØIntegrate polarities ØOpenness to difference while grounded in own worldview & belief

Models of Religious and Spiritual Development Ø Conjunctive faith continued… ØMost adults do not reach this stage ØGod is experienced as both personal and abstract ØLife is considered both rational and mysterious ØSecond naivete—reclaiming past

Models of Religious and Spiritual Development Ø Conjunctive faith continued… ØDevelop a passion for justice ØIt is rare that one moves beyond this stage

Models of Religious and Spiritual Development Ø STAGE 7: UNIVERSALIZING FAITH ØOnly a few people in this category (2 -3 people/1000) ØPeople are “grounded in oneness with the power of being or God” (Fowler, 1991). ØActivists for justice ØExamples: MLK, Jr. Mother Teresa

Models of Religious and Spiritual Development Ø VICKY GENIA’S THEORY ØBased on psychoanalytic theory ØAcknowledges that development is not always linear or smooth ØPeaks and plateaus ØEmotional problems may cause people to adopt unhealthy faith forms

Models of Religious and Spiritual Development Ø STAGE 1: Egocentric Faith ØReligion is rooted in fear and needs for comfort ØPeople here reenact their relationships with their parents in their relationship with God ØSelf deprecation or perfectionistic

Models of Religious and Spiritual Development Ø STAGE 2: Dogmatic faith ØDevotion to earning God’s love and approval ØGravitate toward groups that focus on self-denial ØAllegiance to religious authority ØOften intolerant of diversity and ambiguity

Models of Religious and Spiritual Development Ø STAGE 3: Transitional Faith ØExamine tenets of faith ØOpen to exploring new spiritual paths ØMight switch affiliations ØDoubt leads to spiritual growth

Models of Religious and Spiritual Development Ø STAGE 4: Reconstructed Faith ØPeople at this stage choose a faith that meets their needs ØThey are aware of human limitations ØStrong sense of internalized morals and ideals ØConform to religious behavior codes

Models of Religious and Spiritual Development Ø Reconstructed Faith continued… ØThey relate to God as a caring, reliable parent who is an ally and source of sustenance ØThey may still have trouble with ambiguity and multifaceted dimensions of spirituality

Models of Religious and Spiritual Development Ø STAGE 5: Transcendent Faith ØCommitted to universal ideals and experience community with others of diverse faiths ØThis stage is rare ØLifestyle consistent with values ØIntegration of reason & emotion

Models of Religious and Spiritual Development Ø Transcendent faith continued… ØThey are committed without absolute certainty ØEliminated egocentricity, magical thinking and anthropomorphisms ØAcknowledge the reality of evil and suffering

CASE STUDY Ø Betty is a 42 year old White female who has been hospitalized because of a blood clot in her leg. The hospital chaplain visited Betty and they spoke about her faith. Betty indicated she wasn’t sure anymore about her belief in God. Although she was raised in a strict Presbyterian home, she said she

CASE STUDY Ø Had doubts about whether God really hears prayer. She also wonders if Christianity is really the only “true” religion. She admits that her illness has caused her to think about things she has previously accepted “on faith. ”

CASE STUDY Ø Which of Fowler’s stages seems to best fit for Betty? Ø Which of Genia’s stages seems to best represent Betty’s story? Ø How would you suggest the chaplain talk with Betty about her faith?

Working with Patients’ Religious and Spiritual Issues Ø Refrain from assuming that you do not have the ability or experience to talk with patients’ about religion or spirituality Ø Be careful not to impose your own belief system on patients

Working with Patients’ Religious and Spiritual Issues Ø View the patient as a whole person. Avoid splitting religious and spiritual issues from health or psychological concerns. Ø Accept patients’ religious or spiritual stories as just that without attempting to reframe them as psychological

Working with Patients’ Religious and Spiritual Issues Ø A Social Contructionist Perspective ØHolds that our thoughts and images about reality are subjective creations rather than objective representations (Luken & Lukens, 1988) ØAllows multiple points of view about a single issue or problem

Working with Patients’ Religious and Spiritual Issues Ø People construct their worldview as a result of interactions with others in a social context and the belief systems, values, fears, prejudices, hopes and disappointments of the constructor. Ø It involves working within the patients’ own belief systems and values

Working with Patients’ Religious and Spiritual Issues Three umpires are sitting around and one says, “There’s balls and there’s strikes and I call ‘em the way they are. ” Another says, “There’s balls and there’s strikes and I call ’em the way I see’ em. ” The third says, “There’s balls and there’s strikes and they ain’t nothing until I call ‘em. ” (Anderson, 1990)

Working with Patients’ Religious and Spiritual Issues CHALLENGES: ØShould I disclose anything about my religious/spiritual beliefs? ØWhat about patients’ religious authorities? ØWhat about my own issues?

Working with Patients’ Religious and Spiritual Issues Ø SHOULD I DISCLOSE? ØPatients often ask about caregivers’ personal beliefs. Why? ØInterest ØFear of being devalued ØTesting trust

Working with Patients’ Religious and Spiritual Issues Ø Other reasons: ØNonreligious patients may worry that caregivers will judge them negatively ØThey may worry that nonreligious caregivers may not understand or respond to their belief systems

Working with Patients’ Religious and Spiritual Issues Ø Another reason… ØSome patients fear that religious caregivers may use their situation as an opportunity to convert them

Working with Patients’ Religious and Spiritual Issues Ø SHOULD I SELF-DISCLOSE? ØSome experts believe that caregivers’ selfdisclosure interferes with patients’ own self-exploration ØOthers believe exposing one’s beliefs build rapport and offers clarity ØKelly (1995) suggests deflection of direct questions may be helpful:

Working with Patients’ Religious and Spiritual Issues Example 1: “I value your question, especially because it suggests something of importance to you. Rather than respond directly, I think it might be helpful if you were to talk more about your belief and how it is helpful to you. ” Ø

Working with Patients’ Religious and Spiritual Issues Example 2: Ø “ It sounds like you are concerned that if my beliefs are different form yours that I might try to convince you to change them and that would not be acceptable to you. ” Ø

Working with Patients’ Religious and Spiritual Issues Example 3: Ø “Maybe you are worried that I won’t take your religious or spiritual concerns seriously or that it isn’t safe to raise these topics with me. I want you to know you can trust me to respect your beliefs. ” Ø

Working with Patients’ Religious and Spiritual Issues Ø WHAT ABOUT PATIENTS’ RELIGIOUS AUTHORITIES? Definition: the power to influence or command thought, opinion, or behavior

Working with Patients’ Religious and Spiritual Issues Ø WHAT ABOUT PATIENTS’ RELIGIOUS AUTHORITIES? ØParents ØBible ØDoctrine ØClergy/ Bishops/Pope ØCatechism

Working with Patients’ Religious and Spiritual Issues Ø The more significant the authority, the less power I have in client’s life (unless I happen to be an authoritative person such as clergy) Ø Be careful about direct challenges to patient authorities because you may not be taken seriously

Working with Patients’ Religious and Spiritual Issues Talk openly with patients about their religious/spiritual authorities so you can learn about how they function Ø Use religious/spiritual authorities as tools in clinical practice. ØExample: Talk with patients’ about Biblical texts that are important to them Ø

Working with Patients’ Religious and Spiritual Issues Ø Consult with religious or spiritual authorities themselves. It may be helpful to invite them to participate in your work with a particular patient Ø Some patients will respond only to religious authorities whom they trust. Referral can be in order

Working with Patients’ Religious and Spiritual Issues WHAT ABOUT MY OWN ISSUES? Ø It is imperative to become aware of one’s own issues as a clinical practitioner Ø Ø Clients issues may become “clinical triggers” for caregivers

Working with Patients’ Religious and Spiritual Issues Ø When patients have issues that are similar to the caregivers’ issues the caregivers are more vulnerable to being pulled into their patient’s system Ø Countertransference reactions are common

Working with Patients’ Religious and Spiritual Issues Ø Examples: ØNonreligious practitioners ØRejection of family religion/values ØBeing in a similar stage as patient ØLoss and trauma ØSocial and/or political difference ØClergy abuse

Working with Patients’ Religious and Spiritual Issues Ø Addressing one’s own issues: ØSeek peer consultation ØEmbrace supervision ØEnter personal therapy ØRefer patient

Strategies for Addressing Religion & Spirituality Ø GENERAL GUIDELINES ØAddress personal issues first ØAvoid imposing your values ØEstablish a trusting relationship ØKnow the norms of your setting

Strategies for Addressing Religion & Spirituality Ø GUIDELINES CONT’D… ØBe gentle with confrontation ØSeek consultation with peers and experts ØUncover patients’ sources of support ØKeep patients’ best interest at heart

Strategies for Addressing Religion & Spirituality SPIRITUAL JOURNALING 1. Tool for self-discovery 2. Safety valve for emotions 3. Mirror for the spirit 4. Some patients may write prayers 5. Some may want to share contents

Strategies for Addressing Religion & Spirituality Ø SPIRITUAL BIBLIOTHERAPY ØAllows patients to express concerns that may be outside awareness ØCompare own thoughts to those of others ØProblem-solving information ØPromotes anxiety reduction

Strategies for Addressing Religion & Spirituality Ø GUIDELINES FOR SPIRITUAL BIBLIOTHERAPY ØRead the books you recommend! ØBe sure the book is a good fit for the patient ØAvoid books that present “band-aid” solutions to complex problems

Strategies for Addressing Religion & Spirituality Ø GUIDELINES CONT’D… ØSelect books that support patients’ emotional and spiritual health ØSeek recommendations for colleagues, clergy, mental health professionals

Strategies for Addressing Religion & Spirituality Ø SCRIPTURE & SACRED TEXTS ØWork within patients’ belief systems ØAvoid power struggles & debates ØBe prepared to refer ØMake use of metaphor and narrative (Richards & Bergin, 1997)

Strategies for Addressing Religion & Spirituality Ø Jonathan is a 34 -year-old Jewish attorney and local politician. He came to counseling because he was "torn apart by guilt over an affair he had with a colleague. " Although he and his wife, Patti, are currently involved in couples therapy with another counselor, Jonathan sought out Joshua, a Jewish chaplain, to help him address his guilt and self-loathing.

Strategies for Addressing Religion & Spirituality Ø Because Jonathan specifically asked for a religious dimension to be included in the counseling, Joshua consulted with his rabbi for a text that might be instructive for Jonathan. Rabbi Rosen suggested using the text from 2 Samuel 5 -12: 7 that includes the stories of David's kingship, his victories, and his adultery with Bathsheba.

Strategies for Addressing Religion & Spirituality Ø Ø First, Joshua asked Jonathan to read the text the rabbi had recommended. Next, he asked Jonathan, "How is your life like that of King David? " Immediately, Jonathan saw the connection. He said, "I am a successful businessman and a leader in my community, but I am also human.

Strategies for Addressing Religion & Spirituality Ø Just because I am capable and contributing doesn't mean I am without my faults. And, just because I made a lousy mess of my relationship with Patti by having an affair doesn't mean that I am worthless garbage either. " Joshua then asked, "Based on your understanding of the David story, what do you think God would have you do in your life? "

Strategies for Addressing Religion & Spirituality Ø Jonathan responded, "There will have to be consequences. I won't be able to weasel out of this one easily. I will have to demonstrate to Patti my remorse and I'll have to figure out some way to make amends. And, I will need to start trusting God more for guidance, rather than relying solely on myself. "

Strategies for Addressing Religion & Spirituality Ø PRAYER AND MEDITATION 90% of Americans say they pray 86% believe prayer makes them better people 97% believe prayers are heard (Gallup Organization, 1993)

Strategies for Addressing Religion & Spirituality PRAYER AND MEDITATION Who prays the most? Women African Americans Older persons (Gallup Organization, 1993) Ø

Strategies for Addressing Religion & Spirituality Ø PRAYER AND MEDITATION ØTypes of Prayer: Contemplative Ritualistic Petitionary Intercessory

Strategies for Addressing Religion & Spirituality Ø PRAYER AND MEDITATION ØPrayer used by patients ØPrayer by practitioner for patient ØPrayer with patient ØConsider the setting and purpose

Strategies for Addressing Religion & Spirituality Ø MEDITATION Concentrative—focus on something— mandala, candle, breath Mindfulness—open self; await insight

Strategies for Addressing Religion & Spirituality Ø MEDITATION ØHelps in stress management and relaxation ØAids with health problems ØAssists in managing depression & anxiety

Strategies for Addressing Religion & Spirituality ØVISUALIZATION AND IMAGERY ØUsed in a meditative posture ØPatients imagine scenes or images that call up issues or concerns ØSome imagery is guided

Strategies for Addressing Religion & Spirituality Ø Meditation on Matt. 13: 45 -46 ØHere is a picture of of the Kingdom of Heaven. A merchant looking out for fine pearls found one of very special value; so he went and sold everything he had and bought it. ”

Strategies for Addressing Religion & Spirituality Ø … You become aware that you are searching for something of great value…Following your intuition and God's guidance, choose your path and do whatever is necessary in order to find that for which you are searching…Let yourself experience any struggles or barriers along the way

Strategies for Addressing Religion & Spirituality Ø Also, bring in any help or assistance that you want…Finally you find this thing of great value for which you have been searching…You discover that you must sell or get rid of everything else in your life if you are to obtain this one thing…Become aware of your inner experience as you make this discovery…( Stahl, 1977).

Strategies for Addressing Religion & Spirituality Ø FORGIVENESS & REPENTANCE ØTo give up or give away anger and the actions associated with it, retribution and revenge (Sanderson & Linehan, 1999) ØA willingness to abandon one’s right to resentment

Strategies for Addressing Religion & Spirituality Ø FORGIVENESS results in ØPatients experiencing positive affect ØImproved mental health ØMore personal power ØFreedom to grow

Strategies for Addressing Religion & Spirituality Ø Process of Forgiveness: ØShock & denial ØAwareness of hurt ØAcknowledgement of grief & anger ØValidation of feelings ØJustice and restitution if possible

Strategies for Addressing Religion & Spirituality Ø Process of Forgiveness cont… ØPrevention of further offenses ØForgiveness and moving on ØShort-cutting process can result in depression & anxiety (Richards & Bergin, 1997)

Strategies for Addressing Religion & Spirituality Forgiveness does not require reconciliation Ø An apology may be necessary for reconciliation, but not forgiveness Ø Forgiveness can occur without the offender’s knowledge or involvement (Freedman, 1998) Ø

Strategies for Addressing Religion & Spirituality Ø Four patient choices: 1. Forgive and reconcile 2. Forgive and not reconcile 3. Not forgive and interact 4. Not forgive and not reconcile

Strategies for Addressing Religion & Spirituality Ø SURRENDER ØFirst attempt to change circumstances ØNext, willingness to change self and to accept the direction life takes us

Strategies for Addressing Religion & Spirituality Ø Patient approaches to life’s difficulties: ØDeferring ØPleading ØSelf-direction ØSpiritual surrender (Pargament, Smith, Koenig, & Perez, 1998)

Strategies for Addressing Religion & Spirituality Ø When patients are faced with situations in which there is little personal control such as chronic or terminal illness, death or accidents, surrender might be appropriate for them to consider…

Strategies for Addressing Religion & Spirituality ØSURRENDER involves not only a cognitive shift, but an experiential one as well in which one is in touch with selftranscendence that leads to serenity (Cole & Pargament, 1999).

Strategies for Addressing Religion & Spirituality Ø Guidelines for using Surrender as a strategy: ØAssess patient’s situation ØAvoid using surrender as a means of control ØDistinguish between surrender and learned helplessness

Strategies for Addressing Religion & Spirituality Explore patients’ religious and spiritual beliefs to determine if surrender is appropriate in their context Ø Explore patients’ receptivity by asking, “What would it be like for you to surrender to God? ” (Cole & Pargament, 1999). Ø

Spiritual Strategies with Families For most Americans, the interface between family life and religion or spirituality is very important. Religious/spiritual beliefs are critical aspects of healthy family functioning (Beavers & Hampson, 1990)

Spiritual Strategies with Families Ø In a Gallup Poll (1996) 75% of those surveyed said that religion has been a positive, strengthening force in family life.

Spiritual Strategies with Families Ø Life Cycle Transitions as Opportunities ØMarriage/Coupling ØBirth of Children ØAdolescence ØYoung adulthood ØMidlife ØDeath & Dying

Spiritual Strategies with Families Ø A Family Systems Approach ØProblems or difficulties are understood to be located BETWEEN people instead of WITHIN individuals. ØIn a family, the whole is greater than its parts

Spiritual Strategies with Families Ø A Family Systems Approach: ØAn emphasis on what, rather than why ØReciprocal causality rather than linear cause and effect ØSubjective rather than objective ØPatterns and context

Spiritual Strategies with Families Ø SPIRITUAL GENOGRAM ØMap of multiple generations ØUsed to identify religious/spiritual issues in the extended family ØView of tradition & heritage as well as current practice

Ø Four Steps: 1. Construct the genogram 2. Questions for reflection 3. Connect with family of origin 4. Integrate into the clinical endeavor

Spiritual Strategies with Families Ø Procedure: ØMap the family and record significant events ØColor-code the religious/spiritual traditions ØNote important religious/spiritual events

Spiritual Strategies with Families Ø Procedure cont… ØIndicate if family members left a church or other religious institution/organization ØIndicate closeness or distance or conflict

Spiritual Strategies with Families Ø Genogram-Related Questions: Ø 1. What role, if any did religion/spirituality play in your family of origin? Ø What specific religious/spiritual beliefs are most important for you now? How are they a source of connection or conflict between you and other family members?

Spiritual Strategies with Families ØHow is gender viewed in your religious/spiritual tradition? Ethnicity? Sexual orientation? How have these beliefs affected you and your extended family?

Spiritual Strategies with Families Ø What patterns emerge for you as you study your genogram? How are you currently maintaining or diverting from those patterns?

Spiritual Strategies with Families Ø How does your religious/spiritual history connect with your current distress, or with the problem you presented for counseling? What new insights or solutions may occur to you based on the discoveries made through the genogram? (Frame, 2000).

Spiritual Strategies with Families Ø God as a Member of the Family ØUsing Circular Questions (Griffith, 1986): ØWhen Dad stops working and attends to Mom, what happens to Tyler’s relationship with God?

Spiritual Strategies with Families Ø More circular questions: ØDoes Tyler move closer to God or farther away? ØIf Tyler moves away from God, who else makes a similar move? ØWho would be the most upset if the family did not stay close to God?

Spiritual Strategies with Families Ø More Circular Questions: ØAbout which relationship in the family do you think God would express the most satisfaction? ØThe least satisfaction? ØIf you worked out your sexual relationship with your partner

Spiritual Strategies with Families Ø so that you both found it to be satisfying, would you feel closer or farther away from God? ØTo whom in the family can you talk about God? ØWith whom would you feel it awkward? (Griffith & Griffith, 1992)

Spiritual Strategies with Families Ø Using a Spiritual Framework ØExample: A 25 year old son was overly enmeshed with his mother. He could not work without her supervision and she wasn’t able to travel because she needed him to protect her.

Spiritual Strategies with Families Ø Intervention: (Griffith, 1986) ØReframe the son’s obsession with his mother as a sin because he lacked faith the God would protect her. ØTo son: “By protecting your mother, you are trying to be her God”

Spiritual Strategies with Families Ø TRIANGLES ØThe notion that a 2 person relationship is unstable. ØTo manage the anxiety generated by emotional reactivity, one person brings in a 3 rd to moderate or reduce anxiety (Papero, 2000)

Spiritual Strategies with Families Sometimes one partner in a couple brings in God to create a triangle and diffuse conflict and balance the relationship Ø Types: ØCoalition—each partner competes for the allegiance of God but neither is sure they have it Ø

Spiritual Strategies with Families Ø Types, cont… ØDisplacement: Couple unites against a common enemy. God is blamed for the adversity in the marriage and the couple may be connected by their mutual anger at God

Spiritual Strategies with Families Ø Types contd… ØSubstitutive: God is brought in to the partnership to minimize conflict by diverting attention and intimacy to God rather than to the partner. Case Examples (pp. 219 -220)

Spiritual Strategies with Families Ø RITUALS ØCommon to both religion and spirituality ØIdentify a patient’s experience ØFind significant symbols ØCreate symbolic acts

Spiritual Strategies with Families Ø RITUALS cont… ØPossible uses: ØHealing from abuse ØGrief and loss ØNew relationships ØComing out process ØTransitions

Spiritual Strategies with Families Ø NARRATIVE APPROACHES ØReligious/spiritual language to invite conversations between self and God. ØBuild on work of Karl Tomm (1987) and Michael White (1986)

Spiritual Strategies with Families Ø Ø NARRATIVE APPROACHES cont… Sample Questions: Ø Had you possessed the relationship you now have with God when you first married, how do you suppose your different behavior might have altered the way the relationship evolved?

Spiritual Strategies with Families ØIf God were to restructure this interaction, how do you think it would go? ØIf you were to discover that God had in fact been present and active in this situation all along, where might that have been? (Griffith & Griffith, 1992, p. 73).

Spiritual Strategies with Families Ø Ø Has there ever been even a brief moment when, contrary to your expectations, you did sense approval coming from God? Can you recall a time when your husband might have criticized your relationship with God but didn’t?

Spiritual Strategies with Families Ø In view of all the betrayals you experienced in your life growing up, are you surprised to discover that you have learned to trust God? (Griffith & Griffith, 1992, p. 73 -74).

Spiritual Strategies with Families Ø Ø What difference will your having learned how to trust God make in your learning how to trust your wife? If you see yourself as the person God sees, what new possibilities might you imagine for this relationship?

Spiritual Strategies with Families Ø If you were to agree with the outcome you believe God wants for this relationship, what might be the next step in getting there? (Griffith & Griffith, 1992, p. 74).

Ethical Issues Ø ETHICS ØOur beliefs about what constitutes right behavior ØHow practitioners’ behavior affects patient welfare, social networks, and the helping profession

Ethical Issues Ø Four Dimensions: Ø having sufficient knowledge, skill, and judgment of use efficacious interventions Ø respecting human dignity and freedom of the client

Ethical Issues Øusing the power inherent in the counselor's role responsibly Øacting in ways that promote public confidence in the profession of counseling (Welfel, 1998)

Ethical Issues WELFARE OF THE PATIENT ØAddress religious/spiritual issues when the arise ØBecome familiar with religious language and concepts ØWork within patient belief systems

Ethical Issues INFORMED CONSENT Patients’ right to know what will transpire during a procedure or helping moment Let patients’ know about religious affiliations

Ethical Issues ØProtect patients’ rights to decline the use of spiritual interventions ØProvide referrals to other persons for religious/spiritual guidance and support

Ethical Issues Ø COMPETENCE AND TRAINING ØDo not practice beyond the level of competence and training ØGet supervision at the beginning of this work ØConsult, consult!

Ethical Issues Ø PERSONAL ISSUES ØAddress own religious/spiritual issues ØGet therapy if needed ØSeek spiritual guidance, if appropriate

Ethical Issues Ø PERSONAL ISSUES cont ØBe careful not to place your own needs above those of the patient ØPractice self-evaluation ØClarify your values

Ethical Issues Ø IMPOSITION OF VALUES ØImposing or exposing? ØWhen exposing becomes imposing ØEvaluation one’s interventions for possible value imposition ØAvoid passing judgment on patient values

Ethical Issues ØDUAL RELATIONSHIPS ØWhen practitioners have other types of relationships with patients besides their professional one ØPotential for conflict of interest

Ethical Issues ØReduction in objectivity ØPossible impairment to clinical judgment ØPossible harm

Ethical Issues Ø Examples: ØBlurred social and professional boundaries—role confusion ØCounselor as priest, rabbi ØChaplain as parishioner or friend

Ethical Issues Ø Guidelines (Geyer, 1994) ØGive notice if clinician is providing consultation or supervision— likelihood of confidentiality breaches ØCollaboration between religious organizations to provide mental health services to each other’s staffs

Ethical Issues ØClinicians in leadership roles in churches could reserve the right not to comment when they have information that would jeopardize client confidentiality ØAvoid dual relationships where possible

Ethical Issues ØEstablish personal boundaries ØDefine financial arrangements (if any) clearly ØMaintain regular supervision and consultation

Ethical Issues WORK-SETTING BOUNDARIES 1. Public, govt funded agencies may have policies that prohibit religious/spiritual interventions 2. Obtain informed consent 3. Be careful not to usurp or displace religious leaders

Ethical Issues Ø 4. Take care not to denigrate or criticize religious leaders’ values or belief systems

Ethical Issues Ø CONSULTATION AND REFERRAL ØKnow your limits of effectiveness ØDevelop a network of “friendly clergy” ØBecome cross-culturally knowledgeable