Should psychotherapy training include religion and spirituality?

By David Lukoff, Ph.D.

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In 1985, I proposed a new diagnostic category entitled Mystical Experience with Psychotic Features (MEPF) to identify intense spiritual experiences that present as psychotic-like episodes.  In 1989, Francis Lu, a psychiatrist on the faculty at UC Davis, and I began collaborating on a proposal for a new diagnostic category for the then-in-development DSM-IV, which we saw as the most effective way to increase the sensitivity of mental health professionals to spiritual crises.  The transpersonal movement supported this 4 year effort through publication of articles in JTP and presentations at ATP conferences to fine tune the proposal.  Ultimately in 1994, the proposal for a new diagnostic category was accepted: Religious or Spiritual Problem.  This is not listed as a mental disorder but a problem in living that requires some clinical attention.

Psychology and psychiatry have a long history of ignoring and pathologizing religion and spirituality.  This DSM category has served as a foot the door which has opened the mental health field to a broader consideration of spirituality in mental health.

Today, within mainstream psychological theory and research, we are seeing the continued exploration of transpersonal issues in the attention to “religious coping” and “spiritual struggles.”  Transpersonal psychology, starting with its founder Abraham Maslow’s focus on self-actualization and optimal functioning, has been the tip of the spear in this change.  The early transpersonal work on distinguishing a spiritual emergency from a psychotic disorder which led to a diagnostic category for spiritual problems has laid the groundwork for this new work on spiritual competencies which recognizes spirituality as a resource for wellness and recovery and the value of spiritually oriented interventions such as mindfulness practices.

I have been teaching about spiritual competencies in graduate courses in Sofia University’s PsyD and GPHD programs. Class activities include writing a spiritual autobiography, conducting a spiritual assessment with someone outside the class, keeping a gratitude journal for a week, and other exercises from the book.

(Below is an article written by David Lukoff, et. al:)

Competencies for Psychologists in the Domains of Religion and Spirituality

Religion and spirituality are important parts of the lives of most people in the United States. Gallup polls between 1992 and 2012 (Gallup, 2015) reveal that over the last two decades 79% to 88% of Americans have said that religion is “very important” or “fairly important” in their lives. A full 92% believe in God, and nearly 70% report being either “very religious” or “moderately religious” (Gallup, 2011, 2015).

A recent Pew Research Center (Lugo, 2012) survey found that even among those who report no specific religious affiliation, more than half self- identify as a religious or spiritual person. More than a third of those who are unaffiliated (37%) self-identify as “spiritual, but not religious,” and about 15% to 30% of individuals in the general population report being in this category (Lugo, 2012; Marler & Hadaway, 2002; Moore, 2003).

 

Religion and Spirituality and Psychological Health

Research has shown that for many people, spiritual and religious beliefs and practices (SRBPs; Saunders, Miller, & Bright, 2010) are intertwined with psychological and emotional well-being. Spirituality and religion substantially color the way people understand themselves and the world around them, including their values, morals, and behaviors, their stance or orientation toward other people, their feelings of happiness and safety, their capacities for forgiveness and gratitude, their level of social support and engagement, and how they interpret the meaning of events and situations, including their approach to illness and death in themselves and others (Emmons & Paloutzian, 2003; Norenzayan, Dar-Nimrod, Hansen, & Proulx, 2009; Park, 2013; Schultz, Tallman, & Alt- maier, 2010; Tay, Li, Myers, & Diener, 2014; Vallurupalli et al., 2012).

Spiritual and religious beliefs and practices qualify as aspects of human diversity equivalent in importance to race, ethnicity, gender, or sexual orientation. Based on the ethical codes that have guided our field for over a decade, psychologists should receive training in competencies related to religion and spirituality just as the field of psychology now requires for other forms of cultural competence.

For instance, according to the APA Ethics Code (American Psychological Association, 2003) psychologists should consider religious diversity as they do other forms of diversity such as race, ethnicity, gender, and sexual orientation:

Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups. (p. 1063)

Furthermore, the APA Guidelines on Multi- cultural Education, Training, Research, Prac- tice, and Organizational Change for Psychologists (American Psychological Association, 2003) identify religion and spirituality as important aspects of multiculturalism that should be included in cultural competency training, defining culture as “the embodiment of a world- view through learned and transmitted beliefs, values, and practices, including religious and spiritual traditions” (p. 8).

In 2007, APA adopted a comprehensive “Resolution on Religious, Religion-Based and/or Religion-Derived Prejudice,” condemning prejudice and discrimination against individuals or groups based on their SRBPs and resolving to include information on religious/spiritual prejudice and discrimination in multicultural and diversity training material and activities (American Psychological Association, 2007a).

Attention to spirituality and religion as components of multicultural diversity is inade quate, with most of the focus in training on ethnic and racial diversity (Frazier & Hansen, 2009). For example, Nagai (2008) found that clinicians’ self-ratings were much higher for ethnic/racial cultural competence compared to their ratings of spiritual competence.

 

Avoidance of Religion and Spirituality in Clinical Practice

A survey of more than 300 clinical psychologists on a mailing list of randomly selected APA members who had a doctorate in clinical psychology and were practicing clinicians found that these psychologists discuss religion and spirituality with only 30% of their clients, and fewer than half address clients’ SRBPs in any way during assessment or treatment planning (Hathaway et al., 2004).

Why is this the case? It does not appear to be because of lack of interest. Psychotherapists indicate an openness to engage the topic of religious and spiritual issues with clients (Brown, Elkonin, & Naicker, 2013; Knox, Cat- lin, Casper, & Schlosser, 2005) and a survey of college counselors revealed that more than 70% were open to in-session discussions of religious and spiritual issues (Weinstein, Parker, & Ar- cher, 2002). Moreover, clients report that they would like to discuss religious and spiritual matters in psychotherapy (Goedde, 2000; Post & Wade, 2009). Most clients want to be asked about their SRBPs (Blanton, 2005; Diallo, 2012; Knox et al., 2005; Oxhandler & Parga- ment, 2014; Post & Wade, 2009). For example, in a survey of clients (N 74) from nine different counseling centers, Rose, Westefeld, and Ansely (2001) found that 55% of clients wanted to discuss religious/spiritual concerns with their psychotherapist and 63% thought it was appropriate to do so.

Avoidance of religion and spirituality in clinical practice may instead be attributable to the fact that most psychologists receive little education or training in how to ethically and effectively attend to religious and spiritual domains in clinical practice, or guidance about the extent to and methods by which they should incorporate this dimension into their work.

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