Spirituality in Session
The R/S-shaped elephant in our therapy rooms
Clinicians are aware that religion and spirituality (R/S) has great importance in the general practice of therapy. In the United States, recent polling shows that the majority of the population reports believing in a higher power (about 90 percent), with the majority identifying as Christian (about 70 percent; Pew Research Center, 2018). However, the percentage of self-identified Christians has slowly been decreasing as the percentages of non-Christian faiths and religiously unaffiliated have shown growth.
Religion has been incorporated into the American Psychological Association ethics code as an essential component of our client’s lives to be aware of and respect (APA, 2017). In 2009, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) mandated that counselors be competent in addressing spirituality as a facet of multicultural competence. The Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC) proposed a set of spiritual competencies for counselors to use when navigating R/S in therapy. Despite these efforts made by our field to communicate the essential nature of integrating R/S into clinical practice, many clinicians still feel uncomfortable or unprepared to address R/S issues (Henriksen, Polonyi, Bornsheuer-Boswell, Greger, & Watts, 2015).
This current R/S landscape of the United States and the current role of R/S in therapeutic practice is a reality of which most of us are aware. Awareness is not the issue; rather, the difficulties lie in the how and when to offer R/S interventions. Part of these difficulties stem from the actuality that the therapy room is not the only area of psychological practice where R/S remains sparse. Clinician educators and supervisors have been reluctant or have felt unprepared to integrate R/S into training, supervision and the supervisory relationship (Young, Cashwell, Wiggins-Frame, & Belaire, 2002). This often leaves clinicians with a low sense of competency to integrate R/S into practice.
Most clients want to include R/S into therapy and rate religiously supportive therapists more highly, supporting the use of directive techniques to discuss R/S matter (Harris, Randolph, & Gordon, 2016). However, another group of clients report strongly desiring clinicians who focus on clinical skills and do not discuss R/S (Stewart-Sicking, Fox, & Deal, 2019). Clinicians must navigate this difficult path in their practice. This navigation can be made easier by routinely assessing clients’ treatment preferences in this area, as well as inquiring as to whether or not clients would be interested in R/S interventions. These interventions can be delivered effectively by therapists of all varieties or absences of R/S beliefs and for a variety of clinical presentations (Post & Wade, 2009). For example, these R/S interventions have also been found to show greater improvements in spiritual well-being in eating disorder inpatients (Richards, Berrett Hardman, & Eggett, 2006), childhood sexual abuse survivors (Murray-Swank & Pargament, 2005) and addiction (Avants, Beitel, & Margolin, 2005).
Whereas interventions can feel most salient in the therapy room, another skill essential to successful psychotherapy is case conceptualization. Given the discomfort supervisors may face in integrating R/S into supervision (Young, Cashwell, Wiggins-Frame, & Belaire, 2002) and given the reality that case conceptualization skills are likely to be honed during supervision (Liese & Esterline, 2015), another area in which we fall short is integrating R/S into case conceptualization as we do other aspects of a client’s identity. In fact, spiritual concerns can interface with therapy even among nonreligious clients (Stewart-Sicking, Fox, & Deal, 2019), making the unwillingness to incorporate R/S into our conceptualizations introducing potential blind spots and missing out on relevant information.
For example, a clinician practicing primarily Interpersonal Therapy (IPT) may find the client’s relationship, or lack thereof, with an R/S figure to be a central issue in therapy. If a client with depressive symptoms has developed interpersonal defenses in response to a childhood belief in a punitive, disciplinary R/S figure, those defenses may overgeneralize to other relationships and cause interpersonal disruption. This disruption is what causes and results from depressive symptoms. Disruptions can occur from inflexible coping strategies, including those that encourage the client to move away from others. Repetitive interactions with a punitive R/S figure that required behaviors to manage anxiety can inform what behaviors may currently interfere with not only the client’s R/S relationships but also their current relationships with others.
Failing to adequately assess for this essential R/S component of case conceptualization can lead to sessions spent on issues that are not the root cause of pathology. For example, in the client described above, focusing intensely on the client’s experience with their parents may not actually reveal the interpersonal defenses that currently contribute to the psychopathology. Even if the client above did not identify as having a strong R/S orientation during the intake, the R/S factors can clearly be used to inform effective case conceptualization and subsequent interventions.
This example illustrates the importance of revisiting R/S throughout the course of therapy and in using R/S in our own clinical conceptualizations. Ignoring any aspect of a client’s identity introduces blind spots into practice and potentially masks important clinical information. Models for integrating R/S interventions into therapy are being introduced, but clearly educators and supervisors must realize their responsibility in instilling a sense of urgency in their clinicians to become competent in addressing R/S in clinical work.
R/S does not have to be the awkward topic clinicians feel uncomfortable discussing, nor must it be a piece of case conceptualization that falls through the cracks. Rather, with the proper education, clinical supervision and personal reflection, it can begin to feel safe to integrate R/S into a clinical setting and to forego disregarding it out of fear. Gaining competence in R/S’s role in the clinical world has the potential to give a tremendous gift to clients for whom such issues are of central importance.
Abbie Sell is pursuing her Ph.D in counseling psychology at the University of Louisville.