Integrating Spirituality into Treatment: Resources for Practitioners

"This book is for folks who are serious about this subject. It is very academic and has comprehensive references. I agree with the editor that it's about time the psychological community acknowledged clients' spirituality and integrated it into treatment. This is tough to do without imposing one's own beliefs (or lack thereof) on the client, and I think this book goes a ways toward helping the practitioner understand what's out there and how to relate to it. The editor is a Christian, but eastern spirituality is included in the book, too, as is the 12-step program. The chapters are written by people with experience in the various facets of spirituality. One problem that I see is that the editing is sloppy. For instance the word "for" might appear when "or" is really what's meant. It's distracting and makes the read take longer as one has to keep going back over the text for clarification."
~ Written on 2007-07-23

"I have been using this book in the psychology 495 course (Spirituality and Mental Health) and have found this book invaluable. It shows how really necesary the spirituality of a person is to their mental health and should not be ignored as has been tried in the past. The whole person needs to be treated and part of that whole is the spiritual. Not religious or their religion but their spirituality."
~ Written on 2005-08-03

"Abstract
The following document will critically review the text Integrating Spirituality into
Treatment: Research for Practitioners, edited by William R. Miller. To provide a review with breadth-within the limited size of this critique-one article from each of the text's four sections is investigated. The articles were found to provide a comprehensive synthesis of current professional research, viable hypotheses, and recommendations for further study. Critical review and disagreement with some definitions and applications are noted in this document.

A Critical Review of the Text Integrating
Spirituality into Treatment: Research for Practitioners
Spirituality in psychotherapeutic treatment is a topic that has gained attention in professional research over the last 15 years. The text being critically reviewed covers many of the current issues of importance, synthesizing recent professional research, and providing hypotheses and recommendations for further study.
PART I: SPIRITUALITY AND TREATMENT
Spirituality and Health
The first chapter of the text discusses the topic of spirituality in health. Both terms-spirituality and health-are first defined and then the text addresses how one may affect the other in clinical practice.
Health
In approaching a definition of health, the author refers to the common greeting "how are you," and reflects on how the question could be interpreted as an opening to a complex dialog regarding one's holistic wellbeing. In sum, it is proposed that health can be conceptualized though three vantage points: suffering (or the absence of suffering), function (i.e. the adaptive cognitive function of an individual, and biological operation), and coherence (i.e. inner-peace, or optimism).
In an analysis of this conceptualization, it is possible that health is completely a constructivist phenomenon. With this, the first and the third criteria proposed-suffering and coherence-are equivalent and therefore redundant. Suffering, in its essence, is the antithesis of inner-peace. The idea of one suffering and being at peace at the same time is a logical impossibility unless one is compartmentalizing his/her suffering to one aspect of his/her experience and inner-peace to another. For example, one can be suffering from depression and have inner-peace in regards to their perceived spiritual salvation. It is impossible however, for one to be suffering over depression, and have inner-peace in that aspect of their health, for to do so would be to lack depressive mood.
In regards to the category of function, this criterion too seems problematic for it is odd to state that an individual paralyzed from the waist down is in poor health, though this lack of function is much more extreme than the influenza virus, a condition that often provokes the label of illness.
Spirituality
According to the text spirituality, like health, is multidimensional: even defined as the multidimensional space in which one can be located. It is said that spirituality is not religion, and is not religious practice or ceremony (though such acts can be spiritual experiences). It is also suggested that since spirituality may be an innate aspect of one's being, the concept of one individual as more (or less) spiritual than another person may be fallacious. Lastly, suggestions are made that true spirituality concerns one's subjective experiences. With these presumptions, a design is proposed that states spirituality concerns three domains: practice, belief, and experience.
The Accepted Discrepancy
Despite the author's concept of three domains, the author allows equal credence to other researchers who have qualified spirituality differently; one researcher stating that spirituality is comprised of four domains in the context of religion: the experiential, ritualistic, intellectual, and consequential. Other researchers have proposed a six dimensional model: the mythological, ritual, experiential, dispositional, social, and directional.
The simple fact that so many different qualifying systems for spirituality exist, and are accepted as equally relevant and correct, is suspicious. It seems there can be no wrong answer to the question: "what is the definition of spirituality?" This is problematic for without correct and incorrect designations spirituality has become an ambiguous term; a term with no meaning and therefore no significance. It is not helpful to have an acceptable answer to the question; "is spirituality religious/social/experiential/innate in one's being/solemn/exciting?"-to be "sometimes" or even "depends who you ask."
Spirituality and Clinical Practice
Though spiritual issues are no longer seen as psychosis, it is stated in text that when health problems involve spiritual issues-which often manifest as concerns of faith, guilt, forgiveness, grace, hope, and acceptance-it is often unclear how a prospective client should solicit help. One solution seems to be to educate clergy about psychology and counseling, while another would be to educate psychologists or counselors to be what the text refers to as "bilingual," understanding the terminology of both psychological and spiritual issues.
Accordingly, the call for helping professionals to be versed in multiple domains of human health is reinforced with numerous research studies declaring that "when spiritual and religious involvement has been measured (even poorly), it has with surprising consistency been found to be positively related to health and inversely related to disorders" (p. 11).
Integration Issues
In critical analysis of the text's call for clergy to learn psychology and psychologists to learn spirituality, though the recommendation does point to a necessary criteria for the treatment of clients, such may not be sufficient when taking into account that not only are these disciplines at times uneducated-or wrongly educated-concerning one another, even many properly educated clergy and psychologists are against the process of integrating spirituality and psychology, preferring to keep the disciplines separate in what is known at the "against" model. Clergy critique psychology for their objective and goal is often to reduce personal suffering at all costs, disregarding "unhelpful" religious morality, while psychologists view the clergy as simply "bad psychologists" and view religion as often inhibiting and superstitious. Even with education, it is suspected not all helping professionals are going to embrace the integration of these disciplines, despite the research.
Proposed Solutions
In lieu of this, the text offers several interesting solutions. One, that clergy or psychologists could be called in as a sort of "specialist" to work with a client in one aspect of his/her treatment. This suggestion is interesting for a client would benefit from the expertise of two helping professionals, but it is weak in the fact that individuals want to be understood as a whole person, not in parts.
Two, the author points out that a psychologist does not need to adhere to a person's spiritual or religious beliefs, or even condone them, to be able to help a client by understanding the religious issues. Likewise, clergy can be taught psychotherapy concepts that do not infringe on their religious beliefs-such as cognitive behavioral therapy's concepts of distorted thinking, or person centered therapy's empathetic response. These concepts, likely, the clergy have been applying in some form already though have not been able to perfect it, and have not identified it as "psychology."
Discussion
In sum, though both health and spirituality are multidimensional, and sometimes evasive when one tries to conceptualize a holistic definition, it is apparent the two areas are intertwined into human existence, effect one-another; and it is important people helpers be able to see a "whole person" to help one most effectively.
PART II: ADDRESSING SPIRITUALITY IN TREATMENT
Prayer
According to the text, 90% of Americans pray at least on occasion and 97% of those who pray believe their prayers are heard. Some research has been done to determine when persons pray and it was found that prayer is often more frequent when one is experiencing problems of severity, problems that are intractable, or those which are unresponsive to conventional resolutions. More perplexing perhaps is that research has found persons also pray more when one has a purpose in life, has consumed alcohol, has an adjusted marriage, perceived existential well-being, religious satisfaction, lower delinquency, and reduced fear of death. Frequency of prayer has been found to be unrelated to negative affect, happiness, loneliness, anxiety, or self-esteem.
Inconclusive Research
This research is convoluted, if not directly contradictory. On one hand persons are praying more when they are experiencing grave or irresolvable personal problems, on another hand prayer frequency is unaffected by affect, and increases with life-satisfaction. Though, with this, it is apparent research has not yet confirmed a theory on external determinants for increasing or decreasing prayer frequency, according to the text research has uncovered consistent data on the affects or prayer.
Affects of Prayer
Prayer has been found to be an affective coping device, appearing in some studies as a stress deterrent, and others as a stress buffer. Either way, research shows that persons "who pray frequently are less likely than people who pray infrequently to encounter psychological or physical illness and impairment in the aftermath of serious life stressors" (p. 91). This data feeds well into a point that is made later in the text: that prayer is useful for mental health practitioners. The text outlines five ways prayer can be used to effectively assist mental health treatment:
1. Professionals can identify one's praying style to assess one's religious coping style
2. Clients can be encouraged to pray outside of session, to reap its stress buffering benefits
3. Prayer can be used to promote cognitive changes with religious clients
4. Practitioners may find it beneficial to pray with clients during session
5. Practitioners can pray for their clients in private (p. 99).
Discussion
In analysis of these five options, the text does not serve to reinforce the benefits of
the last two with any type or professional research. Though it could be assumed that since a client's praying behaviors are effective tools outside of counseling they would remain effective in counseling, the text does not provide further support for this, nor does it address the dual relationships that can develop when professional and pastoral lines are blurred. In addition, the text does not address that a client may feel pressured into agreeing to pray with a counselor-a request some religious persons may be inclined to agree to even if they truly are uncomfortable with the request-a process that could leave a client feeling violated.
Regarding tenet five, it is interesting that it is suggested that the professional could pray for the client "in private" for the text does not provide any research evidence for the efficacy of prayer when it is directed toward another human without their knowledge! Just because research may exist that shows one's personal praying behaviors may buffer or dissuade that person's personal stress, this in no way provides evidence that praying for another person in private would be an effective endeavor toward that person.
PART III: SOME SPIRITUAL ISSUES IN TREATMENT
Acceptance and Forgiveness
Similar to the chapters before it, the section on acceptance and forgiveness first defines its terms, and then investigates the implication of the ideas in psychotherapeutic process.
Acceptance
Acceptance is said to be:
...the developed capacity to fully embrace whatever is in the present moment. It requires a spacious mind, and open heart, and strength to bear one's experience...although it might include the following, does not necessarily mean resignation, agreement, servitude, or passivity" (p. 200).
Further, it is stated that the process of acceptance is not for the "faint hearted" because acceptance deals with embracing reality at all costs. Examples in text are that of Jesus accepting his death on the cross (i.e. the will of God), Buddha accepting his old age and death, and Mohammad accepting the full judgment of Allah. Acceptance is said to be non-passive therefore, and instead of being synonymous with "receiving," a better understanding is to view acceptance as to catch or seize something.
Acceptance in Psychotherapy
Acceptance is something that has been rooted in psychotherapy: for existential psychotherapy, cognitive therapy, and humanistic theories all deal with perceiving reality. Further, the text points out that many psychological problems are rooted in one's disconnectedness from reality! These problems include the denial of pain and reality, dissociate identity issues, phobias, anxiety, and substance abuse issues-to mention a few.
Acceptance Discussion
However, the text makes it seem that accurate perception of reality-and its acceptance-is a cure-all for psychological problems. This may not be so. Though Buddha accepted his agedness and was well, Jesus, accepting his fate on the cross, suffered greatly! Therefore, it could be proposed that in order for acceptance to be therapeutic it must include a subject's "want for nothing," or synonymously, one's contentment with a current situation. In the quotation written at the beginning of this section, the author uses ambiguous metaphor in his definition of acceptance and states it to be a state that "requires a spacious mind, an open heart, and strength to bear one's experience." This is insufficient for use in a therapeutic process that will decrease suffering for-to present a cliché example-one in a concentration camp can "bear one's experience" in agony (as for "open heart" and "spacious mind" these defining characteristics need defining themselves!). However, if the definition includes a "want for nothing," a desire for nothing more or less than one's current situation, pain has no place left in a person's experience. This Buddha discovered.

Forgiveness
A word similar to acceptance, compassion, and tolerance; forgiveness involves a change in emotion and means to get rid of one's anger, and thoughts of retribution or revenge. Christ states that one should be able to forgive his brother in all situations (and in unlimited quantities), and in a recent survey of Christians and Buddhists, similar sentiments were stated. Lastly, it is stated in text how profoundly therapeutic forgiveness is for clients who can achieve it.
Forgiveness Discussion
The question that is not investigated in the text-one of more profundity-is "how does a psychotherapist empower a client to forgive?" There are likely many clients who understand that they are "told" to forgive by their religion's doctrine, are aware that if they "forgive" they will reap emotional or psychological benefits, though cannot do so because even though they may consciously choose to forgive, the anger they experience toward a situation or person does not allow them to consistently maintain a spirit of forgiveness. In sum, this chapter summarized some points that are commonsense to anyone with a basic knowledge of forgiveness in religion or forgiveness in psychotherapeutic practice. This chapter fails however to contribute what has been necessary for so long: an effective plan for instilling forgiveness in persons seeking help.
PART IV: SPIRITUALITY IN PROFESSIONAL TRAINING
Diversity Training in Spiritual and Religious Issues
The author quotes the American Medical Association as stating that psychiatrists should endure enough instruction about issues of religion and spirituality to facilitate the competent care of patients from different religious and spiritual backdrops. In agreement, Miller (2000) states with "the training or psychotherapists, spirituality deserves neither more nor less attention than other important aspects of human nature" (p. 261). The basic fact that the majority of the American population possesses explicit religious beliefs and practices, and that most claim that their spiritual faith is of central importance in their lives and that according to surveys of the American population 40%-50% have even had a spiritual or mystic experience serves to show that to ignore spirituality in treatment is to miss an astoundingly important aspect "of human motivation that influences personality, development, relationships, and mental health" (Miller, p. 261).
Lastly, the text states correctly that prejudice of religion may have wrongly become commonplace in counseling therapy: and may be in violation with the healer's ethical principal to "do no harm." In specific, it is stated that though it is professionally impermissible to ignore or attack ones ethnic race, cultural upbringing, or gender, it is common for a client to be berated about his/her religious or spiritual faith-which may even be viewed as pathology by a psychotherapist.
Psychotherapy Theory and Religious Acceptance
Reportedly, several psychotherapeutic theories embrace spirituality. For example, transpersonal psychology is deeply concerned with the spiritual and religious aspect of human nature, and existential therapy-like world religions-focuses on broad meanings or existence. However, in critique, the author fails to admit existential therapy is greatly opposed to any religion that instates a moral code, for such would eliminate a client's absolute "freedom." In likeness, religion contradicts the common existential claim that life is meaningless and an afterlife cannot exist.
The further repugnance of psychotherapy toward spirituality and religion involves Albert Ellis, the founder of Rational Emotive Behavior Therapy (REBT), who stated outright in one professional journal that the therapeutic solution to emotional problems is for one to become non-religious and without any dogmatic faith unfounded in fact. He continued on to propose the less religious an individual is, the more emotionally healthy that person will be (this opinion contradicts contemporary research, however). Lastly, persons with a basic background in the history of psychology know of Sigmund Freud's hatred of religious thought, considering it mass hysteria, developmental immaturity, and viewing God as a wish fulfillment.
Spirituality Training
Miller (2000) states that he is not proposing an additional course on world religions be added to psychology program curricula. Instead, he states spiritual and religious issues should be integrated into psychotherapy training as an involved component to existing educational topics including personality, assessment/interviewing, psychopathology, and supervision.
Regarding personality, it is stated that the search for the sacred has influenced in significant ways every culture throughout history, and the topic is wrongly ignored in personality studies. Miller (2000) also points out that spirituality and personality are by definition very similar, for both can be defined as a
...multidimensional latent construct of individual differences. [And that] There is a large scientific literature within the psychology of religion, seldom examined in clinical training, regarding definitional and measurement issues related to spirituality and religion (p 258).
Concerning Assessment/Interviewing, along with other areas where practitioners are trained to gather relevant information on a client, which include family history, sexual history, personality, cognitive functioning, and psychopathology, psychologists in training need to be instructed in understanding a client's religious history and be able to effectively assess current spirituality.
Psychopathology is important because in the past spiritual and religious beliefs have been wrongly anecdotally related to mental illness. Schools should instruct future practitioners that spiritual and religious issues are not precursors to psychopathology, but are often useful in preventing psychopathological disorders.
Lastly, supervision allows a seasoned psychologist to assist a new therapist to not overlook one's spiritual issues, but to effectively integrate them into treatment. In addition, a new therapist can be instructed when it is, and when it is not, appropriate to challenge a client's religious beliefs, or how a professional can tell if one's spiritual beliefs are genuinely destructive. In supervision, issues of proselytizing can be addressed in milieu of an ongoing counseling situation, as can the ethical issue of a therapist disclosing his/her religious beliefs to a client.
Discussion
The points mentioned in this chapter are good ones. They include the concern that spirituality and religion should not be challenged as psychopathology-as they have been throughout the history of psychology. Also, the notion that mental health practitioners should have a suitable understanding and active respect for a client's faith is an important observation that not even conservative religious clergy could disagree with. However, what has not been mentioned is a plan for improving a client's spiritual health. Culture, race, gender-these are generally static conditions.
Spirituality is different in the respect that it is not. It is more than a facet of an individual's being that needs to be considered when diagnosing and treating a mental health issue. Like mental health, spiritual issues may need educated guidance and therapy to first become devoid of illness (spiritual health) and later to promote spiritual growth within a client.
"
~ Written on 2005-04-03

"If you are seeking to integrate spirituality into patient care in a hospital, medical practice, or ambulatory surgery center -- you should seek other works.

Psychologists, psychotherapists, behavioral therapists and ministers or chaplains who have an ongoing relationship with patients (e.g. chronic illnesses) will find this book useful and important.

Chapters on: Spirituality and Health, Historical Context, Assessing Spirituality, Mindfulness and Meditation, Prayer, Spirituality and the 12-step Programs, Values Spirituality and Psychotherapy, Behavioral Approaches to Enhance Spirituality, Spiritual Surrender: A Paradoxical Path to Control, Acceptance and Forgiveness, Evoking Hope, Serenity and Diversity Training in Spiritual and Religious Issues.

The only critique is the absence of an instrument to assess spirituality (or even guidance for the reader on which existing assessments are the best in practice)."
~ Written on 2003-04-13