Ethical Issues for the Integration of Religion and Spirituality in Therapy
The past decade has witnessed increased attention to the importance of understanding and respecting client/patient spirituality and religiosity to psychological assessment and treatment, as well as recognition that religious and spiritual factors remain underexamined in research and practice (APA, 2007d). Advances in addressing the clinical relevance of faith in the lives of clients/patients have raised new ethical dilemmas rooted in theoretical models of personality historically isolated from client/patient faith beliefs, the paucity of research on the clinical benefits or harms of injecting faith concepts into treatment practices, group differences in religious practices and values, and individual differences in the salience of religion to mental health (Shafranske & Sperry, 2005; Tan, 2003).
The Secular–Theistic Therapy Continuum
Integration of religion/spirituality in therapy can be characterized on a secular–theistic continuum. Toward the secular end of the continuum are “religiously sensitive therapies” that blend traditional treatment approaches with sensitivity to the relationship of diverse religious/spiritual beliefs and behaviors to mental health. Midway on the continuum are “religiously accommodative therapies” that do not promote faith beliefs but, when clinically relevant, use religious/spiritual language and interventions consistent with clients’/patients’ faith values to foster mental health. Toward the other end of the continuum are “theistic therapies” that draw on psychologists’ own religious beliefs and use sacred texts and techniques (prayer, forgiveness, and meditation) to promote spiritual health.
The sections that follow highlight ethical challenges that emerge along all points of the secular–theistic therapy continuum.
All psychologists should have the training and experience necessary to identify when a mental health problem is related to or grounded in religious beliefs (Standards 2.01b, Boundaries of Competence, and 2.03, Maintaining Competence; see also Bartoli, 2007; W. B. Johnson, 2004; Plante, 2007; Raiya & Pargament, 2010; Yarhouse & Tan, 2005). Personal faith and religious experience are neither sufficient nor necessary for competence (Gonsiorek, Richards, Pargament, & McMinn, 2009). There is no substitute for familiarity with the foundational empirical and professional mental health knowledge base and treatment techniques. While personal familiarity with a client’s/patient’s religious affiliation can be informative, religious/spiritual therapeutic competencies for mental health treatment include
· understanding how religion presents itself in mental health and psychopathology;
· self-awareness of religious bias that may impair therapeutic effectiveness, including awareness that being a member of a faith tradition is not evidence of expertise in the integration of religion/spirituality into mental health treatment;
· techniques to assess and treat clinically relevant religious/spiritual beliefs and emotional reactions; and
· knowledge of data on mental health effectiveness of religious imagery, prayer, or other religious techniques.
Collaboration With Clergy. Collaborations with clergy can help inform psychologists about the origins of the client’s beliefs, demonstrate respect for the client’s religion, and avoid trespassing into theological domains by increasing the probability that a client’s incorrect religious interpretations will be addressed appropriately within his or her faith community (W. B. Johnson, Redley, & Nielson, 2000; Richards & Bergin, 2005; Standard 3.09, Cooperation With Other Professionals). When cooperation with clergy will be clinically helpful to a client/patient, psychologists should
· obtain written permission/authorization from the client/patient to speak with a specific identified member of the clergy,
· share only information needed for both to be of optimal assistance to the client/patient (Standard 4.04, Minimizing Intrusions on Privacy),
· discuss with the clergy where roles might overlap (e.g., family counseling, sexual issues), and
· determine ways in which the client/patient can get the best assistance.
Avoiding Secular–Theistic Bias
Psychologists must ensure that their professional and personal biases do not interfere with the provision of appropriate and effective mental health services for persons of diverse religious beliefs (Principle D: Justice and Principle E: Respect for People’s Rights and Dignity; Standards 2.06, Personal Problems and Conflicts, and 3.01, Unfair Discrimination).
Disputation or Unquestioned Acceptance of Client/Patient Faith Beliefs. Trivializing or disputing religious values and beliefs can undermine the goals of therapy by threatening those aspects of life that some clients/patients hold sacred, that provide supportive family and community connections, and that form an integral part of their identity (Pargament, Murray-Swank, Magyar, & Ano, 2005; Standard 3.04, Avoiding Harm). Similarly, some religious coping styles can be deleterious to client/patient mental health (Sood, Fisher, & Sulmasy, 2006), and uncritical acceptance of theistic beliefs, when they indicate misunderstandings or distortions of religious teachings and values, can undercut treatment goals by reinforcing maladaptive ways of thinking or by ignoring signs of psychopathology. In addition, psychologists should not assume that religious or spiritual beliefs are static and be prepared to help clients/patients identify changes reflecting spiritual maturity positively tied to treatment goals (Knapp, Lemoncelli, & VandeCreek, 2010). To identify if clients’/patients’ religious beliefs are having a deleterious effect on their mental health, psychologists should explore whether their beliefs (a) create or exacerbate clinical distress, (b) provide a way to avoid reality and responsibility, (c) lead to self-destructive behavior, or (d) create false expectations of God (W. B. Johnson et al., 2000). When appropriate, psychologists should consider consulting with clergy to determine if a clients’/patients’ religious beliefs are distortions or misconceptions of religious doctrine.
Imposing Religious Values
Using the therapist’s authority to indoctrinate clients/patients to the psychologists’ religious beliefs violates their value autonomy and exploits their vulnerability to coercion (Principle E: Respect for People’s Rights and Dignity; Standard 3.08, Exploitative Relationships). When clients/patients are grappling with decisions in areas in which religious and secular moral perspectives may conflict (e.g., divorce, sexual orientation, abortion, acceptance of transfusions, end-of-life decisions), therapy needs to distinguish between those religious values that have positive or destructive influences on each individual client’s/patient’s mental health—not the religious or secular values of the psychologist. Professional license to practice psychology demands that psychologists provide competent professional services and does not give them license to preach (Plante, 2007). Psychologists should guard against discussing religious doctrine when it is irrelevant to the clients’/patients’ mental health needs (Richards & Bergin, 2005).
Confusing Religious Values With Psychological Diagnoses. The revised Guidelines for Psychological Practice With Lesbian, Gay and Bisexual Clients (APA, 2012d) encourages psychologists to consider the influences of religion and spirituality in the lives of lesbian, gay, and bisexual specifically and transgender and questioning clients in general. The linking of religious values and psychotherapies involving LGBT clients/patients has drawn a considerable amount of public attention. Spiritually sensitive, accommodative, and theistic therapies have a lot to offer LGBT clients/patients (Lease, Horne, & Noffsinger-Frazier, 2005). LGBT persons vary in their religious backgrounds and the extent to which it affects their psychological well-being. Ethical problems arise, however, when psychologists confuse a client’s/patient’s conflicted feelings about their sexual orientation and religious values with psychological diagnoses. Such ethical challenges have raised considerable professional dialogue as they relate to the application of conversion therapies to alter sexual orientation.
All major professional mental health organizations have affirmed that homosexuality is not a mental disorder (www.apa.org/pi/lgbc/publications/justthefacts.html#2). In addition, to date, empirical data dispute the effectiveness of conversion/reparative therapies aimed at changing sexual orientation (www.Psychology.org.au/Assets/Files/reparative_therapy.pdf). Psychologists who offer such therapies to LGBT clients/patients risk violating Standard 2.04, Bases for Scientific and Professional Judgments. Moreover, when psychologists offer “cures” for homosexuality, they falsely imply that there is established knowledge in the profession that LGBT sexual orientation is a mental disorder. This, in turn, may deprive clients/patients of exploring internalized reactions to a hostile society and risks perpetuating societal prejudices and stereotypes (Cramer, Golom, LoPresto, & Kirkley, 2008; Haldeman, 1994, 2004; Principle A: Beneficence and Nonmaleficence; Principle B: Fidelity and Responsibility; and Principle D: Justice; Standard 3.04, Avoiding Harm). In addition, when psychologists base their diagnosis and treatment on religious doctrines that view homosexual behavior as a “sin,” they can be in violation of Standard 9.01, Bases for Assessments, and may be practicing outside the boundaries of their profession.
Multiple relationship challenges arise when clergy who have doctoral degrees in psychology provide mental health services to congregants or nonclergy psychologists who treat members of their faith communities (Standard 3.05, Multiple Relationships).
Clergy–Psychologists. Clergy–psychologists providing therapy for members of their faith over whom they may have ecclesiastical authority should take steps to ensure they and their clients/patients are both aware of and respect the boundaries between their roles as a psychologist and as a religious leader. Distinguishing role functions becomes particularly important in addressing issues of confidentiality. Psychologists and clergy have different legal and professional obligations when it comes to mandated reporting of abuse and ethically permitted disclosures of information to protect clients/patients and others from harm (Standard 4.05, Disclosures).
Therapists at all points along the secular–theistic continuum who share the faith beliefs of clients/patients or work with fellow congregants must take steps to ensure that clients do not misperceive them as having religious or ecclesiastical authority and understand that the psychologists do not act on behalf of the church or its leaders (Gubi, 2001; Richards & Potts, 1995). This may be especially challenging for nonclergy religious psychologists working in faith-based environments (Sanders, Swenson, & Schneller, 2011). Psychologists also need to take steps to ensure that their knowledge of their joint faith community does not interfere with their objectivity and that clients/patients feel safe disclosing and exploring concerns about religion or behaviors that might ostracize them from this community.
Fee-for-Service Quandaries. While psychologists can discuss spiritual issues in therapy, when services are provided as a licensed psychologist eligible for third-party payments, the primary focus must be psychological (Plante, 2007). A focus on religious/spiritual rather than therapeutic goals may risk inappropriately charging third-party payors for nonmental health services not covered by insurance policies (Tan, 2003; see also Principle C: Integrity; Standard 6.04, Fees and Financial Arrangements). Clergy and nonclergy psychologists practicing theistic therapies may find it difficult to clearly differentiate in reports to third-party payors those goals and therapeutic techniques that are accepted mental health practices and those that are spiritually based. In most instances clergy–psychologists should encourage their congregants to seek mental health services from other providers in the community and refrain from encouraging their congregants to see them for fee-for-service therapy (Standard 3.06, Conflict of Interest). When clergy or nonclergy psychologists provide spiritual counseling free of charge in religious settings, they should clarify they are counseling in their ecclesiastical role and that content will be specific to pastoral issues (Richards & Bergin, 2005).
The role of religion/spirituality in clients’/patients’ worldview may determine their willingness to participate in therapies along the secular–theistic continuum. Some may find the interjection of religion into therapy discomforting or coercive, while others may find the absence of religion from therapy alienating.
When scientific or professional knowledge indicate that discussion of religion may be essential for effective treatment (Standards 2.01b, Boundaries of Competence; 2.04, Bases for Scientific and Professional Judgments), informed consent discussions can help the client/patient and psychologist identify and limit for treatment those religious beliefs and practices that facilitate or interfere with treatment goals (Rosenfeld, 2011; Shumway & Waldo, 2012). In some contexts, it may be ethically appropriate to discuss the risks involved in exploration of the client’s religious beliefs, including loss of current coping mechanisms, stress produced by self-questioning of religious beliefs, and diminished capacity to seek support from one’s religious community (Rosenfeld, 2011). The goal of such discussions is to enhance the therapeutic alliance and treatment context through client–therapist mutual understanding and respect.
When treatments diverge from established psychological practice, clients/patients have a right to consider this information in their consent decisions. Consequently, informed consent for theistic therapies should explain the religious doctrine and values upon which their treatment is based, the religious methods that will be employed (e.g., prayers, reading of scripture, forgiveness), and the relative emphasis on spiritual versus mental health goals. In addition, since theistic therapies are relatively new and currently lack empirical evidence or disciplinary consensus regarding their use (Plante & Sherman, 2001; Richards & Bergin, 2005), psychologists practicing these therapies should consider whether informed consent requirements for “treatments for which generally recognized techniques and procedures have not been established,” described in Standard 10.01b, apply.
There is a welcome increase in research examining the positive and negative influences of religious beliefs and practices on mental health and the clinical outcomes of treatment approaches along the secular–theistic therapy continuum. Ethical commitment to do what is right for each client/patient and well-informed approaches to treatment will reduce, but not eliminate, ethical challenges that will continue to emerge as scientific and professional knowledge advances. Psychologists conducting psychotherapy with individuals of diverse religious backgrounds and values will need to keep abreast of new knowledge and ethical guidelines that will emerge, continuously monitor the consequences of spirituality and religiously sensitive treatment decisions on client/patient well-being, and have the flexibility and sensitivity to religious contexts, role responsibilities, and client/patient expectations required for effective ethical decision making.
Fisher, C. B. (20120904). Decoding the Ethics Code: A Practical Guide for Psychologists, 3rd Edition. [MBS Direct]. Retrieved from https://mbsdirect.vitalsource.com/#/books/978145228587