Running head: SPIRITUALITY, RELIGION AND PSYCHOLOGY 1

Spirituality, Religion, and Psychology John Laing University of Calgary APSY 603 Dr. Irene Estay

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Spirituality and religion are a big part of many peoples lives. Debate continues to exist in the literature regarding spirituality and religion and their place in psychological intervention (Barnett & Johnson, 2011). Some researchers posit the need for a distinction between religion and psychology, whereas others advocate for an integration of the two (Gonsiorek, Richards, Pargament, & McMinn, 2009). Incorporating religion and spirituality into work with clients can cause practitioners anxiety and poses several ethical dilemmas (Barnett & Johnson, 2011). Incorporating religion and spirituality into work with clients can be difficult for practitioners. This can become particularly difficult when the client wishes to incorporate their beliefs into the intervention process when the practitioner does not have training on the integration of religion, spirituality, and therapy (Barnett & Johnson, 2011). The goal of this paper is to review research related to the ethical dilemmas that exist regarding the integration of religion, spirituality, and psychology. This paper will outline the specific ethical principles and standards relevant to the dilemma posited. Furthermore, this paper will present a case example to highlight the potential dilemma that will be discussed throughout. This paper will then discuss a brief decision making model that could be affective in resolving the issue. Lastly, this authors conclusions about incorporating religion and spirituality with psychological intervention will be presented. Importance of Addressing the Issue

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Religion and spirituality are important aspects of the lives of many people who seek psychological intervention. Many practitioners are illequipped to effectively and ethically address these issues with their clients (Barnett & Johnson, 2011). Religious or spiritual concerns may be relevant to the reasons clients seek treatment. Such clients may experience conflict in their spiritual or religious beliefs and others may rely on their beliefs as a source of support that the practitioner can utilize during the intervention process (Barnett & Johnson, 2011; Corsini & Wedding, 2007)). Due to the desire of some clients to incorporate such beliefs into intervention, coupled with many practitioners lack of training in the area, this question creates several ethical dilemmas for practitioners. This is an important ethical dilemma for practitioners to reflect on as it could influence the quality of intervention they can deliver to their clients. Furthermore, without professional and personal reflection of the topic, practitioners run the risk of allowing undiscovered biases to influence their practice. Although some psychologists base their practice on working specifically with those with spiritual or religious difficulties, they are not the only practitioners who will likely face such an ethical dilemma. Spiritual or religious concerns can often be related to, or influence, clients reason for services (Barnett & Johnson, 2011). According to Barnett and Johnson, clients experiencing such difficulties often seek the assistance of psychotherapists who do not necessarily specialize in spiritual or religious guidance and/or

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intervention. The issue of integration of spirituality and psychology is further highlight by Barnett and Johnson (2011) who presented data that indicated that over 70% of Americans have a belief in God and over 56% said that religion played a role in their daily lives. Such numbers are likely to be congruent across North American communities and indicate that those who seek psychological intervention are likely to be influenced by religious or spiritual concerns to some extent (Barnett & Johnson, 2011). Spiritual or religious beliefs can be a source of strength and can influence the outcome of the intervention if utilized during treatment Kelly, (1998). According to Corsini and Wedding (2007), and Plante (2007), empirical evidence supports the use of clients religious and spiritual beliefs to produce positive outcomes of therapy. Due to the possible utility of using religious and spiritual beliefs in treatment, coupled with the lack of training many practitioners have in the area, whether to incorporate such beliefs into therapy poses an important ethical dilemma and is worth exploring. The following section will present a brief case example of an ethical dilemma for practitioners. The ethical principles that must be considered when contemplating such a dilemma will follow. Case Example The following case example will present a general case that could cause a psychologist, with no training in the integration of spirituality and religion into his or her practice, with an ethical dilemma. Although specific principles and standards will be outlined in the sections to follow, the case example aims

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to present the general dilemma of working with clients who present with spiritual or religious concerns when the practitioner has little to no experience or training in the area. A 50 year old woman is experiencing depression and anxiety. The woman states that she does not wish to take medication and has tried Cognitive-Behavioural Therapy in the past. The woman said that her past therapists would not address her issues of spirituality because they were not trained in the area. The woman believes her issues are related to her spirituality and not following the religious values she was raised on. She also believes that the dissonance between being raised to follow strict religious principles and her struggle to accept Gods existence is the root cause of her anxiety. She asks you to work with her to help reduce her anxiety and depression and insists she would like you to incorporate her spiritual and religious beliefs into therapy. Relevant Ethical Principles and Standards According to Barnett and Johnson (2011), specific standards are contained in each mental health professions code of ethics. Although standards within various professional codes of ethics differ to some extent, each attempt to address clients religion and spirituality in a respectful and competent manner. Furthermore, ethics codes compel practitioners to respect each clients religious and spiritual beliefs and practices (Barnett & Johnson, 2011). Such standards aim to reduce the potential for professional and personal bias on behalf of the practitioner. Standards also ensure that the

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values, religious beliefs, and practices of clients are addressed during treatment if appropriate. Although many professional codes exist to guide practitioners who work with people seeking counselling or other intervention services, the Canadian Code of Ethics for Psychologists Third Edition (Sinclair & Pettifor, 2001), provides standards to guide psychologists in the provision of ethical services to those clients who present with spiritual or religious concerns. The following standards are important to address such a dilemma and can be considered the second step in the decision making process following the identification of those who will be affected by the decision. Principle I: Respect for the Dignity of Persons According to the Canadian Code of Ethics for Psychologists Third Edition (Sinclair & Pettifor, 2001), Respect for the Dignity of Persons is an essential element to good psychological practice. The code posits that all human beings are appreciated and their innate worth is not dependent on such things as religion or culture. Particularly, in demonstrating Respect for the Dignity of Persons psychologists must demonstrate appropriate respect for the knowledge, insight, experience, and areas of expertise of others (Sinclair & Pettifor, 2001). This ethical standard of General Respect can create problems if psychologists do not respect the right of others to experience religion and spirituality as they wish. Furthermore, psychologists must adhere to standard (I.9) of the code that sates that psychologists must not practice, condone, facilitate, or collaborate with any forms of unjust discrimination. This can be taken to mean that psychologists cannot discriminate against others who seek

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their services due to, among other things, spirituality and religion. Standard (I.12) of the code states to work and act in the spirit of fair treatment of others; standard (I.16) directs psychologists to seek as full participation from clients in decisions that affect them while respecting and integrating their opinions and wishes whenever possible. Another important ethical standard to the issue of spirituality and religion in psychology is standard (I.23) of the code. When seeking informed consent it is important to provide the client with as much information as possible before they make a decision to proceed with services. This becomes particularly important when the practitioners religious or spiritual beliefs may potentially be in conflict with the clients. Furthermore, this standard becomes important when the practitioner does not wish to bring spirituality and religion into intervention strategies even if requested by the client. Following this standard will ensure that the client is not engaging in services that may not be desirable for them or may not be exactly what they are looking for in their treatment. Principle II: Responsible Caring Similar to the principle of Respect for the Dignity of Persons, the principle of Responsible Caring provides direction for psychologists to ensure their activities benefit society and demonstrate concern for individuals, families, groups, and communities in which they work with (Sinclair & Pettifor, 2001). Responsible Caring demands psychologists be competent and selfknowledgeable (Sinclair & Pettifor, 2001). Furthermore, incompetent action by psychologists is seen as unethical behaviour because it can be harmful to

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clients. According to the principle of Responsible Caring, psychologists should only utilize interventions in which they have competence. The code posits that it is important for psychologists to engage in self-reflection regarding how their own values and beliefs toward, among other things, religion affects their actions, interpretations, and recommendations (Sinclair & Pettifor, 2001). Such reflection increases insight into personal and professional biases, thus increasing potential benefit to the client. Many psychologists do not have training in the integration of religion and spirituality into psychological practices. As such, the standard of Responsible Caring poses an ethical dilemma for most psychologists. Standard (II.1) and (II.2) of the code are relevant in that they direct psychologists to promote and protect the welfare of clients, as well as avoid doing harm to clients (Sinclair & Pettifor, 2001). Harm can potentially be caused when psychologists religious views conflict to a high degree with their clients. Harm can be done when the psychologist forces their views on the client or when the psychologist does not respect the views of the client. Standards (II.6), and (II.10) are very important to guide psychologists regarding their degree of competence and self-knowledge. Standard (II.6) of the code demands that psychologists only provide services that they are competent to perform. Given that few psychologists are trained to integrate religion and psychology, this standard creates a dilemma if clients wish to have the two integrated. Furthermore, standard (II.10) of the code states that to ensure Competence and Self-Knowledge, psychologists must evaluate how

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their own experience, attitudes, culture, beliefs, values, social context, individual differences, specific training, and stresses influence their interaction with others, and integrate this awareness into all efforts to benefit and not harm others (Sinclair & Pettifor, 2001). Such self-reflection and competence is also essential to meet standard (II.21) of the code. This standard ensures psychologists provide the best services as possible for those in need, including appropriate interventions that are relevant to the clients needs and have empirical support. Furthermore, this standard encourages psychologists to incorporate those outside of the field that could be of benefit to the client, such as those involved in the church for example. Principle III: Integrity in Relationships This principle can also cause an ethical dilemma for psychologists and may be of particular importance when working with clients who wish to integrate religion or spirituality into their treatment. Integrity in relationships requires psychologists to be accurate and honest, straightforward and open, as objective and lacking in bias as possible, and avoid conflict of interests (Sinclair & Pettifor, 2001). Furthermore, psychologists have a duty to maintain competence in the area they practice and declare their expertise (Sinclair & Pettifor, 2001). When working with clients who wish to have their religious or spiritual beliefs incorporated in the intervention process, it is important for psychologists to adhere to standards (III.2), (III.4), and (III.8). Standard (III.2) compels psychologists to accurately represent their credentials, qualifications,

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education, experience, competence, and affiliations. When working with clients who struggle with religious or spiritual concerns psychologists should maintain competence in their current area of activity (III.4). This can be problematic for those psychologists who do not have training working with clients with such concerns, even though many psychologists may choose to work with such clients as to not discriminate against them based on their religion. Standard (III.8) is also imperative and can cause a dilemma when working with clients with religious concerns. Acknowledging the limitations of their own knowledge, interventions, and views is important for psychologists because it not only opens them up to other possibilities, but it also ensures clients can make an informed decision when consenting to services. Objectivity and lack of bias are important ethical considerations for psychologists when deciding whether or not to integrate religion and spirituality into their work with clients. Similar to standard (II.10) of the code, standard (III.10) is important to ensure integrity in relationships. Before deciding to work with clients who wish to have spirituality and religion incorporated into their treatment, psychologists must first deicide if they can maintain integrity in the alliance. Toward this end psychologists must begin by evaluating how their own personal experiences, attitudes, values, social context, individual differences, stresses and training influence their ability to be objective and unbiased when working with such clients (Sinclair & Pettifor, 2001). Furthermore, standards (III.11) and (III.12) must be addressed as well. A psychologist must decide if they can adhere to these standards before

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beginning work with certain clients. The ability to communicate as objectively as possible and clearly differentiate fact, opinions, theories, and hypotheses, when communicating findings is paramount to ethical practice (III.11). Similarly, standard (III.12) must be met to ensure ethical practice, as it dictates psychologists present instructional information accurately and avoid bias in the selection and presentation of information (Sinclair & Pettifor, 2001). This can pose a problem for those psychologists who are unaware of how their attitudes and beliefs about religion and spirituality affect their work with clients. Furthermore, a problem can exist if the psychologists religious views determine the selection of certain information when it is in stark contrast to the clients view. The avoidance of conflict of interest is also an important consideration. This is likely to affect psychologists who hold a particular position within religious or spiritual groups. For example, therapists who also act as the community pastor may be in conflict of interest when working with certain clients. Another example relates to a therapist who holds a position in a spiritual or religious group that is in opposition to the clients religious or spiritual allegiances. Standard (III.34) must be addressed to mitigate such issues pertaining to conflict of interest. Standard (III.34) states that unavoidable dual or multiple relationships must be managed to reduce bias, increase objectivity, and mitigate the risk of exploitation of one party over the other (Sinclair & Pettifor, 2001). If any of the standards related to integrity of

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relationships cannot be adhered to, ethical practice will be compromised when working with clients with particular spiritual or religious concerns. Principle IV: Responsibility to Society According to the Canadian Code of Ethics for Psychologists Third Edition, psychologists have a responsibility to society in which they live and work in. Furthermore, practitioners should increase the knowledge base of psychological principles and promote the welfare of all people within society. Responsibility to society requires psychologists to use their professional knowledge for beneficial purposes including the support and development of social structures and policies (Sinclair & Pettifor, 2001). Three important standards under the Principle of Responsibility to Society include standards (IV.1), (IV.6), and (IV.16). Standard (IV.1) is an important consideration when working with people who belong to a certain religious or spiritual faculty. This standard promotes free inquiry and the transmission of knowledge and ideas that increase societys understanding of itself, as well as make contributions to the further development of psychology as a practice (Sinclair & Pettifor, 2001). Standard (IV.6) demands that psychologists participate in critical selfevaluation of psychologys place in society, as well as promote the development of structures and procedures that facilitate beneficial societal functioning (Sinclair & Pettifor, 2001). The last standard that seems important to consider is standard (IV.16). This standard directs psychologists to show respect for and abide by community mores, social customs, and cultural expectations in professional behaviour (Sinclair & Pettifor, 2001). Taken

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together, the standards encapsulated under the principle of Responsibility to Society, suggest that the study of psychology to improve the human experience may not be able to be cleanly severed from religion and spirituality, as both help to explain the human experience. Disentangling the two may be a futile task, whereas using psychology principles to promote and draw upon religion and spirituality may be an excellent way to improve the lives of people in society when appropriate. Steps to Solve the Dilemmas Although a full review of a specific decision making model to address the above dilemmas is beyond the scope of this paper, some important steps to solve the issue will be reviewed including a brief discussion of an appropriate decision making model.

Informed Consent Psychologists who are going to potentially work with a client similar to the woman presented in the case study should discuss with clients their approach to treatment, their levels of comfort, and expertise in addressing spirituality and religious issues in treatment (Barnett & Johnson, 2011). Furthermore, the psychologist should discuss with the client how each of their religious and spiritual beliefs may potentially influence treatment and outcomes. Barnett and Johnson also stated that practitioners who face such a dilemma should discuss with their prospective client what other treatment

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options are available to them. Griffith and Griffith (2002) posit that questions pertaining to clients religious and spirituality can help the client discover if their beliefs are impacting their current distress and can provide them insight into what they want from the intervention. Such questions during the intake or initial consultation can also help to identify possible courses for treatment such as the integration of spirituality and religion, a referral to a more suitable professional, or the avoidance of such integration (Griffith & Griffith, 2002). However, psychologists should avoid making religion and spirituality the focus of the assessment/consultation process if it is obvious they are not relevant to the concerns or to the client in general (Hodge, 2006). Competence According to Barnett and Johnson (2011), many psychologists are not trained or educated to integrate spirituality and religion into therapy to meet the needs of those clients experiencing such difficulty. Furthermore, research indicates that religion and spirituality are integrated into the training of practitioners in a sporadic and inconsistent manner (Barnett & Johnson, 2011). Adequate training is an essential component to ensure competence in addressing spiritual and religious concerns of clients. Professional development, education, and ongoing training are essential components to ethically address and meet the needs of clients who present with spiritual and ethical concerns. Plante (2007) posited that competent and ethical practice depends on the level of sensitivity and awareness about how spiritually and religion impacts their clients life. Furthermore, practitioners must be

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educated and knowledgeable about the impact spirituality and religion can have on mental health. Plante (2007) argued that a lack of knowledge for clients religious or spiritual beliefs can cause the client to feel demeaned and can alter the clients beliefs and values. Psychotherapists must develop needed competence prior to attempting to integrate spirituality or religion into a clients treatment (Hathaway, Scott, & Garver, 2004). According to Barnett and Johnson (2011); Corey, (2009); and Hathaway et al. (2004), competent practitioners must be familiar with the religious and spiritual beliefs, values, and practices of their clients. Furthermore, practitioners must be educated about and recognize healthy and unhealthy forms of client religiousness and spirituality and be trained to effectively integrate religious and spiritual treatment goals into clients treatment plans (Barnett & Johnson, 2011). Boundary issues Boundary issues between client and practitioner is of relevance when incorporating religion and spirituality into therapy (Walker, Gorsuch, & Tan, 2004). Practitioners must be careful to not cross the line between therapist and spiritual and/or religious leader (Barnett & Johnson, 2011). According to Barnett and Johnson, self-disclosure is an important element to mitigate the risk of boundary issues. The appropriate use of self-disclosure by the practitioner can be a useful intervention when working with clients regarding religious and spiritual concerns. Disclosure of religious and spiritual beliefs may be appropriate, as doing so may be an important part of the informed

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consent process to assist clients in deciding if they wish to utilize the services of the practitioner (Barnett & Johnson, 2011; Corey, 2009). Decision Making Model When faced with ethical dilemmas it is important for practitioners to work through the dilemma using a structured decision making model. The Canadian Code of Ethics for Psychologists Third Edition, presents an effective model for making decisions when ethical dilemmas arise. Using the 10 steps involved in the decision making model, psychologists are able to resolve the dilemma by balancing and honouring the principles involved (Sinclair & Pettifor, 2001). It is vitally important to work through each of the steps to identify alternative courses of action and resolve potential conflict between principles. The model would be an effective tool to address the standards and ethics described in earlier sections of this paper. Along with using the model presented in the Canadian Code of Ethics for Psychologists Third Edition, this author would also incorporate the decision making steps posited by Barnett and Johnson (2011), for addressing dilemmas related to working with religious clients and concerns of religion in therapy settings. According to Barnett and Johnson (2011), practitioners have lacked an ethical decision-making model that specifically addresses dilemmas related to spiritual and religious concerns during treatment. Barnett and Johnson propose a nine stage ethical decision-making model for determining a clients religious or spiritual beliefs, along with steps to help determine how to proceed with the client. This model outlines questions and considerations

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most relevant to providing services when religious or spiritual issues are important factors to the intervention process (Barnett and Johnson, 2011). This model can be a useful decision making tool to supplement the ethical decision making model presented in the Canadian Code of Ethics for Psychologists Third Edition. The utility behind this model is that it specifically addresses issues related to integrating spirituality, religion, and intervention services. Barnett and Johnson (2011) outline nine stages to help practitioners address dilemmas related to spirituality and religion including: respectfully assess the clients religious or spiritual beliefs and preferences; carefully assess any connection between the presenting problem and religious or spiritual beliefs and commitments; weave results of this assessment into the informed consent process; honestly consider your counter transference to the clients religiousness; honestly evaluate your competence in the case; consult with experts in the area of religion and psychotherapy; If appropriate, clinically Indicated, and client gives consent, consult with clients own clergy or other religious professionals; make a decision about treating the client or making a referral; and assess outcomes and adjust plans accordingly. Personal Reflections and Conclusion Sensitivity and skill in working with spiritual and religious clients do not require practitioners to be personally spiritual or religious (Hall et al., 2004). Corey (2009) posited that a practitioners religious and spiritual beliefs do not ensure that they are sensitive to their clients religious needs, nor does it ensure that practitioners with strong religious backgrounds will effectively

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work with clients with similar beliefs. Nonreligious practitioners have been found to show little difference from religious practitioners in their assessment and intervention practices of religious or spiritual clients (Corey, 2009). Corey further articulated that nonreligious practitioners who are trained to provide treatment to religious clients are equally as effective as religious therapists. Counselors' authentic respect for others, their relationship abilities, and their technical competence, not their personal religious or spiritual beliefs, constitute the fundamental base for sensitive and effective counseling with religious as well as nonreligious clients (Corey, 2009). Furthermore, evidence suggests that non-religious practitioners do not generally assess or treat spiritual or religious clients differently from counselors with a spiritual or religious background. The field of counselling has been slow in recognizing the need to address spiritual and religious concerns (Corey, 2009; Corsini & Wedding, 2007). According to Corey (2009) spiritual and religious concerns are often therapeutically relevant and potentially significant topics for the practice of counselling. Counsellors must be prepared to deal with their clients issues of the human spirit. Counselling can help clients gain insight into the ways their core beliefs and values are reflected in their behaviour (Corsini & Wedding, 2007). Clinicians must remain open and nonjudgmental, recognizing that there are multiple paths toward fulfilling spiritual needs. It is not the role of the counsellor to prescribe any particular pathway. Counsellors can make use of the spiritual and religious beliefs of their clients to help them explore and

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resolve their problems. Training programs must incorporate discussions on how to work with religious and spiritual values as a part of the therapeutic process (Corey, 2009). Utilizing the decision making model in the Canadian Code of Ethics for Psychologists Third Edition, coupled with Barnetts and Johnsons (2011) nine stage decision making model would aide practitioners in ensuring they are practicing ethically and competently. Barnetts and Johnsons model deals with the specific dilemmas associated with the integration of religion, spirituality, and psychology, and provides a supplemental resource to other decision making models to ensure ethical practice. The biggest area of concern for this author is competence. Both decision making models presented in this paper provide guidelines to monitor the clients needs, as well as to make ethical decisions to begin services or discontinue should the situation change. However, having formal education and training regarding the integration of religion and spirituality into psychology would be useful and would reduce this authors reluctance to embark in a therapeutic relationship with a client who experienced religious or spiritual distress. Furthermore, remaining neutral, open-minded, and straightforward with clients would help ensure clients can render an informed decision about services and also ensures clinicians practice according to their professional ethics.

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religion into psychotherapy. Professional Psychology: Research and Practice, 40, 385395. Hall, C., Dixon, W., & Mauzey, E. (2004). Spirituality and religion: Implications for counselors. Journal of Counseling & Development, 82(4), 504507. Hathaway, W., Scott, S., & Garver, S. (2004). Assessing religious/spiritual functioning: A neglected domain in clinical practice? Professional Psychology: Research and Practice, 35(1), 97104. Hodge, D. (2006). A template for spiritual assessment: A review of the JCAHO requirements and guidelines for implementation. Social Work, 51, 317 326. Kelly, E. (1998). Spirituality and religion in counselling and psychotherapy: Diversity in theory and practice. American Counselling Association, 1, 16-28 retrieved August 10 from http://www.geocities.com/njaservic/ACAspirit Plante, T. (2007). Integrating spirituality and psychotherapy: Ethical issues and principles to consider. Journal of Clinical Psychology, 63, 891902. Sinclair, C., & Pettifor, J. (Eds.). (2001). Companion manual to the Canadian code of ethics for psychologists (3rd ed.). Ottawa, ON: Canadian Psychological Association Walker, D., Gorsuch, R., & Tan, S. Y. (2004). Therapists integration of religion and spirituality in counseling: A meta-analysis. Counseling and Values, 49(1), 6980.

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