Maia Nikitovich October 15, 2014

Smith College School for Social Work

Thesis Proposal

Client Perceptions on Therapeutic Quality of Care When Disclosing Spiritual and

Religious Beliefs or Experiences: A Mixed Methods Study

Introduction

Spiritual and religious considerations are integral aspects of human life,

individual identity, and personal worldview. Such factors will either be present or

conspicuously absent within every therapeutic relationship. If present a client’s spiritual

and religious beliefs (S/R’s) could have a significant effect on their daily lives and inner

world. When absent as an important identified aspect of a client’s life, spiritual and

religious experiences may still be pertinent to the individual through generational trauma

(such as the religious genocide during the Holocaust, or family members having

experienced sexual abuse at the hands of catholic clergy), a client’s childhood

experiences (with parents who were or were not religious), or through daily life

experiences with family members, friends, media, and beyond. Studies have indicated

that S/R (as well as its absence) can significantly bolster wellbeing or lead to distress.

Additionally, extreme states that resemble mystic or transcendental experiences can be an

integral aspect of spiritual/ religious based practice; these same states can often occur, or

be co-related with, what is typically termed psychotic or dissociative episodes

experienced within multiple DSM diagnoses. These issues must therefore be regarded as

important clinical social work concerns and as such demand significant research.

For my thesis I intend to examine spiritually/religiously oriented clients’ attitudes

towards disclosing spiritual/religious faith and experiences with their therapist, and how,
if disclosed, therapists responded and to what extent this response met clients’ identified

needs. The questions I hope to answer from this thesis study are: Are clients who

endorse religious/spiritual beliefs or experiences receiving what they need in therapy,

why or why not? What factors affect their perception of the quality of care in this

regard? I hypothesize that many may report experiences of stigma at the intersection of

their mental health diagnosis and spiritual/religious beliefs.

There has been some research done on the topic of therapist attitudes towards S/R

in therapy, as well as studies that delineate types of spiritual interventions used, but there

have been no studies that focus on client-needs and attitudes during or after therapy.

Given that 75% of the adult population in the United States endorses some form of

religious identification, this thesis topic has high relevance in the field of social work. If

roughly three out of every four adults in the United States have some sort of S/R belief it

is ethically sound to train therapists who are competent and statistically helpful in

supporting and aiding those clients. Furthermore, religious prejudice and stigma remain

realities today, and as such spiritual/religious based training is an important aspect of

“culturally competent” clinicians who come from myriad religious and ethnic

backgrounds and work with clients who range similarly. Finally, the topic of stigma and

best practice methods is of paramount importance to those who are at highest risk for

maltreatment from the medical establishment through traumatic experiences with forced

hospitalization or over medication, something survivor-led movements attest is very

common. Is it ethical, therefore, for a person who has been given a diagnosis of

schizophrenia, bipolar disorder, borderline personality disorder, or psychosis to live in

fear of disclosing to mental health professionals what they perceive to be meaningful

spiritual experiences or conclusions? What is the line differentiating a state labeled

psychosis, or “delusions” that could need immediate attention, and an experience of

religious transcendence? This client-centered research could illuminate important

considerations in the future of social work, specifically what is and is not useful to S/R

oriented clients who seek therapy, as well as specific ways to aid clients who experience

the most stigma and trauma within and by the mental health system.

Literature Review

Sheridan, Bullis, Adcock, Berlin, & Miller (1992) were the leading proponents of

quantitative studies on social workers’ personal beliefs and professional attitudes towards

religiously based interventions, and have operationalized not only clinicians’

spiritual/religious perceptions and beliefs, but also defined what types of interventions are

most utilized and correlated these findings with social workers’ attitudes about said

interventions. They offer multiple surveys and measuring scales related to spiritual and

religious attitudes and intervention.

There is a general consensus found in the research that clinical social work

training may not be adequate for future clinicians, and that there is likely a serious lack of

application or conversation between clinician and client regarding clients’ spiritual and

religious worldviews (Sheridan, Bullis, Adcock, Berlin, & Miller, 1992, Stewart, Koeske,

& Koeske 2008, & Dwyer, 2010). It has been shown that a clinician’s personal

spirituality predicts utilization of spiritual or religious based interventions (Sheridan et al.

1992, Stewart, Koeske, & Koese, 2008, & Dwyer, 2010). In earlier research such

utilization also predicted positive attitudes and self-reported competency regarding these

types of interventions (Sheridan et al. 1992, Stewart et al. 2008, Cummings, Ivan, Carson,
Stanley & Pargament, 2014). Dwyer (2010), however, noted a trend in her study that

positive attitudes towards the appropriateness of spiritual/religiously-based interventions

have decreased, yet the percentage of practice of interventions remains the same. She

suggests that ethical considerations between social work values and individual social

workers’ rights and opinions may be at odds (Dwyer, 2010). These studies each note

deficits in generalizability and diversity of samples, and recommend studying efficacy

and client perceptions of interventions (Sheridan et. al 1992, Stewart, Koeske, & Koeske

2008, & Dwyer, 2010). Thus there is a clear need for the research I am proposing, which

will be tailored more specifically as time goes on.

A systematic review of relevant quantitative studies of therapist and client

religious and spiritual belief was undertaken in 2014; out of 560 articles only 29 matched

inclusion criteria for the review. The inclusion criteria were: original empirical research,

publication in a peer-reviewed journal, total n > 10, therapist religion/spirituality was

measured and varied, the relationship between therapist religion/spirituality and

therapeutic alliance, outcome, or interventions was examined, participants were adults,

and the study was published in the English language (Cummins et al., 2014). This review

revealed multiple correlations and themes that are pertinent to this proposal, such as but

not limited to the effect of religious belief on therapeutic attitudes towards clients, the

relationship between therapist religious/spiritual orientation and outcomes with clients of

similar or different orientations, the use of religious or spiritual interventions in treatment

and its relationship to positive outcome, and whether therapist religious/spiritual values

are related to their theoretical orientation. This article reinforces findings from previous

articles mentioned, and offers additional insight into future directions, such as supporting
the need for studies to include client perceptions, highlighting the lack of longitudinal and

experimental studies of this nature with therapist-client dyads, improving the validity

measures of religious/spiritual attitudes and beliefs, as well as studying in detail specific

religious constructs and their effects on therapeutic treatment and psychological

functioning (Cummings, et al., 2014).

A second body of literature is thematically situated around the effects of religious

or spiritual belief and practice on the mental health status of participants. Stewart et al.

(2008) cite multiple studies in which lower levels of depression, anxiety, and pessimism

are correlated with personal spiritual and religious values and experience. Calhoun,

Cann, Tedeschi, & McMillan (2000) discuss the healing potential of spiritual and

religious based practices in posttraumatic growth when coupled with a type of cognitive

“rumination” that searches for personal meaning within the trauma, highlighting the

useful and healing potential of what spirituality is commonly defined as: a feeling of

connection to something beyond the self and a sense of deep personal meaning. More

research must be done to determine the protective value of religious or spiritual belief and

experiences for both therapists and clients (Cummings, et al., 2014).

Religious and spiritual based practice and its effect on mental health and

wellbeing are culturally meaningful. Moreira-Almeida & Koss-Chioino (2009) studied

Spiritist healers who worked with patients diagnosed with schizophrenia in Puerto Rico

and Brazil. They note that a spiritually based etiology had positive benefits for patients

and their families as it externalized the causes of psychosis and schizophrenia, which

increased hopefulness that the illness would not remain chronic; this was correlated with

a greater abatement of symptoms (Moreira-Almeida & Koss-Chioino, 2009). Spiritist

healers were also long-term participants in the lives of patients and families, providing

needed relief and support in a way that medication and hospitalization cannot necessarily

provide (Moreira-Almeida & Koss-Chioino, 2009). In comparison, Christianity is the

religion most practiced by social workers and other counselors in studies done in the

United States (Stewart et al., 2008, Dwyer 2010). Christian therapists are more likely to

introduce prayer or spiritually based interventions in their work with clients, though

clients who are not religious or spiritually inclined would consider such interventions

unprofessional (Cummings, et al., 2014). There is a correlation between religious beliefs

and unhelpful or stigmatizing attitudes, for example Wesselmann & Graziano (2010) note

the role of spiritual and religious belief in creating stigmatic bias towards individuals

with a psychiatric diagnosis due to Christian notions of sin, retribution, and possession.

It is important to consider the ways in which both clinicians’ and clients’

religious/spiritual beliefs affect their choice of treatment. Cummings et al. (2014) cited a

study in which clinicians’ theoretical orientations were correlated with clinicians’

religious or spiritual beliefs. Rosmarin, Green, Pirutinsky, & McKay (2013) found

results that CBT oriented therapists are less religious than the general population,

replicating previous findings. This result may be related to the spiritual and religious

affiliation of the early proponents of CBT and its associated therapies, suggesting that the

underlying values of theorists may relate to the types of therapy developed, which could

also attract similarly minded individuals (Rosmarin, et al., 2013). This possibility further

highlights the importance of religious and spiritual beliefs on the ways in which human

beings interact in the world and with each other, and suggests that practitioners who do
identify as spiritual or religious could aid individuals who have a similar identification

and need.

These studies endorse the necessity of further study on the efficacy and value of

spiritually based attitudes and interventions, especially when tailored to or at odds with

clients’ cultures and belief systems. Complexity arises when social workers either

attempt to practice such interventions but do not share a similar belief, conviction, or

faith in the practice, or refuse to act because of personal bias or discomfort (Weselmann

& Graziano 2010, Dwyer, 2010, Cummings, et al., 2014). Best practice methods are

discussed in multiple sources, describing interventions such as referring to appropriate

spiritual or religious providers and increasing clinician education regarding different

faiths and cultural-spiritual worldviews (Sheridan et al. 1992, Dwyer, 2010). Many

clients who are spiritually/religiously identified may not come into treatment at all, or

may be resistant to aid that could help them because of their spiritual/religious

convictions; in some cases a person’s faith may harm them rather than help them. An

empathic, informed therapist must be able to understand these clients’ spiritual needs and

perceptions before healing work can be done. More research on survivor-led movements

and the benefits and limitation of different modes of treatment, such as the Open

Dialogue method developed in Finland, have the possibility to redevelop Western-based

medical model practices to promote the highest levels of healing and decrease the levels

of chronicity and disability that stem from mental health struggles. Focusing on current

practice with clients who endorse spiritual or psychotic/organic based experiences and

beliefs could help to illuminate and change harmful practices today that cause individuals

to live with a sense of stigmatization and fear.

 Other issues of importance to this research are the psychological theory of

religion, analyses of historical trends, case study examples, needs assessments, and

clinical considerations in working with clients who have religious or spiritual values.

Trends in psychoanalysis, for example, show that analysts are no longer embracing the

idea that religious belief is a defense of the mind, and are instead able to hold ambiguity

and work with a client within the client’s own worldview (Josephson, Nicholi, &

Tasman, 2010). Cummins, et al. (2014) touch on the topic of specific religious or spiritual

understandings and how they may affect an individual’s psychological well-being or vice

versa, while Schafranske (2005) writes a detailed case study depicting the development

of a client’s god-image as directly related to the client’s internal struggles in object

relations. Wiggins’ chapter (2009) in Spirituality and The Therapeutic Process: A

Comprehensive Resource from Intake to Termination, is a useful tool for therapists who

would like to be more attuned to therapeutic ways of working with religion and

spirituality in therapy. This topic is being taken into greater consideration by the APA,

which has now written a handbook on psychology, religion, and spirituality (Hathaway,

2013).

Methodology

The purpose of this research is to explore, describe, and evaluate clients’ attitudes

towards disclosing their spiritual/religious beliefs and experiences with their therapist,

and if they have done so then explore the clients’ perceptions of their therapist’s

relational and professional abilities in responding. This writer hopes that through such

research the field of clinical social work will gain a greater understanding of how

clinicians have responded and do respond to the complexities of spiritual/religious belief

in therapy, whether or not clients consider this an important part of treatment, evaluate if

clients’ needs are being met, determine what is useful and beneficial currently, and

discuss what is lacking or could be improved upon. The question this research will

attempt to answer is: Are clients who endorse religious/spiritual beliefs or experiences

receiving what they need in therapy, why or why not? What factors affect their

perception of the quality of their care in this regard? This question is based on a

hypothesis that clients may likely report experiences of stigma at the intersection of their

mental health diagnosis and spiritual/religious beliefs.

There are some biases inherent within this study due to my own mental health

experiences and personal spiritual/religious convictions. I myself often struggle with

depression and anxiety related symptoms, and one method of coping I use is various

spiritual practices stemming from my spiritual/religious beliefs. I have also had some

spiritual experiences and convictions that others who have not practiced meditation or

prayer may not understand. I identify as a multi-faith practitioner and focus on more

mystic forms of spirituality, or direct relationships and experiences with my concept of

the divine. I determined this research question after experiencing my own discomfort

with the idea of sharing these beliefs or experiences with therapists or psychiatrists, and

my distaste with aspects of the medical model; I believe many may feel similarly. I am

training to become a clinical social worker, and I am very aware of the missing spiritual

dimension within the academic curricula, as well as the religious prejudice inherent in the

founding father of psychoanalysis and clinical psychology— a primary theorist within

my studies— Sigmund Freud. Therefore I was resolved to learn more about this rich and

important subject, and create a space for clients of many faiths to share their own stories.
 Due to the exploratory nature of this proposal a mixed methods study is proposed.

Data will be collected quantitatively, through a survey, and qualitatively, through

interviews from participants who are mental health clients over the age of 18, that

identify as spiritual/religious, and who have been in therapy for at least six months at

some point in time. I prefer that clients define their spirituality or religious beliefs and

experiences for themselves, however, a working definition of spirituality that I will use

will be based primarily on William James’ definition in “The Varieties of Religious

Experience.” James describes spirituality as “feelings, acts and experiences of

individual[s] in their solitude, so far as they apprehend themselves to stand in relation to

whatever they consider to be divine…” Such “divine” experiences may additionally be

atheistic yet remain sacred. There will be a section in the survey portion for individuals to

choose or label for themselves what tradition they are a part of, or how they describe their

own belief system and form of practice. The time period in therapy was chosen so that

individuals have had, hopefully, an amount of time long enough to form a relationship

with their therapist that is beyond the beginning stages.

A mixed methods study was chosen because it provides the possibility for

empirical data and empirically based conclusions, while also giving participants the

ability to voice in detail their own experiences, thoughts, and feelings. The quantitative

data will be found through survey use, and will include data such as: number of

participants, median and mean of age, race, gender, time in therapy, therapist credentials

(if remembered), personal descriptors of religious/spiritual practice, tradition, and

experiences, and general opinions and considerations of spirituality/religion within

therapy today using Likert scales or yes/no/other format for questions such as “Do you
consider your clinical training in spiritual/religious considerations satisfactory?” The

qualitative data will include data from comment boxes in the surveys and from personal

interviews. The research will be informed throughout by historical and contemporary

theories of psychology of religion and clinical practice; it may include survey questions

or statements and variables used in other research, which will be cited as used. Examples

of questions or statements that may be used in the survey include:

- Do you identify as spiritual or religious? Please check a box that most closely resembles your
spiritual/religious identification, or write your own in the space provided.
- During the past year, how often did you participate in religious services at a place of worship
(once a day or more, almost daily, once a week, once a month, rarely, never) (Rosmarin, et al., 2013)
- Which statement best describes your beliefs about God? (I know that God really exists and I have
no doubt about it, while I have some doubts I feel I do believe in God, I don’t believe in God but I believe
in a higher power, I don’t believe in God, I don’t know) (Rosmarin, et al., 2013)
- Do you believe in or hold sacred any of the following (please check all that apply and define or
explain any terms further in the space provided if you need): (this list will include common theological
beliefs and themes and will be grouped by the major religions of the world) Please add anything important
to you that is not on this list.
- Do you practice any of the following: yoga, meditation, chanting, prayer, reading scriptural or
sacred texts (please describe which ones). Please describe how often (once a day or more, almost daily,
once a week, once a month, rarely, never). If there is any practice you participate in that is missing from the
above list, please describe below.
- How important is religion to you? (very important, important, moderately important, of little
importance) (Rosmarin, et al., 2013)
- How important is spirituality to you? (very important, important, moderately important, of little
importance)
- Have you ever received a psychiatric diagnosis? If so, what was it?
- Have you ever had any experiences that you consider spiritual or religious in nature? Please
describe below and/or check any of the following:
- Have you ever had a spiritual/religious experience that caused you distress?
- Have you ever had a spiritual/religious experience that caused you joy?
- Spiritual and religious experiences can often appear similar to symptoms found within many
psychiatric diagnoses. Have you had any experiences that you consider to be related directly to your
psychiatric diagnosis which you do not consider to be spiritual/religious in any way? Please describe if you
feel comfortable to do so.
- Have you had beneficial experiences as a consumer within the mental health system in general? If
so, please describe.
- Have you had negative experiences as a consumer within the mental health system in general? If
so, please describe as you are comfortable.
- Have you ever spoken with your therapist about your spiritual/religious beliefs?
- Have you ever spoken with your therapist about spiritual/religious experiences?
- If yes, how did your therapist respond?
- Was this response beneficial to your wellbeing, why or why not?
- If no, what was your reason for not sharing this information?
- What kind of response do you believe would be most helpful for you if you did share? What kind
of response might be the least helpful or harmful?
- Have you ever experienced stigma due to your S/Rs? Please describe if you are comfortable. For
example, you may describe where, when, how, or why this occurred.
- Have you ever experienced stigma due to your mental health struggles or psychiatric diagnosis?
Was it ever related to your S/Rs in any way? Please describe if you are comfortable. For example, where,
when, how, or why? This can be as general or as specific as desired.
- Do your mental health struggles hold meaning for you? Please describe the meaning to the best of
your abilities if so.
- Does your psychiatric diagnosis (or diagnoses) hold meaning for you? Please describe the
meaning to the best of your abilities if so.
- Do your spiritual/religious beliefs have meaning to you? Please describe to the best of your
abilities if so.
- If you have had any spiritual/religious experiences, do they hold meaning for you? Please describe
if so.
- If you have any spiritual/religious practices, do they hold meaning for you? Please describe to the
best of your abilities if so.
-
Others questions I may introduce to clients could include: please rate your level of

comfort in talking with your therapist about religious or spiritual concerns (quantitative),

do you consider your improvement in therapy to be related to your religious/spiritual

values and experiences (qualitative and quantitative), can you describe an experience

with your therapist where they were helpful regarding religious/spiritual concerns?

(qualitative) can you describe an experience with your therapist where they were

unhelpful regarding religious/spiritual concerns? (qualitative).

Some examples of variables that may be looked at or coded could include:

- religious/spiritual affiliation (Sheridan, et al., 1992)
- satisfaction with therapist response to S/R disclosures (Sheridan, et al., 1992)
- attitude towards use of religious/spiritual language or concepts in therapy (Sheridan, et al., 1992)
- level of stigma personally identified and described
- spiritual/religious/mystical experiences described
- spiritual experiences correlated with psychotic diagnoses
- correlation of identifying factors, diagnosis, and stigma
- perceptions, attitudes, and desires regarding disclosure to therapist
- perceptions, attitudes, and desires regarding responses from therapist after disclosure

The interviews will be recorded and saved in a way that protects participants’

identity, either by encrypting data or saving the data in a password-protected location.

The survey will include comment spaces for qualitative data, which will then be coded

thematically. If I use an internet survey exclusively then I can guarantee anonymity; if

written surveys are used I can guarantee those participants’ identities to be protected and
confidential. The demographics of my participants will be clients who are being seen by

licensed therapists and who identify as spiritual or religious. Efforts will be made to

secure a more racially diverse group of participants than in previous studies, and I hope to

receive clients with diverse gender identities, ethnicities, socioeconomic status, and

religious convictions as well. Past studies have primarily consisted of Christian or Jewish

participants and I would like to recruit participants from a greater variety of traditions if

possible. I believe that the data from the survey can provide descriptive, correlational,

and cross-sectional results. The qualitative data can offer important themes and

discoveries that can be coded descriptively as well.

I will recruit participants by reaching out to community members that are

connected to the mental health field as consumers or practitioners; for those who choose

to participate in both the survey and the interview portion of the study I will offer $5 as

compensation if approved by the HSR committee. To find participants I will post in

online forums directly related to mental health needs and intersectional identities through

personal websites and on Facebook (The Icarus Project Forums, Center for Clinical

Excellence, NASW chapters, Smith College SW Groups, POOR Magazine, Queer

Identified Forums and Groups, Racial Solidarity Forums and Groups, Various Faith

Forums and Groups). I will also reach out to important individuals who are studying and

organizing for social justice and change in the mental health system, such as but not

included to: Julie Exline, Phil Borges, Sandra Ingerman, Lisa J. Miller, Dr. Susan

Mitchell, Will Hall, Monica Cassani, Dr. David Lukoff, Paul Levy, and Mary Olson. I

will send advertisements to clinicians that I know personally who could refer participants

to the study. I will also personally speak with agencies in NYC area to see if I could post
information in their lobbies or waiting rooms. Finally, I will recruit with permission to

specific organizations or groups that focus on spirituality or religious practice, such as

yoga shalas, meditation retreats, Buddhist Centers, various Churches, Synagogues,

Temples, Mosques, and Community organizations. At times, specifically when

advertising to fellow clients, my recruitment advertisements may include my own identity

and personal experiences with mental health, stigma, and spiritual/religious beliefs and

experiences.

HSR Application (in progress)

Conclusion

This study could result in important research for the future of clinical social work,

and fulfills a need stated in the literature, that of client’s own perceptions. If participation

is at a high rate then this study could hold meaningful or generalizable data on the topic

of clients’ needs in therapy, their experiences with mental health stigma as related to

spiritual/religious identities and experiences and their perceptions of clinician capabilities

when discussing spiritual/religious topics in therapy. This will help inform the field of

what practices are working therapeutically as perceived by clients, and what ways of

being could be improved upon when working with clients who identify as

spiritual/religious, especially for those individuals who experience stigma and trauma

within the medical model due to the nature of their extreme states and the varieties of

their experiences. Most importantly, the qualitative nature of this study will allow many

individuals, who are not always granted the opportunity to use their voice or share their

stories, to reach the larger academic and professional world. This study will additionally
 offer informed discussions of theoretical constructs within clinical and psychodynamic

relational work with clients who identify as S/R, suggestions of best practice methods,

and discussion regarding the education of clinical social workers in the future.

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