A Rationale for Spiritually Integrated Psychotherapy

A Rationale for Spiritually Integrated Psychotherapy

Kenneth I. PargamentDepartment of Psychology

Bowling Green State [email protected]

Presented at Samaritan Annual Conference

Spiritually Integrated Psychotherapy Denver, Colorado

August 8, 2009

Overview of the Day

A Rationale for Spiritually Integrated Psychotherapy

Understanding Spirituality Assessing Spirituality Addressing Spirituality

Albert Ellis on Religion

“Obviously the sane and effective psychotherapist should not go along with the patient’s religious orientation and try to help these patients live successfully with their religions, for this is equivalent to trying to help them live successfully with their emotional illness” (p. 15; The Case against Religion).

Reasons for the Tension between Religion and

Health

Irreligiousness among Health Professionals


Health Irreligiousness among Health

Professionals Competing Religions

Values of Health and Religion

Empiricism Individualism Skepticism Autonomy Pragmatism Physical and Mental

Health

• Faith• Love• Humility• Surrender• Transformation• Forbearance


Health

Irreligiousness among Health Professionals

Competing Religions Lack of Knowledge

A Lack of Training

Only 15% of Ph. D. training programs in clinical psychology in the United States and Canada offer a course in religion and spirituality

Why Consider Spiritual Issues? Patients want spiritually sensitive

care

Rose et al (2001)Journal of Counseling Psychology

74 clients surveyed from 9 diverse counseling centers

Only 18% say they prefer not to discuss religious or spiritual issues in counseling

Spiritual Needs of Clients

Lindgren and Coursey (1995) 65% of people with serious mental illness would

like to talk about spiritual concerns with therapists 35% talk to their therapists about spiritual

concerns

Why Consider Spiritual Issues? Patients want spiritually sensitive care Many people turn to spirituality in

stressful times

Drawing on the Sacred as a Resource on Flight 232

“The plane was moving more erratically. I knew it wasn’t good by the increase in activity of the stewardesses. . . The guy next to me at minus four minutes said, ‘We ain’t going to make it’. . . I noticed the nun across from me had been praying on her rosary. I remembered I had a cross in my pocket. I pulled it out and held it in my hand for the rest of the ride.”

“I’d done a lot of Buddhist meditation in my life, and this trained me to become one pointed in my awareness. I was totally focused on the brace position.”

Most Frequent Method of Coping

Conway (1985-1986) Black and white elderly women with medical

problems Prayer was most frequent method of coping Prayer was more common than resting, seeking

information, prescription drugs, or going to a physician

Coping with 9/11

Schuster et al. (2001) 90% of national sample of Americans sought

solace and support from religion

Spirituality among People with Serious Mental Illness

Tepper et al. (2001) Surveyed over 400 people with serious mental illness 80% cope with their symptoms and daily problems

through religion 65% found religious coping helpful 30% say religion was most important resource More religious coping over time tied to less frustration,

less depression and hostility, and fewer hospitalizations


stressful times Spirituality has been linked to

positive health outcomes

Church Attendance as a Predictor of Mortality

Hummer et al. (2000)National sample of adultsFrequent church attendance is tied to 7

year increase in life expectancyFrequent church attendance is tied to 14

year increase in life expectancy among African-Americans

Spiritual Meditation among Patients with Vascular Headaches

(Wachholtz & Pargament, 2005)

83 college students with vascular headaches according to criteria of the International Headache Society (1988)

Random assignment to four groups Spiritual Meditation (e.g., “God is peace,” “God is joy” ) Internally Focused Secular Meditation (“I am content,” “I am joyful”) Externally Focused Secular Meditation (“Grass is green,” “Sand is soft”) Progressive Muscle Relaxation

Practice technique 20 minutes per day for four weeks Assess changes in headache frequency, pain tolerance, affect,

headache control efficacy

Headache Occurrence Prior to and during the Intervention

Time

21

He

ad

ach

es

15

14

13

12

11

10

9

8

GROUP

Spiritual Meditation

Internal Secular

External Meditation

Relaxation

Diary Analyses of Headache Occurrence by Group and Time

Time Period

He

ad

ach

es

2.2

2.0

1.8

1.6

1.4

1.2

1.0

.8

.6

GROUP


Internal Secular

External Meditation

Relaxation

Pain Tolerance by Group and Time

TIME

21

Pa

in T

ole

ran

ce (

seco

nd

s)120

110

100

90

80

70

60

50

40

30

GROUP


Internal Secular

External Meditation

Relaxation

Negative Affect by Group and Time

Time

21

NP

AN

AS

28

26

24

22

20

18

16

GROUP


Internal Secular

External Meditation

Relaxation

Migraine Specific Quality of Life by Group and Time

Time

21

MS

QL

83

82

81

80

79

78

77

76

75

GROUP


Internal Secular

External Meditation

Relaxation

Headache Management Self-Efficacy by Group and

Time

Time

21

HM

SE

130

120

110

100

90

GROUP


Internal Secular

External Meditation

Relaxation


stressful times Spirituality has been linked to positive

health outcomes Spirituality has been linked to

negative health outcomes

Spiritual Struggles

Divine struggles Interpersonal spiritual struggles Intrapsychic spiritual struggles

Ano and Vasconcelles Meta-Analysis(2004, Journal of Clinical Psychology)

Number of Studies Cumulative Confidence

Effect Size Interval

Religious Struggles

with Negative Health 22 .22* .19 to .24

Outcomes

Spirituality and Health Study Participants

1629 participantsAge: Mean = 49.1 years, SD = 17.7675.3% Christian56.2% Attend religious services “almost every day” or

“every day”55.3% Engage in private prayer “almost every day” or

“every day”59.9% “Very religious” or “fairly religious”

Spirituality and Health Study Measures

Mental Health: Symptom Assessment-45 Questionnaire (Davison, Bershadsky, Bieber, Silversmith, Maruish, & Kane, 1997)

AnxietyDepressionHostilityInterpersonal Sensitivity

Religious Struggle: Negative Religious Coping Subscale of Brief RCOPE (Pargament, Koenig, & Perez, 2000)

Social Support: Six items adapted from previous research (Zimet, Dahlem, Zimet, & Farley, 1988)

Obsessive-CompulsiveParanoid IdeationPhobic AnxietySomatization

Spirituality and Health Study Procedure

Sample recruited from sampling frame maintained by Survey Sampling International

Sampling frame reflects demographics of 2000 U.S. census

Contacted 8,500 individuals1,895 completed the survey (22% response rate)266 surveys excluded due to missing data

Spirituality and Health Study

SummaryReligious struggle positively associated with

various forms of psychopathologyRelationship between religious struggle and

psychopathology stronger for individuals with recent illness or injury

Measures (Pargament, Koenig et al. 2004)

Number of Active Diagnoses Subjective Health Severity of Illness Scale (ASA) Activities of Daily Living (ADL) Mini-Mental State Exam (MSE) Depressed Mood Quality of Life Positive Religious Coping and Religious Struggle Global Religious Measures (Church Attendance, Private

Religiousness, Religious Importance) Demographics

Consequences of Religious Struggles Study of medically ill elderly patients over two years

(Pargament, Koenig, Tarakeshwar, & Hahn, 2004) Struggles with the divine predicted increases in depressed

mood, declines in physical functional status, declines in quality of life after controls

Struggles with the divine predicted 22-33% greater risk of mortality after controls

Struggles also predict stress-related growth

Specific Religious Struggle Predictors of Mortality

“Wondered whether God had abandoned me” (RR = 1.28)

“Questioned God’s love for me” (R = 1.22) “Decided the devil made this happen” (R =

1.19)


stressful times Spirituality has been linked to positive

health outcomes Spirituality has been linked to negative

health outcomes Spirituality cannot be separated from

treatment

A Forgiveness Intervention

Rye and Pargament (2002) College students hurt in romantic relationship Religious forgiveness intervention Secular forgiveness intervention Both groups facilitate forgiveness and well-being No group differences in efficacy

Strategies for Forgiveness

Two of top three strategies for secular forgiveness group“I asked God for help and/or support as I was trying to

forgive.”“I prayed for the person who wronged me as I was

trying to forgive.”

The Secular Impacts the Spiritual

Theresa Tisdale et al. (1997) Evaluation of psychiatric inpatient treatment Individual, group, milieu, and psychotropic

interventions Patients in treatment improved in adjustment Patients in treatment developed more positive

images of God

Common Measures of Religiousness and Spirituality

What is your religious denomination? How often do you attend religious services at your

congregation? How often do you pray outside of your congregation? On a 1 to 5 scale, would you say you are very religious (5)

or not at all religious (1)? On a 1 to 5 scale, would you say you are very spiritual (5)

or not at all spiritual (1)?

Research Populations Victims of 1993 Midwest floods Survivors of OK City bombing Parents of autistic children Medically ill hospitalized elderly Hospice care providers Cardiac pacemaker patients African-Americans coping with racism People coping with 9/11

Stereotypes about Spirituality

Spirituality is a defense against anxiety

Spirituality and the Search for Comfort

College student recovering from an eating disorder

“He just watches over me all the time. When something good happens, God’s there. But when something bad happens, God’s there too. . . Just knowing that there’s somebody up there . . . who is paying attention. . . makes me feel more secure.”

Spirituality and the Search for Meaning

Quadriplegic young man paralyzed by spinal cord injury:

“Well, I’m put in this situation to learn certain things, ‘cause nobody else is in this situation. It’s a learning experience; I see God’s trying to put me in situations, help me learn about Him, and myself.”

Spirituality and the Search for Intimacy

Roman Catholic priest describing mother’s funeral:

“The funeral was astounding. The whole church was there. Many, many friends were there. My blind niece played the piano and my best friend gave the homily. So there were many powerful religious expressions and family expressions. It is hard to separate one from the other.”

Spirituality and the Search for Transformation

Mormon man describing death of wife in car crash:

“I knew that she was killed. There was a big gash on her wrist, and it wasn’t bleeding and I couldn’t get any pulse. And I felt that I could lay my hands on her head and bring her back. And a voice spoke to me and said: ‘Do you want her back a vegetable? She’s fine. She’s alright. And . . . to let her go.’ That [voice] was just as clear to me as though somebody spoke to me.”

Spirituality and the Search for the Sacred

9 year old boy:

“I’d like to find God! But He wouldn’t just be there, waiting for some spaceship to land! He’s not a person, you know! He’s a spirit. He’s like the fog and the mist. . . I should remember that God is God, and we’re us. I guess I’m trying to get from me, from us, to Him with my ideas when I’m looking up at the sky!” (Coles, 1990)

Stereotypes about Spirituality Spirituality is a defense against anxiety Spirituality is a passive or avoidant way of coping

Three Styles of Spiritual Coping

Self-Directing -- “When I feel nervous or anxious, I calm myself without relying on God.”

Deferring -- “I do not think about different solutions to my problems because God provides them for me.”

Collaborative -- “When it comes to solving a problem, God and I work together.”

Who Says We’re Not a Science?

Collaborative Religious Coping

Intrinsic Religiousness

Psychosocial Competence

Deferring Religious

Coping

.2

2*

.32

*

C.P.S C.R.C.

.64**

-.57

.51*

.77

.40*

.74*

.40*

.84*

BAPC

Trust

S-E

Y

Y

Y

32

5

6

7

.65*.27*

.85 .60*

D.P.S. D.R.C.

Y1 Y2

Y3 Y4

.12*

.14*

Hoge

Feagin

X1

X2

.93

.94*

.83*

.72*.86*

y21

x11

y11

x21

11

21

.87 .61*

.62**.25*

y32

y42

y53

y63

y73

5

6

7

3

4

21

1

2

1

2

* p < .05 ** p < .10

Stereotypes about Spirituality Spirituality is a defense against anxiety Spirituality is a passive or avoidant way of coping Spirituality is a form of denial

Spirituality and Denial

“Since I got Jesus, I don’t have no memories of the past” (prisoner serving time for theft and robbery offenses)

Spirituality and Hope

“It’s all right to cry. It’s all right to hurt. It’s all right to be confused. Hope will rebuild landmarks. Hope will outlive the broken hearts” (pastor of the First Baptist Church in Oklahoma City following devastating tornadoes).

Envisioning a Spiritually Integrated Psychotherapy

Based on a theory of spiritualityEmpirically-orientedEcumenicalTransformational

Some Dangers of a Spiritually Integrated Psychotherapy

Trivializing spiritualitySpiritual reductionismValue imposition

Respect for Client’s Autonomy

“We need to be honest and open about our views, collaborate with the client in setting goals. . ., then step aside and allow the person to exercise autonomy and face consequences” (Bergin, 1995, p. 107).

Some Dangers of a Spiritually Integrated Psychotherapy

Trivializing spiritualitySpiritual reductionismValue impositionOverstating the importance of spirituality

The Law of the Instrument

“When you have a hammer in your hand, everything around you starts to look like a nail.”

The Greatest Danger “Medical and mechanistic models have made useful contributions

that should be integrated into any comprehensive theory of psychotherapy, but when these models serve as the foundation of our profession, they produce a psychology that is barren of soul. Thus, they unintentionally participate in the further desacralization of our society and in the de-souling of individual lives. Make no mistake: Soulless therapies produce soulless results. When our psychotherapies . . . become permeated with the same desacralizing assumptions that often cause our clients problems in the first place, then perhaps it is time for us to ask what we are doing as therapists and to seek other approaches that support rather than destroy the soul” (Elkins, 1995, p. 82).

Documents

A Rationale for Spiritually Integrated Psychotherapy