Religion and Spirituality in Mental Health

1. Religion and Spirituality in Mental Health Angelic Chaison Ph.D., Houston Daryl Fujii, Ph.D., Honolulu Nancy Cha, Honolulu (intern) and the Multicultural & Diversity Committee (2010-2011) VA Psychology Training Council Contact persons:  Daryl Fujii Ph.D., Honolulu (Daryl.Fujii@va.gov) Rachael Guerra Ph.D., Palo Alto (Rachael.Guerra@va.gov)

2. Multicultural/Diversity Committee Committee 2010-2011 Loretta E. Braxton Ph.D., Durham (Co-Chair) Linda R. Mona Ph.D., Long Beach (Co-Chair) Angelic Chaison Ph.D., Houston Daryl Fujii Ph.D., Honolulu Rachael Guerra Ph.D., Palo Alto Jamylah Jackson Ph.D., North Texas Monica Roy Ph.D., Boston Christina Watlington Ph.D., Perry Point Miguel Ybarra Ph.D., San Antonio Susana Blanco Ph.D., Bedford (Postdoc) Nancy Cha, Honolulu (Intern) Paul Lephuoc, Houston (Intern) Katherine Hoerster Ph.D., Long Beach (Postdoc)

3. Overview • Definitions • Learning objectives • Introduction • Empirical research on religion/spirituality • Conceptualizations of the role of religion/spirituality in mental health • Clinical issues in which faith can become salient • Ethics • Assessment and therapy • Case examples and interactive activity • References

4. Definitions • Religion usually refers to “beliefs, practices, and rituals related to the sacred” (Koenig, 2009, p.284). The term “sacred” often refers to objects or beings (i.e. God, Allah) considered to be supernatural, holy, or transcendent (Paragament, 1990). • Religion can be organized and practiced within a community that follows certain traditions and holds certain beliefs (Koenig, 2009). • Spirituality is viewed as more personal and defined by the individual. It is considered to be “largely free of the rules, regulations, and responsibilities associated with religion” (Koenig, 2009, p.284) and focuses on aspects of life that are “transcendent” or larger than the individual without necessarily having religious overtones (Pargament, 1990).

5. Learning Objectives • Participants will: • Become familiar with literature on religion/spirituality and mental health • Learn multiple ways to conceptualize the role of religion/spirituality in the lives of persons of faith • Identify presenting issues for which religion/spirituality can become salient • Learn ways to incorporate religion/spirituality in assessment and treatment

6. Introduction • Results from the 2010 Gallup Poll indicate that at least 65% of the U.S. population said that religion is important in their lives (Gallup Poll, 2010). • The American Religious Identification Survey provides data regarding ethnic representation among faiths in the US.

7. Introduction cont. • The nature of religion as it relates to psychology is a highly debated topic and has been for a number of years. Prominent psychologists such as Sigmund Freud, Albert Ellis, and Carl Jung have often disagreed about whether religion is helpful or harmful for people’s wellbeing. • Early empirical research yielded mixed results concerning the impact of religiousness on mental health (e.g., Payne, Bergin, Bielema, & Jenkins, 1991). • Due to methodological limitations in early research, the beneficial and potentially therapeutic aspects of clients’ religiousness was often overlooked (Richards, Smith & Davis, 1989).

8. Introduction cont. • Later research has demonstrated how individuals who draw on a more deeply established system of religious beliefs, practices, feelings, and relationships are in a good position to find compelling religious solutions to various problems and cope with everyday living (Pargament, 1997; Schaefer & Gorsuch, 1991). • At the same time, others have demonstrated how religion can negatively impact coping during times of crises and can be associated with poor mental health and event-related outcomes (Pargament, 1997; Pargament, Zinnbauer, et al., 1998). • Given that research has shown that religion/spirituality can positively or negatively impact coping during times of crises, it is important to understand the role of religion/spirituality on mental health outcomes.

9. Review of Empirical Research on Religion in Mental Health • In a review of studies examining the relation between religion and mental health, Koenig (2009) summarized that : • Religion/spirituality is generally related to improved coping and less depression, anxiety, suicide, and substance abuse across different ethnic backgrounds, age groups, settings and geographic locations. • “Healthy normative religious beliefs and practices” may be reassuring for people who experience psychosis with religious delusions. • Koenig encouraged clinicians to be aware of the value of religion as a resource for healthy mental and social functioning and to recognize when religious beliefs contribute to pathology.

10. Review of Empirical Research on Religion in Mental Health cont. • Koenig (2009) asserts that religious coping is often found among patients with medical and mental illness because faith: • Provides a sense of meaning and purpose during difficult transitions in life • Promotes hope and optimism • Provides role models for acceptance • Offers a sense of indirect control • Provides a community of support – human and divine • Is available at anytime regardless of financial, social, physical or social circumstances

11. Ways to Conceptualize Religion and Spirituality

12. Conceptualization of Religion in Mental Health • With the development of the field of psychology of religion, religion has become increasingly viewed as a multidimensional construct that includes: • Orientation towards their faith (e.g., religious orientation or internalization) • Application of their faith (e.g., religious coping) • Interpersonalconnectedness to others with similar faith perspectives (e.g., religious social support) • Understanding how these aspects of religion impacts clients’ attributions of problems and preference for coping strategies can assist in case conceptualization and identifying treatment interventions.

13. Orientation Towards Faith • Religious Orientation (Allport & Ross 1967) • IntrinsicReligiousOrientation – describes individuals who embrace their religious beliefs and find their “master motive” in religion. • Generally associated with desirable variables, such as self-esteem (Payne et al., 1991), personal adjustment (Bergin, Masters, & Richards, 1987), etc. • ExtrinsicReligiousOrientation – describes individuals who use religion for their own ends, including security, comfort, sociability, and status. • Generally associated with prejudice (Allport & Ross, 1967), trait anxiety (Peterson & Roy, 1985), personal distress, (Genia, 1996), and sexual permissiveness (Haerich, 1992) • A meta-analytical review showed that intrinsic and extrinsic religious orientations are associated with lower and higher levels of depression, respectively (Smith, McCullough, & Poll, 2003)

14. Orientation Towards Faith cont. • Religious Internalization (Ryan, Rigby, & King, 1993) • IdentifiedReligiousInternalization – when religious practices are experienced as personally valuable and are performed voluntarily because individuals see these practices as self-initiated. • Positively associated with measures of psychological adjustment, and negatively associated with depression, anxiety, and somatization (Ryan, et. al, 1993) • IntrojectedReligiousInternalization – when religious practices are performed because not performing the behavior could bring about guilt, anxiety, and loss of esteem. • Positively related to anxiety, depression and somatization and negatively related to psychological adjustment measures (Ryan, et. al, 1993)

15. Application of Faith • Religious attributions (Pargament, 1990) • Religious problem-solving styles (Pargament, Kennell, Hathaway, Grevengoed, Newman, & Jones, 1988). • Self-directive • Deferring • Collaborative • Positive and negative religious coping (Pargament, Smith, et al. (1998) • Spiritual surrender (Cole & Pargament, 1999)

16. Social Connectedness in Religious Communities • Research (Baetz & Toews, 2009; Pargament, 1990) has shown that social support in religious communities can be experienced as helpful when support: • Meets the psychological need of belongingness • Provides material resources (e.g., housing, food, etc.) • Offers helpful coping suggestions • Social support in religious communities can be experienced as harmful when individuals perceive members of religious communities as (Baetz & Toews, 2009; Pargament, Zinnbauer, et al.,1998): • Unavailable or uncaring • Critical and judgmental

17. Clinical Issues in Which Faith becomes Salient: PTSD

18. PTSD and Religion/Spirituality • PTSD and Religious Faith • “One of the most pervasive effects of traumatic exposure is the challenge that people experience to their existential beliefs concerning the meaning and purpose of life.” (Fontana & Rosenheck, 2004). • Traumatic exposure often has a weakening effect on religious faith (e.g. Calhoun and Tedeschi, 1999; Decker, 1993; Janoff-Bulman, 1992; Liefton, 1988). • Traumatic exposure also has a strengthening effect on religious faith (Calhoun et al., 2000; Drescher and Foy, 1995; Lawson et al., 1998; Racklin, 1998) • Strength of religious faith has an inverse association to severity of PTSD symptoms (e.g. Astin et al., 1993; Davis et al., 1998; Klingler, 1999; Murad, 1991; Phan and Kingree, 2001; Saunders, 1999)

19. PTSD and Religion/Spirituality • PTSD, Religious Faith and Mental Health Service • Veteran’s pursuit of mental health services appears to be driven more by their guilt and the weakening of their religious faith than by the severity of their PTSD symptoms or their deficits in social functioning (Fontana & Rosenheck, 2004). • Raises the broader issue of whether spirituality should be more central to the treatment of PTSD, either in the form of a greater role for pastoral counseling or of a wider inclusion of spiritual issues in traditional psychotherapy for PTSD.

20. PTSD and Religion/Spirituality • Guilt and Mental Health • Trauma related guilt in the war-zone (Kulbany et al. 1997) • PTSD, Forgiveness and Religious Coping • Witvliet, Phipps, Feldman & Beckham (2004) found significant associations between difficulty forgiving others, difficulty forgiving oneself, and negative religious coping (e.g., appraisal of the problem as God’s punishment, interpersonal religious discontent) with difficulties in mental health for veterans with PTSD.

21. Clinical Issues in Which Faith becomes Salient: Sexual Orientation

22. Conflict between religion and non-heterosexual orientations • Mainline Protestant, Catholic, Islamic, Judaism prohibit homosexuality • Social implications for negative attitudes:  • LGB participate in organized religion less than heterosexuals • Participation can be detrimental to psychological health • Implications for GLB individuals • Struggle in integrating sexual identity with religious faith   • LGB individuals can abandon their faith in securing a LGB identity • LGB individuals also feel their faith has abandoned them • Development of internalized homo-negativity • Associated with shame, depression, suicidal ideation, psychological distress, low self-esteem, lack of perceived social support, and difficulty accepting LGB identity, (review Lease, Horne, Noffsinger-Frazier, 2005)

23. Interventions • Help GLB individuals developing own personal spirituality associated with greater psychological health • Help clients separate non-affirming doctrine with faith practices and principles that support the goodness in all people • Replace redemption and sin model with one that celebrates all creation • Encourage involvement in LGB-affirming faiths • Faiths evolved by altering traditional doctrine to be more inclusive or developing own doctrines  

24. Clinical Issues in Which Faith becomes Salient: Religion and end of life -beliefs and practices

25. Islam (Hendi, 2011) • Muslims believe in an afterlife • Illnesses are part of life and not punishment for sins • Cures should be sought, but only God grants cures • Those who endure illness with patience will be rewarded at time of judgment • It is okay to complain of pain as long as the person does not blame God • Euthanasia or attempts to shorten life are prohibited • If person done wrong to someone, forgiveness should be sought as the rights of man are more important than the rights of God • Islamic creed should be recited at moment of death

26. Buddhism (Kramer, 2011) • Buddhists believe in karma and reincarnation; a person will be reborn until one achieves enlightenment. • Clarity of mind is important at time of death as it can profoundly affect state of next rebirth. Thus clinicians should: • Encourage patient to express love and kindness to others • Encourage reflection and rejoicing in virtuous activities • Past regrets can be addressed by asking forgiveness, making amends, or confessing to a spiritual leader • Facilitate a peaceful and calm environment • Avoid excessive medications that can cloud consciousness

27. Judaism (Kinzbrunner, 2011) • Judaism is focused on life and how to live it versus how to get into heaven. Judaism believes in an afterlife but has little dogma about it. • After death, a person’s soul is purified/punished by fire in Gehinnom (maximum of 12 months, time contingent upon amount of sin). The soul eventually ends up in Gan Eden (heaven) • All souls are eventually resurrected during Olam Ha-Ba “World to Come“ • Jewish beliefs and End Of Life (EOL) care: • Euthanasia and forms of intentionally hastening death is prohibited • For more conservative Jews, food and fluid even when provided artificially are considered basic care • For Orthodox Jews, the Rabbi must be included as a named surrogate to ensure decision –making is made in accordance to Jewish law • Jewish rituals and EOL care: • Many different prayers (e.g. Mi'sheberachprayer for sick; Vidui,a confession) • Many restrictions (e.g. only Kosher foods eaten, prohibition of inter-gender contact/care providers, rituals for cleansing of body at time of death )

28. Christianity (Nichols, 2011, Picchi, 2011) • Christians are highly heterogeneous in interpretation of the Bible, worship practices, and beliefs about the afterlife and salvation • The key is asking the right questions • Christians generally believe in an eternal afterlife involving either heaven and hell • Heaven is generally perceived as being with God, while beliefs about hell range from a place of eternal torture to an eternity without God • Beliefs about how one is selected to go to heaven vary widely • Catholics believe salvation is achieved through repentance made to a priest • Many Protestant sects believe salvation is achieved through direct prayers to God • Some sects believe that persons are preselected • EOL concerns often pertain to personal salvation • For examples, Catholics believe it is a time for Reconciliation: attending to unfinished business, seeking amends, restoring a right relationship with oneself, others, and God • Prayers, Reading scriptures, and visits by clergy are general interventions for Christians

29. Ethics, Assessment, and Treatment

30. Ethics • Baetz & Toews (2009) review multiple positions regarding incorporating religion/spirituality in clinical settings. • For • Using a biopsychosocial-spiritual model meets patients desire to be asked about their spiritual commitments and concerns • A preponderance of research supports the potential health benefits of religion/spirituality for clients who are religiously-inclined. • Against • Religion is a private matter not to be discussed with health professionals • The power differential between provider and patient may appear as coercion.

31. Assessment • ClinicalInterview – acronyms have been created to assist in assessing for clients’ spirituality in the psychosocial history • FICA (Puchalski & Romer, 2000) • Do you have Faith or believe? • Importance in clinical care? • Are you part of a faith Community? • Is there a way you would like it to be Addressed as part of care? • HOPE (Anandarajah & Hight, 2001) • Source of Hope or meaning • Organized religion • Personal spirituality or Practices • Effect on medical care and/or End of Life

32. Assessment • Measures • Religious Orientation Scale (Allport & Ross 1967; Genia, 1993; Gorsuch & McPherson, 1989) • Christian Religious Internalization Scale (Ryan, Rigby, & King) • Religious Problem-Solving Styles (Pargament, et al. 1988) • Positive and Negative Religious Coping (Pargament, Smith, et al., 1998)

33. Therapy • Establish of a collaborative relationship that provides a safe context to explore religious concerns (Miller & Thorensen, 1999) • Consult with religious leaders/clergy and coordinate care as appropriate (Miller & Thorensen, 1999) • Baetz & Toews (2009) reviewed ways religion/spirituality can be incorporated in treatment: • Attributions for life events • Reframing of problems as spiritual opportunities • Religious behaviors that contribute to self-regulation and self-calming • Religious coping that promotes forgiveness, gratitude, compassion, and altruism

34. Case Examples and Interactive Activity

35. Case Example: Presenting Problem JS is a 41 year-old Latino male who had his first psychotic break while serving in the Marine Corps. He is married with a 6 year-old son. Just before his son was born, JS attempted suicide by jumping off a bridge. He sustained a brain and spinal cord injury, the latter resulting in paraplegia. JS was hopeful to walk during his first 2 years in inpatient rehab, but was transferred to a long term care facility after it was determined that he would not walk again. JS became depressed. About a year later, JS reported hearing God saying "sky" to him from the bathroom which he interpreted as God wanting him to be with him. JS became obsessed with dying and going to heaven and constantly begged the doctors to kill him.

36. Clinician Intervention • Knowing JS was a Catholic, psychologist KM asked him what Catholics believed about death and suicide. JS knew that suicide was not right, but rationalized that God wanted him in heaven. KM stated that if God wanted him to die, he would have died in the fall. The fact that he is alive must mean that God had a plan for him. JS agreed, however, due to cognitive deficits, including memory and executive problems, it took about a month before his conversation with KM stuck with him. KM then worked with JS to find meaning in his life which focused on being a good father to his son and helping others.

37. Case Example: Presenting Problem Dana (aged 31 years) was a Christian female who presented to psychotherapy with several symptoms of depression. As psychotherapy progressed, Dana explored negative beliefs about herself. Her most problematic core belief was that she was worthless and no one would ever love and accept her as she was. These beliefs seemed related to childhood physical abuse by her mother, who eventually abandoned her. Dana was a committed Christian. At intake she asked to incorporate issues of R/S in her psychotherapy. Case example with therapy interventions comes from Worthington, Hook, Davis, & McDaniel (2011)

38. Clinician Intervention The cognitive model of depression emphasizes the role of maladaptive cognition in causes and treatment (Beck, Rush, Shaw, & Emery, 1979). Christian-accommodative cognitive therapy for depression retains the features of the secular theory, yet places the psychotherapy in a religious context. For example, the rationale for psychotherapy, the homework assignments, the challenging of negative automatic thoughts, and core beliefs are integrated with and based on biblical teachings regarding the self, world, and future (Pecheur & Edwards, 1984). As Dana and her therapist explored and modified her negative core beliefs, they discussed how Dana thought God viewed her. Several passages of the Bible comforted Dana and helped her realize that although she viewed herself negatively, God and other people loved and accepted her as she was.

39. Case Example: Presenting Problem Dave (aged 47 years) did not profess a religion. He considered himself to be spiritual. After he lost his job because he failed a drug test, he checked into a rehabilitation facility. He had been dependent on drugs and alcohol on and off for 30 years. Case example with therapy interventions comes from Worthington, Hook, Davis, & McDaniel (2011)

40. Clinical Intervention Spiritual self-schema therapy integrates cognitive-behavioral techniques with Buddhist psychological principles (Avants & Margolin, 2004). The goal of this psychotherapy is to modify a person’s self-schema. When a self-schema is activated, beliefs about the self energize specific behaviors. This psychotherapy attempts to facilitate a shift from an ‘‘addict’’ self schema to a ‘‘spiritual’’ self-schema that fosters mindfulness, compassion, and doing no harm to self or others (Margolin et al., 2007). Psychotherapy sessions focus on aspects of the Buddhist Noble Eightfold Path, which include training in mindfulness, morality, and wisdom. During psychotherapy, Dave was taught about the wandering nature of the mind and how this contributed to his addict self-schema. When Dave did not work to control his mind, he thought of using drugs. He practiced a meditation technique called anapanasati, which involved sitting silently with eyes closed and focusing on the sensations experienced while breathing naturally. Dave improved his concentration and mindfulness with practice and began to discipline his maladaptive thoughts.

41. Interactive Activity • Case discussion is often a helpful way to identify ways to proceed with challenging cases. Now that you have discussed the case examples included in this presentation, take a moment to reflect on one of your past or current cases that involved religion/spirituality. • Discuss various ways to approach the case in light of the information discussed during this presentation.

42. References • Allport, G.W., & Ross, J.M. (1967). Personal religious orientation and prejudice. Journal of Personality and Psychology, 5(4), 432-443. • Anandarajah, G, & Hight, E. (2001). Spirituality and medical practice: Using HOPE questions as a practical tool for spiritual assessment. American Family Physician, 63, 81-89. • Baetz, M. & Toews, J. (2009).Clinical implications of research on religion, spirituality, and mental health. The CanadianJournal of Psychiatry, 54(5), 292-301. • Bergin, A.E., Masters, K.S., & Richards, P.S. (1987). Religiousness and mental health reconsidered: A study of an intrinsically religious sample. Journal of Counseling Psychology, 34(2), 197-204. • Cole, B.S., & Pargament,K.I. (1999). Spiritual surrender: A paradoxical path to control. In W.R. Miller (Ed.), Integrating spirituality into treatment: Resources for practitioners. (pp. 179-198). Washington, DC: American Psychological Association. • Gallup Poll. (2010). Religion. Retrieved May 5, 2011, from http://www.gallup.com/poll/142727/Religiosity-Highest-World-Poorest-Nations.aspx • Genia, V. (1996). I, E, quest, and fundamentalism as predictors of psychological and spiritual well-being. Journal for the Scientific Study of Religion, 35(1), 56-64. • Haerich, P. (1992). Premarital sexual permissiveness and religious orientation: A preliminary investigation. Journal for the Scientific Study of Religion, 31(3), 361-365.

43. References • Hendi, Y. (2011). Islamic spirituality and end-of-life care: Guidelines for chaplains and counselors. In K. Doka & A. Tucci (Eds.), Living with Grief: Spirituality and End-of-Life Care. Washington, DC: Hospice Foundation of America. (pp. 181-190). • Koenig, H.G. (2009). Research on religion, spirituality, and mental health: A review. The CanadianJournal of Psychiatry, 54(5), 283-291. • Koenig, H.G., Cohen, H.J., Blazer, D.G., Pieper, C., Meador, K.G., Shelp, F., Goli, V., et al. (1992). Religious coping and depression among elderly, hospitalized medically ill men. American Journal of Psychiatry, 149(12), 1693-1700. • Kramer, B. (2011). Buddhist perspectives on end-of-life care. In K. Doka & A. Tucci (Eds.), Living with Grief: Spirituality and End-of-Life Care. Washington, DC: Hospice Foundation of America. (pp. 207-220). • Kinzbrunner, B. (2011). Jewish perspectives on end-of-life care. In K. Doka & A. Tucci (Eds.), Living with Grief: Spirituality and End-of-Life Care. Washington, DC: Hospice Foundation of America. (pp. 119-134). • Lease, S., Horne, S., Noffsinger-Frazier, N. (2005). Affirming faith experiences and psychological health for Caucasian lesbian, gay, and bisexual individuals. Journal of Counseling Psychology, 52, 378-388. • Miller, W.R., & Thorensen, C.E. (1999). Spirituality and health. In W. Miller (Ed.), Integrating spirituality into treatment. Washington, DC: American Psychological Association. (pp. 3-18). • Nichols, S. (2011). Caring for Protestants: Asking the right questions. In K. Doka & A. Tucci (Eds.), Living with Grief: Spirituality and End-of-Life Care. Washington, DC: Hospice Foundation of America. (pp. 165-178).

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