About the author: Dan Carpenter is a clinical psychologist working at the Oregon State Hospital. He received a Master's in religious studies and is an ordained clergyman specializing in working with religious clients. Dan was among the original editorial staff at Gestalt!. One of his current project's (in press) is entitled "Cross-Cultural Counseling with Clients of Diverse Religious Worldviews".

Abstract

In order to remain ethical in their practices, clinicians should have a thorough knowledge and understanding of how to work with religious issues that arise in therapy. This article summarizes some of the dangers inherent in working with spirituality, while at the same time challenging the clinician to take advantage of religious issues in therapy. Gestalt therapists are seen as particularly equipped for this type of work, being focused on a dialogical relationship as opposed to a rigid challenging of the client's religious beliefs. Ethical guidelines are considered to be related to the client's position in the field as well as each client's individual organization of that field. Guidance is offered for Gestalt therapists in order that their work with religious clients might be enhanced.

Key words: field, ethics, religiosity

Introduction

It seems obvious that unique populations require unique mental health delivery systems or models. That psychotherapy is not a "one size fits all" proposition is seen in the broad range of models currently in place in order to address the idiosyncratic nature of humanity. For example, techniques, systems, and approaches can be seen to differ in groups such as dual diagnosis clients (Miller, Leukefeld & Jefferson, 1994), lesbian women and gay men (Brown, 1991), African-American clients (Cook, 1993), adult borderline clients (Nehls & Diamond, 1993), homeless teenagers (Ray & Roloff, 1993), and rural Americans (Murray & Keller, 1991).

Religous clients, just as in these other populations, have unique needs for mental health care (King, 1978, p. 276, Carter & Narramore, 1979, p. 47, Worthington, 1986, p. 429), and they respond best to the sensitive support of their unique experience. The same ethical considerations necessary in other cross-cultural issues, should be present in work with such religious clients.

Ethical Considerations

Principle D, of the Ethical principles of psychologists and code of conduct (APA Ethics Code, 1992) states:

Where differences of age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language, or socioeconomic status significantly affect psychologists' work concerning particular individuals or groups, psychologists obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals. (APA Ethics Code, 1992)

The same Code (Principle B) states that "Psychologists strive to be aware of their own belief systems, values, needs, and limitations and the effect of these on their work" (APA Ethics code, 1992).

Similarly, Pate and Bondi (1992) pointed out that the Ethical Standards of the American Counseling Association state that counselors are to "guard 'the individual rights and personal dignity of the client'" and to do so "must learn during their professional education to respect the importance of spirituality and religion in the lives of clients and how to incorporate that respect in their practice" (p. 108).

Many religious clients are uncomfortable with therapists who do not share their beliefs

In view of these clearly-stated ethical guidelines, it is a curious fact that many religious clients are uncomfortable with therapists who do not share their beliefs. In such cases it becomes crucial to help the client gain support. Indeed, the client's ability to support him or herself may need the initiative of the therapist, acting as catalyst. Genia (1994) wrote that "the tendency for secular psychotherapists to reject organized religious involvement points to a 'religiosity gap' between mental health providers and the religiously committed United States majority" (p. 395). That such an awkward relationship is correlated with resistance to therapy and high rates of premature termination was demonstrated by Worthington (1986), Lovinger (1979) and King (1978). In such instances it has been the client's inability to find such needed support that has resulted in a stillborn therapeutic relationship. In this regard Gestalt therapists, of all people, ought to display an adept sensitivity to the need for support in the contact cycle of their religious clients.

In the culture at large perhaps one reason for the dissonance between therapist and client is that the cross-cultural distinctives of the religious client are not given the same "value" as those given to clients who are clearly racially different or speak in a language not understood by the therapist. We tend to recognize and respect diversity of skin color, language, sexual orientation and cultural background, but often the less overt trait of religiosity gets overlooked. For example, Lovinger (1984) wrote that scientific literature regarding religion and psychology has been relatively scarce, but that the "silence indicates the degree to which American psychology tacitly views a nonreligious position as normative and a belief position as worthy of study, if not pathological. Since the bulk of the American population is at least conventionally religious, this is indeed a curious stance" (p. 88).

An illustration of this adverse phenomena is found in Brook's (1996) Presidential Address to the APA Convention in Toronto:

Here I reach the heart of my message and the point at which I most sharply diverge from the objectives of the Religious Right and the Promise Keepers [as if the terms were synonymous]. Yes, we who support families wish to empower them and help them fulfill their most lofty promises. But this cannot be done by seeking return to an era when men were 'real men' and their wives were 'the little woman,' when father knew best and mother knew (or pretended) that he did, when boys were made of snakes and snails and puppy dogs tails; girls were made of sugar and spice and everything nice. Instead of trying to distort the reality of contemporary life, we family psychologists need to help families cope and develop their maximum potential. To do this, we cannot be agents of moralizing, suppression, or coercion of women and men into outmoded social roles. (Brooks, 1996, p. 5)

Brooks' portrayal, an attack on what many Christians consider healthy or even Biblical roles, lends no credence to the possibility that a family with religiously traditional role definitions may indeed be very happy and highly functional. His use of language labeled such a functional family system as "outmoded," resulting in the tendency to "rescue" it, despite the fact that it may not have been calling for help! Note that "we cannot be agents of...suppression", apparently means "unless religious values differ from our own, and in that case we'll make an exception." The cultural ignorance and insensitivity displayed here by Brooks is exactly the problem that drives religious clients away from necessary services.

In Gestalt therapy there may indeed be a place for differences of opinion in which the beliefs of both therapist and client can be mutually explored, but there is a critical difference between a therapist who makes a place for the different beliefs of his or her client, and the challlenging therapist on a crusade to save his client from primitive fundamentalism. A phenomenological approach saves both client and therapist from a rigid standoff. The therapist is free to explore just how his or her client makes meaning from experience, offering support in the process, and the ultimate epistemology of either's belief system, while important, recedes to play a minor and manageable role in their relationship.

Field Work With Religious Clients

Regardless of the position of "historical psychology" toward religion, it seems clear that in order to remain true to the ethical guidelines of professional psychology the issue should at least be considered within the context of a cultural framework--that is, the field--lest religious clients be denied the same understanding afforded to those more overtly culturally distinct. As Ridley (1995) has appropriately stated "...all clients deserve equitable treatment, regardless of their background" (p. 6).

Gestalt therapists are interested in having their patients/trainees discover for themselves what values fit their own way of looking at life--Jim Simkin

Gestalt therapists must keep alert for the point at which the phenomenology of their clients intersects the religious field characteristics in which their clients reside. As Jim Simkin noticed, twenty years previously, "Rather than impose on their patients their own values or strictures on how to live, the Gestalt therapists are interested in having their patients/trainees discover for themselves what values fit their own way of looking at life." (1974, p. 22) With religious clients this will pertain to a distinct religious subculture, or position in the field.

In the last two decades there has been a huge increase in sensitivity to culture in professional literature (Sue & Sue, 1990, p. 159). For example, compared to 1990, the word "culture" appeared in professional abstracts approximately 50% more in 1996 (PsychLIT). A similar survey of the ATLA Religious database shows that the phrase "cross-cultural" doubled in its use in abstracts from 1991 to 1993 (ATLA, 1996).

Because this writer is most familiar with the religious tradition of Christianity, that religion has been used as an example.

"I, personally, without any particular conscious intention, have moved far from my early dry and narrowly intellectual atheism as I absorbed the Gestalt style" --John Enright

Readers more familiar with other faiths should find it a relatively small challenge to make application to the faith worldview of their choice. It should go without saying that the focus, practically speaking, is not on the therapist's religious worldview anyway, but on the worldview (religious or otherwise) brought to the session by the client. Gestalt therapists seem particularly adept at working in this fashion, and for many Gestalt therapists this article serves as a timely reminder of why they do therapy as they have chosen to do. Indeed, writing in 1971, John Enright noted, "All of life, not just the narrow and grim domain of problems and symptoms, is the field of application of the Gestalt way...I, personally, without any particular conscious intention, have moved far from my early dry and narrowly intellectual atheism as I absorbed the Gestalt style..."(p.11-12)

Sue & Sue (1990) reported several factors which define culture. These included class values, language factors, unique experiences, communication style (p. 161) as well as outlook on individuality, verbal/emotional/behavioral expressiveness, self-disclosure, cause/effect orientation, structure/flexibility /ambiguity (pp. 35-45). Their "shorthand" version for culture was "all those things that people have learned to do, believe, value, and enjoy in their history. It is the totality of ideals, beliefs, skills, tools, customs, and institutions into which each member of society is born" (Sue & Sue, 1990, p. 35). This is very reminiscent of Kurt Lewin's concept of field, which Dorwin Cartwright (1951) described in the foreward to Lewin's Field Theory in Social Science as anything having demonstrable effects (p.xii). Malcolm Parlett (1997), writing with a more contemporary world view, stated that Gestalt therapists remember again and again, "...it is the organism-in-environment, person-in-situation, family-in-society..." that one encounters (p. 21).

Using the above terms to define culture, it is easy to see that Christianity and other world religions are indeed cultures of their own: individual-in-community of faith, church-in-denomination, faith-in-panoplay of religion.

Within Christianity one may find specific cross-cultural values (e.g. negative attitudes toward sexual intercourse outside of marriage, cohabitation, or use of alcohol and drugs), language factors (implicit in phrases like "born again" and "filled with the Spirit", plus peer pressure for "correct speech" such as lack of cursing), unique experiences (e.g. conversion, Eucharist, baptism), communication style (intercessory prayer, speaking in tongues), outlook on individuality (focus on serving others, including those outside of the Christian community), verbal/emotional/behavioral expressiveness (often demonstrated in worship expressions such as raising of hands, shouting or dancing), self-disclosure (seen both in verbal prayer requests and in repentant requests for forgiveness), cause/effect orientation (concept of omnipotent, omniscient God) , and structure/flexibility/ambiguity (as seen in liturgical form and doctrinal statements).

Clearly, not only is Christianity a culture of its own, but it is also made up of many subcultures. Denominations are created by distinct differences of opinion (often reflected in doctrinal statements) while still remaining under the larger "Christian" cultural umbrella. Kitayama and Markus (1994, p. 347) pointed out the concept of "micro-cultures" when they wrote:

In the United States, men and women, African-American or European-American, Jewish or Christian, may share similar culturally organized ways of thinking about self and others because they share a single, broadly defined cultural and sociopolitical reality. However, each person must also respond to a set of cultural requirements that are associated with being of a particular ethnic group, gender, religion, [denomination], age, generation, region of country, and so on. (Kitayama and Markus, 1994, p. 347, emphasis provided)

Christianity and Psychology--The Schism

The culture of Christianity has been influenced by a history of dissatisfaction with psychology. Part of the responsibility for this turbulent past rests with therapists who condemned religiosity as pathological. Worthington (1986) wrote "Conservative Christians prefer like-minded counselors and distrust secular counselors" (p. 425). Citing research by Beutler, Pollack and Jobe (1978), Worthington added "When clients agreed with the initial values of their therapists, they were more attracted to their therapists and were more trusting of them than were clients who did not (p. 425).

Contemporary insensitivity toward religious belief was preceded in the field by early comments on the part of several prominent members of the psychological community. Warnock captured the essence of the "anti-religious" spectrum of psychology:

Through the years, religion has been viewed by psychologists and those in related professions in many ways: by Freud as an illusion, an obsession and a fulfillment of infantile wishes; by Jung as an Archetype; by Fromm as human love; by Erikson as an epigenetic virtue; by James as an intensely personal experience, by Sargant as a matter of classical conditioning; by Skinner as a matter of operant conditioning; by Allport as a matter of personal becoming; [and] by Maslow as a quest for man's higher nature...(Warnock, 1989, p. 263)

Fritz Perls viewed theology as projection, the attribution of characteristics to the universe, and he admired those ministers who shifted from belief in a personalized God to embrace "...the basic creative energy of the universe." (Walker, p. 188-89) Perhaps one of the most famous quotes capturing the anti-religion bias in psychology was made by Albert Ellis (1962) who said "...And because any deity-positing religion almost by necessity involves endowing those members who violate the laws of its gods with a distinct concept of blameworthiness or sinfulness, I am inclined to reverse Voltaire's famous dictum and to say that, from a mental health standpoint, if there were a God it would be necessary to uninvent Him" (p. 142)

Reasons for an often-negative view of religion from psychologists vary from an unthinking acceptance of the "traditional" depreciating views espoused above, which portray religious belief as detrimental to mental health, to more personal issues such as past experience of the therapist.

Why is it that "compared with the public at large, secular psychotherapists are less likely to affiliate or participate in organized religion and are more likely to express their spiritual interests in nontraditional ways"? (Genia, 1994, p. 395). Lovinger (1984) posited that training in the sciences (such as psychology, psychiatry and nursing) "is at odds with the religious orientation and background of many Americans" (p. 1). He also stated that the humanist orientation and liberal political outlook of training institutions tends to complement a worldview which is essentially nonreligious, if not anti-religious (p. 2).

Additionally, he offered a taxonomy of three types of nonreligious therapists:

• the nonaffiliated
  ("an explicit religious tone or orientation is essentially absent")
• the anti-affiliated
  ("clear, antireligious orientation")
• and the formerly affiliated
  (who typically changed to a nonaffiliated position following a painful religious experience) (p. 5)

A starting point for all therapists may be to identify themselves in this inventory and respond accordingly with a thorough self-examination before encountering religious issues (of self or other) in the therapy process.

Tan (1994) points out several "pitfalls" regarding therapy with religious clients. Although his article is specifically targeted for religious psychotherapists, his comments are nonetheless applicable to all religious interaction with clients.

• Take care to not impose therapist's beliefs or values on the client.
• Don't fail to provide adequate therapist worldview (e.g. Christian, athiest, agnostic, Islamic) data in the informed consent process.
• Focusing mainly on religious goals rather than therapeutic goals (although there will clearly be overlap) is a violation of the therapeutic contract.
• Therapist's competence in the area of conducting therapy with religious clients is important--if you're short on knowledge, then consult.
• Don't become involved in arguing over doctrinal issues rather than clarifying them.
• Be careful of avoiding religious issues by misusing the client's resources (e.g. prayer).
• Be aware of blurring professional boundaries necessary for maintenance of the therapeutic relationship (e.g. becoming a surrogate spiritual guide instead of therapist).
• Refer to appropriate clergy/shaman for ecclesiastical functions.
• Don't become so focused on religious issues that when medication and/or other treatment may be necessary, it is ignored.

Consultation with clergy of the client's faith (when authorized by the client, of course), or referral to a clinician with more experience and expertise in the clinician's weak area, may often be appropriate to the situation. Additionally, the clinician should be aware when a desire to avoid religious issues arises from either the client or therapist.

Conclusion

References

• APA ethics code. (1992). Washington, D.C.: American Psychological Association.
• ATLA (1996). ATLA religious database. Evanston, IL: American Theological Library Association.
• Beutler, L., Pollack, S. & Jobe, A. (1978). "Acceptance", values and therapeutic change. Journal of Consulting and Clinical Psychology 46 (1), 198-199.
• Brooks, G. (1996, Fall) Gender equality in families: A promise worth keeping. The Family Psychologist 12 (4), 5-6. Brown, L. (1991). Commentary on the special issue of the counseling psychologist: Counseling with lesbians and gay men. Counseling Psychologist 19 (2), 235-238.
• Carter, J., & Narramore, B. (1979). The integration of psychology and theology: An introduction. Grand Rapids: Zondervan Corporation.
• Cartwright, D. (1951) in the foreword to Kurt Lewin's sField theory in the social sciences. Westport: Greenwood Press Publishers
• Cook, D. (1993). Research in African-American churches: A mental health counseling imperative. Journal of Mental Health Counseling 15 (3), 320-333.
• Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, N.J.: The Citadel Press.
• Enright, J.P. (1971) in the foreward Body and soul, by J. Lyn Walker. Nashville: Abingdon Press.
• Genia, V. (1994). Secular psychotherapists and religious clients: Professional considerations and recommendations. Journal of Counseling & Development 72, 395-398.
• King, R. (1978). Evangelical Christians and professional counseling: A conflict of values? Journal of Psychology and Theology 6 (4), 276-281.
• Kitayama, S. and Markus, H. (1994). Emotion and culture. Washington, D.C.: APA Press.
• Lovinger, R. (1979) Therapeutic strategies with "Religious" resistances. Psychotherapy: Theory, Research and Practice 16 (4), 419-427.
• Lovinger, R. (1984) Working with religious issues in therapy. Northvale, NJ: Aronson Press.
• Miller, T., Leukefeld, C. & Jefferson, B. (1994). Dual diagnosis: clinical issues in substance abuse treatment. Journal of Contemporary Psychotherapy 24 (3), 169- 177.
• Murray, J. & Keller, P. (1991). Psychology and rural America: Current status and future directions. American Psychologist 46 (3), 220-231.
• Nehls, J. & Diamond, R. (1993). Developing a systems approach to caring for persons with borderline personality disorder. Community Mental Health Journal 29 (2), 161-171.
• Parlett, M. (1997) "The unified field in practice." Gestalt review, vol1, no.1, p. 16-33. Lawrence: The Analystic Press.
• Pate, R. & Bondi, A. (1992). Religious beliefs and practive: An integral aspect of multicultural awareness. Counselor Education and Supervision 32, 108-115 PsychLIT Database (1996) Washington, D.C.: American Psychological Association.
• Polster, E. and Polster M. (1973) Gestalt therapy integrated New York: Vintage Books.
• Ray & Roloff, (1993). Church suppers, pony tails and mentors: Developing a program for street kids. Child and Adolescent Social Work Journal 10 (6), 497-508.
• Ridley, C. (1995). Overcoming unintentional racism in counseling and therapy: A practitioner's guide to intentional intervention. Thousand Oaks: Sage Publications.
• Simkins, J. (1974) "Ethical considerations." Mini-lectures in Gestalt therapy. Albany: Wordpress.
• Sue, D. & Sue, D. (1990). Counseling the culturally different: Theory & practice, Second edition. New York: John Wiley & Sons.
• Tan, S. (1994). Ethical considerations in religious psychotherapy: Potential pitfalls and unique resources. Journal of Psychology and Theology 22 (4), 389-394.
• Walker, J. L. (1971). Body and soul: Gestalt therapy and religious experience Nashville: Abingdon Press.
• Warnock, S. (1989). Rational-emotive therapy and the Christian client. Journal of Rational Emotive and Cognitive Behavior Therapy 7 (4), 263-273.
• Worthington, E. (1986, March). Religious counseling: A review of published empirical research. Journal of Counseling and Development, 64, 421-430.