Ethics Of Religion

65

3 ETHICAL GUIDELINES FOR USING

SPIRITUALLY ORIENTED INTERVENTIONS

WILLIAM L. HATHAWAY

The empirical literature pertaining to clinical practice with religious and spiritual issues is still at a relatively early stage, but in recent years a substantial amount of attention has been paid to ethical issues in this domain (Gonsiorek, Richards, Pargament, & McMinn, 2009; Hathaway & Ripley, 2009; Plante, 2007, 2009; Richards & Bergin, 2005; Sperry & Shafranske, 2005). This liter- ature has focused on a wide range of ethical concerns, such as protecting against harmful bias, practicing within one’s boundaries of competence, and exploring role considerations in working with religious issues.

In this chapter, I begin by bringing attention to how psychologists’ rela- tive lack of religious commitment has the potential for creating and introduc- ing biases into treatment. A brief introduction provides readers with common conceptualizations of spiritually oriented interventions in the recent psycho- logical literature. This is followed by an examination and application of rele- vant ethical codes to the use of spiritually oriented interventions. Spiritually oriented interventions are then discussed from an accountable practice perspec- tive. Training recommendations are also provided to help facilitate the ethical application of such interventions. Brief clinical examples and questions are also offered to help readers delve deeper into thinking about the ethical issues that

To the psychologist the religious propensities of man must be at least as interesting as any other of the facts pertaining to his mental constitution.

—William James (1997)

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http://dx.doi.org/10.1037/12313-003 Spiritually Oriented Interventions for Counseling and Psychotherapy, by J. D. Aten, M. R. McMinn, and E. L. Worthington, Jr. Copyright © 2011 American Psychological Association. All rights reserved.

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must be considered before using spiritually oriented interventions in clinical practice.

POTENTIAL FOR PROBLEMATIC BIASES

It has been frequently noted that professional psychologists appear to be atypically irreligious compared with the general North American popu- lation. Plante (2009), for instance, cited Gallup polls indicating that 95% of Americans believe in God and 40% of attend religious services on a weekly basis. Despite a widespread prevalence of religiousness in the general popula- tion, researchers (Bergin & Jensen, 1990; Delaney, Miller, & Bisono, 2007; Hathaway, Scott, & Garver, 2004; Shafranske, 2000) have noted that, relative to the general population, psychologists (a) have double the rate of claiming no religion, (b) are more likely by a factor of three to report religion being unim- portant in their life, (c) have a five-fold higher rate of denying belief in God, and (d) report lower likelihoods of attending religious services, being a member of a congregation, or engaging in prayer.

The risk is that this lower level of conventional religiousness among psy- chologists may result in biasing blind spots that lead them to erroneously dis- regard significant religious issues in clinical practice. Unfortunately, there is evidence that just this sort of neglect is occurring. Russell and Yarhouse (2006) found that over two thirds of a sample of training directors at American Psychological Association (APA) internships never foresaw offering training in religious and spiritual issues at their sites. Brawer, Handal, Fabricatore, Roberts, and Wajda-Johnston (2002) surveyed training directors of APA- accredited doctoral training programs and found that only 17% reported sys- tematic coverage of religion and spirituality in their programs. There is little evidence that such findings cause much concern outside of the niche of psychologists who specialize in the clinical psychology of religion. Imagine if such lassitude in the profession were the case for any of the other named diversity domains highlighted for particular attention in the APA (2010) Ethics Code (hereafter referred to as the Code).

Yet the situation may be even more problematic than just a climate of indifference. There is evidence that psychologists may be more likely than the general population to be hostile and prejudicial to conventional religion. Delaney, Miller, and Bisono (2007) noted that “it appears to be a relatively fre- quent experience among psychologists to have lost belief in God and disaffili- ated from institutional religion” (p. 542). They found this experience to be nearly 7 times more frequent in their sample of psychologists than in the gen- eral population. In a study of whether antireligious discrimination may be occurring in admissions to doctoral programs in clinical psychology, Gartner

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(1986) found that a sample of faculty at doctoral programs accredited by the APA were less likely to grant admission or to have positive feelings about appli- cants whose admissions protocols contained a conventional religious identifi- cation than about those whose protocols were otherwise identical except for the absence of such religious identification.

It seems unlikely that a negative or less receptive atmosphere among psy- chologists toward conventional religion would not translate into problematic clinical practice patterns toward this client population or niche. In a random national sample of clinical psychologists, Hathaway et al. (2004) found that most psychologists do not routinely assess for clinically relevant spiritual or reli- gious issues in practice. They also noted that a sizeable portion of their sample did not feel that religion is more than a slightly important adaptive domain for such focus.

Although there is no systematic research on the prevalence of apparent antireligious biases and/or overt discrimination toward conventionally religious clients by psychologists, numerous anecdotes have been recounted by clini- cal psychologists (Cummings, O’Donohue, & Cummings, 2009). A doctoral psychology intern at a respected internship informed me about being instructed by his supervisor to diagnose a client with a delusional disorder because the client expressed belief in intelligent design as opposed to evolution. The client reportedly did not display any other indications of thought disorder, psychotic process, or life impairment related to her beliefs. The intern expressed concern about giving this diagnosis, but the supervisor insisted and explained that the intelligent design belief itself was sufficient to warrant the diagnosis.

Let us assume that naturalism is true and all of the varieties of beliefs self- identified as intelligent design are false. This would hardly justify a mental health professional diagnosing a believer in intelligent design with a delusional disorder. It has become common in the polemics surrounding the new atheism to declare either theistic or atheistic belief to be a delusion (Dawkins, 2006; Hart, 2009). In terms of pure logic, either atheism or theism is true, but not both, so one of the two groups believes something that is false. Yet having a false belief is not the same thing as having a delusional belief, in a technical psy- chological sense. Delusional beliefs involve a disordered thought process and not just acceptance of beliefs that turn out to be factually incorrect (Clarke, 2001). Giving such a diagnosis in the absence of a genuine psychotic process runs a significant risk of iatrogenic consequences for the client, such as bearing the stigma of receiving an unwarranted diagnosis of a serious psychiatric con- dition, potentially having career and life options adversely affected, or being the recipient of unnecessary treatments. Thus, this practice may constitute a violation of the cardinal ethical concern of doing no harm.

Although negative or undervaluing biases toward conventional religion appear to be a common risk among psychologists, problems can also arise from

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proreligious biases. The American Psychiatric Association (1989) adopted guidelines warning against a psychotherapist imposing his or her religious val- ues or beliefs on clients. The ethical principle of nonmalfeasance (i.e., doing no harm) implies that psychologists should not attempt experimental proce- dures in lieu of standard proven psychotherapies without clear warrant and informed consent. I have encountered some psychologists who are personally religious abandoning standard approaches to common clinical problems for which well-supported treatments exist in favor of stand-alone explicitly reli- gious interventions. The stand-alone approaches eschew any other form of assistance apart from the religious or spiritual practice. Typically, these reli- gious caregivers have justified the stand-alone spiritual approaches in terms of their own religious beliefs about what is right for the person. Sometimes these spiritual-only-approach psychotherapists are licensed mental health professionals and other times they are not.

Some of their care recipients report benefits from such stand-alone spiritual-only approaches, but others do not. Their clients are not typically given any scientific data about likely responses to the approach (e.g., success rates, rates of nonresponders, adverse risks), although testimonials of success are frequently shared with the clients. Some persons in our community sought assistance from nonreligious caregivers after dropping out from these stand- alone spiritual-only treatments. The stand-alone dropouts indicated that they were not typically informed by the spiritual-only-approach provider about standard treatments for their concerns or about the experimental nature of the approach. In cases in which this care was being provided by a nonmental health professional, this is perhaps not surprising, but some of these cases involved licensed mental health professionals.

The stand-alone dropouts typically reported that their presenting issues had not improved. In fact, they sometimes now had added guilt and shame over not getting better from the stand-alone spiritual approach. When the lack of positive treatment response is attributed to God being unable or unwilling to help, it may deepen recipients’ faith conflicts and emotional pain.

Now, I am not suggesting that such anecdotes prove the stand-alone spir- itual treatments to be ineffective or noxious. Every treatment, even ones with good empirical support, has nonresponders and dropouts. Furthermore, there is a growing body of evidence that spiritually focused and accommodative approaches that combine spiritual interventions with standard psychotherapeu- tic techniques and relational skills are benign and helpful to clients (Tan & Johnson, 2005; Worthington & Sandage, 2002). My concern has more to do with ethical issues raised by the way the licensed caregivers engaging in the stand-alone spiritual approaches practiced (Gonsiorek et al., 2009).

These stories call attention to the need for psychologists to adequately consider the range of relevant ethical principles, standards, and other consid-

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erations that should guide our practice with regard to religious and spiritual issues (Knapp & VandeCreek, 2006). Hathaway and Ripley (2009) pointed out that such guidance can be found by reflecting on relevant ethical codes, pol- icy statements, practice guidelines, legal precedents, exemplar guidance, and evidence-based practice considerations. Let us now reflect on their relevance for the explicit use of spiritually oriented interventions by psychologists.

SPIRITUALLY ORIENTED INTERVENTIONS

A growing literature on spiritually oriented interventions provides detailed descriptions of how to conduct such interventions competently and ethically (Plante, 2009; Richards & Bergin, 2005; Schlosser & Safran, 2009). There is no standard language used to identify this group of interventions. Plante (2009) described them as spiritual practices or tools. Richards and Bergin (2005) referred to them as either theistic or spiritual interventions (p. 281). Schlosser and Safran (2009) called them spiritual interventions and techniques (p. 199). There is considerable overlap among the spiritually oriented interven- tions enumerated by these authors (see Table 3.1). Although some of these would likely be readily thought of as spiritual by most individuals (e.g., the use of prayer), others may be less obvious examples to some of a specifically “spiri- tual” intervention (e.g., meaning making or relaxation).

Among psychotherapists who seek to incorporate an explicitly spiritual aspect to treatment, Schlosser and Safran (2009) also distinguished between two general approaches: “spiritually accommodative approaches typically com- bined a manualized treatment with practices and beliefs from a particular world religion, whereas spiritually oriented approaches are typically less standardized and more inclusive” (p. 200). It should be noted that none of the psychologists whose work is cited in Table 3.1 is proposing a stand-alone use of spiritual and religious interventions or techniques regardless of whether they are used in a spiritually accommodative or spiritually oriented manner.

RELEVANT ETHICAL GUIDANCE

The Code provides psychologists with a list of ethical aspirational princi- ples and enforceable standards that are either explicitly or implicitly relevant to the use of spiritually oriented interventions in clinical practice. An example of an explicitly relevant principle from the Code is Principle E, titled “Respect for People’s Rights and Dignity.” The principle states the following:

Psychologists respect the dignity and worth of all people and the rights of individuals to privacy, confidentiality, and self-determination.

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Psychologists are aware that special safeguards may be necessary to pro- tect the rights and welfare of persons or communities whose vulnerabil- ities impair autonomous decision making. Psychologists are aware of and respect cultural, individual, and role differences, including those based on . . . religion . . . and consider these factors when working with mem- bers of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices. (APA, 2010, p. 1063)

The earlier discussion of the role of bias in psychological practice with religious issues directly and explicitly intersects with Principle E. Psychologists should be diligent and intentional in preventing relevant biases from affect- ing religious or spiritual issues in treatment. The simplistic characterization of

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TABLE 3.1 Three Lists of Spiritually Oriented Interventions

Theistic/spiritual Spiritual interventions interventions and techniques Spiritual practices or tools

Richards & Bergin (2005) Schlosser & Safran (2009) Plante (2009)

Therapist prayer Teaching spiritual

concepts Reference to Scripture Spiritual self-disclosure Spiritual confrontation Spiritual assessment Religious relaxation

or imagery Therapist and client prayer Blessing by therapist Encouragement for

forgiveness Use of religious community Client prayer Encouragement of client

confession Referral for blessing Religious journal writing Spiritual meditation Religious bibliotherapy Scripture memorization Dream interpretation

Prayer (therapist or client guided)

Teach spiritual concepts Forgiveness Reference sacred writings Meditation Spiritual self-disclosure Encourage altruism and

service Spiritual confrontation Spiritual assessment Spiritual history Spiritual relaxation and

imagery Clarify spiritual values Use Spiritual community

and spiritual programs Spiritual journaling Experiential focusing

methods Encourage solitude and

silence Use spiritual language

and metaphors Explore spiritual elements

of ereams Spiritual genogram

Prayer Meditation Meaning, purpose, and

calling in life Bibliotherapy Attending community

services and rituals Volunteerism and charity Ethical values and

behavior Forgiveness, gratitude,

and kindness Social justice Learning from spiritual

models Acceptance of self and

others (even with faults)

Being part of something larger than oneself

Appreciating the sacred- ness of life

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a client’s belief in intelligent design as a delusional disorder illustrates the inap- propriate operation of such a bias. However, the desire of a proreligious psy- chologist to promote a spiritual activity in psychotherapy when the spiritually oriented intervention is not chosen in deference to an informed client’s own beliefs, values, and preferences would also be example of such bias.

The Code’s second standard on competence has both explicit and implicit relevance to the use of spiritually oriented interventions. Standard 2.01a states, “Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience” (APA, 2010, p. 1063). Thus, a psychologist who is not trained to appropriately use spiritually oriented interventions would be wise in avoiding their use until he or she takes steps to ensure competency and avoidance of client harm. Until such training is received, it would be appropriate to make a referral for a client who requests explicit use of spiritually oriented inter- ventions or who presents with prominent religious and spiritual issues.

Yet this does not mean that psychologists should be content simply to avoid this domain indefinitely. Standard 2.01b further states the following:

Where scientific or professional knowledge in the discipline of psychol- ogy establishes that an understanding of factors associated with . . . religion . . . is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consulta- tion, or supervision necessary to ensure the competence of their services, or they make appropriate referrals. (APA, 2010, pp. 1063–64)

The relatively ubiquitous nature of religion and spirituality renders it pro- pitious for general practitioners to obtain at least a basic competence in this domain. Standard 2.01c states that “psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or tech- nologies new to them undertake relevant education, training, supervised experience, consultation, or study” (APA, 2010, p. 1064). Given that formal training in this domain is the exception for most psychologists as part of their prelicensure preparation for practice, seeking out continuing education, con- sultation, and a supervisor to obtain a religious and spiritual practice compe- tency would be a commendable priority for many psychologists. For those psychologists who do have a proficiency in working with religious and spiritual issues, continued consultation and professional development is advised, partic- ularly when encountering clients whose spirituality diverges from one’s prior preparation.

APA’s Division 36 (Psychology of Religion) appointed an ad hoc com- mittee that has formulated preliminary practice guidelines for clinical work with religious and spiritual issues (Hathaway, 2005). The guidelines were developed by identifying common shared recommendations offered by over

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20 exemplar professionals in the clinical psychology of religion. Guidelines related to assessment, intervention, and relevant multicultural competency issues in the domain were formulated. The subset of preliminary guidelines specifically addressing the use of religious and spiritual interventions can be found in Exhibit 3.1. The full set of preliminary guidelines can be found in Hathaway and Ripley (2009).

As part of the ad hoc committee’s ongoing work, I presented a set of five principles that undergird the preliminary practice guidelines (Hathaway, 2009). The Division 36 preliminary guideline principles are presented in Exhibit 3.2 and include awareness, respect, routine assessment focus, clinically congruent roles, and competence. These themes converge with those noted as relevant for clinicians seeking to appropriately incorporate spirituality and religion into practice by Plante (2004, 2007, 2009) and others (Gonsiorek et al., 2009). Plante has summarized the relevance of five ethical principles derived from the Code for guiding psychologists in the use of spiritually oriented interventions in practice under the acronym RRICC (i.e., Respect, Responsibility, Integrity, Competence, and Concern).

ETHICAL USE IS APPROPRIATE CLINICAL USE

Many of the spiritual and religious practices listed in Table 3.1 are fre- quently used in nonclinical contexts and for other purposes. For instance, the use of directed prayer or scripture reading could be used as an evangelistic tool designed to cultivate or instill faith. If these practices were used in an evan- gelistic context, such use would be congruent with the explicit purpose of the context. However, if they were being used for this purpose in the context of professional psychological practice, it would likely violate numerous ethical principles and standards.

Principle B of the Code states the following:

Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations. (APA, 2010, p. 1062)

A professional psychologist operates within a publically and legally granted fiduciary space (Reaves, 1996). As licensed professionals, psychologists agree to practice congruent with applicable scope of practice, standards, legal precedent and other structures arising from relevant regulatory codes.

To appropriately use spiritually oriented interventions, licensed psychol- ogists must do so congruent with their clinical role and regulating standards.

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ETHICAL GUIDELINES 73

EXHIBIT 3.1 Division 36 Preliminary Religious and Spiritual Intervention Guidelines

1. Psychologists obtain appropriate informed consent from clients before incorpo- rating religious/spiritual techniques and/or addressing religious/spiritual treat- ment goals in counseling.

2. Psychologists accurately represent to clients the nature, purposes, and known level of effectiveness for any religious/spiritual techniques or approaches they may propose using in treatment.

3. Psychologists do not use religious/spiritual treatment approaches/techniques of unknown effectiveness in lieu of other approaches/techniques with demon- strated effectiveness in treating specific disorders or clinical problems.

4. Psychologists attempt to accommodate a client’s spiritual/religious tradition in congruent and helpful ways when working with clients for whom spirituality/ religion is personally and clinically salient.

5. Religious/spiritual accommodations of standard treatment approaches/protocols are done in a manner that (a) does not compromise the effectiveness of the standard approach or produce iatrogenic effects, (b) is respectful of the client’s religious/spiritual background, (c) proceeds only with the informed consent of the client, and (d) can be competently carried out by the therapist.

6. Psychologists are mindful of contraindications for the use of spiritually/ religiously oriented treatment approaches: (a) Generally, psychologists are discouraged from using explicit religious/spiritual treatment approaches with clients presenting with psychotic disorders, substantial personality pathology, or bizarre and idiosyncratic expressions of religion/spirituality. (b) Psychologists should discontinue such approaches if iatrogenic effects become evident.

7. When psychologists use religious/spiritual techniques in treatment, such as prayer or devotional meditation, they (a) clearly explain the proposed technique to the client and obtain informed consent, (b) do so in a competent manner that is respectful of the intended religious/spiritual function of the technique in the client’s faith tradition, and (c) adopt such techniques only if they are believed to facilitate a treatment goal.

8. Psychologists appreciate the substantial role faith communities may play in the lives of their clients and consider appropriate ways to harness the resources of these communities to improve clients’ well-being.

9. Psychologists avoid conflictual dual relationships that might arise in religious/ spiritually oriented treatment or in adjunctive collaborations with faith communities.

10. Psychologists set explicitly religious/spiritual treatment goals only if (a) they are functionally relevant to the clinical concern, (b) can be competently addressed within the treatment, (c) can be appropriately pursued within the particular context and setting in which treatment is occurring, and (d) are consented to by the client.

11. Psychologists commit to a collaborative and respectful demeanor when addressing aspects of a client’s religion/spirituality the psychologist deems maladaptive or unhealthy. The preferred clinical goal in such cases is to pro- mote more adaptive forms of the client’s own faith rather than to undermine that faith.

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This can be illustrated by considering one such spiritually oriented intervention. Moriarty and others have been investigating interventions to alter God image (Moriarty & Hoffman, 2007), defined as “the complex, subjective emotional experience of God” (p. 2). A variety of strategies have been deployed in an effort to alter God image, including bibliotherapy, appropriate use of cognitive psy- chotherapy strategies, group psychotherapy, and integrative–psychodynamic approaches. Certain types of God image are more associated with depressed states and others with less depressed states. Let us suppose that God image psy- chotherapies are successful at fostering a shift toward God images that are less associated with depression. When would such an intervention be appropriate? Several factors that are highlighted in Exhibit 3.1 would impinge on determin- ing whether such an intervention is ethical. Did the client provide informed consent from the intervention? Did the information provided to the client prior to this consent “accurately represent to the client(s) the nature, purposes, and known level of effectiveness” (see Exhibit 3.1, item 2) for the God image inter- vention? Was the God image intervention used adjunctively and not in lieu of other interventions that have higher levels of demonstrated effectiveness for treating the clinical concern (unless the God image intervention has been demonstrated to be equally effective as a stand-alone treatment through ade- quate research)? Is the God image intervention being used in a manner that is respectful of the client’s religious and spiritual tradition? If the God image inter- vention is being used adjunctively with another established treatment, is it being done in a manner that does not compromise the effectiveness of the stan- dard treatment? Can the psychologist using the God image intervention do so in a competent manner? A negative answer to any of these considerations would contraindicate that use of the God image intervention.

The fourth Division 36 preliminary practice guideline principle states, “When engaged in spiritually oriented practice activities, psychologists should do so congruently with their clinical roles” (see Exhibit 3.2, item 4). So in

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EXHIBIT 3.2 Division 36 Preliminary Practice Guideline Principles

1. Awareness: Psychologists aspire to cultivate deliberate and nuanced awareness of relevant religious and spiritual issues in practice.

2. Respect: Psychologists seek to maintain a respectful demeanor towards the religious and spiritual domain in clinical practice.

3. Routine assessment focus: Psychologists strive to routinely and intentionally assess for relevant religious and spiritual considerations in practice.

4. Clinically congruent roles: When engaged in spiritually oriented practice activities, psychologists should do so congruently with their clinical roles.

5. Competence: Psychologists seek to maintain ongoing competence in their spiritually oriented practice activities.

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