Integrating Spirituality and Religion Into Psychotherapy: Persistent Dilemmas,Ethical Issues,and a Proposed Decision-Making Process

Religion and spirituality are important aspects of the lives of most psychotherapy clients. Unfortunately, many psychotherapists lack the training to effectively and ethically address these issues with their clients. At times, religious or spiritual concerns may be relevant to the reasons clients seek treatment, either as areas of conflict or distress for clients or as sources of strength and support that the psychotherapist may access to enhance the benefit of psychotherapy. This article reviews persistent ethical issues and dilemmas relevant to providing psychotherapy to clients for whom issues of religion and spirituality are clinically relevant. Ethical considerations include assessment, advertising and public statements, informed consent, competence, boundary issues and multiple relationships, cooperation with other professionals, and how to effectively integrate religious and spiritual interventions into ongoing psychotherapy. A decision-making process is presented to guide psychotherapists in their clinical work with clients for whom religious and spiritual issues are salient or clearly linked to their presenting problems.     

心理治疗中的脱落

脱落是指在心理咨询与治疗中, 来访者由于种种原因在导致他前来寻求帮助的心理困扰或问题尚未解决之前就终止治疗的现象。研究者对脱落概念内涵的理解比较一致, 但脱落的操作性定义存在多种且各有利弊。脱落在临床治疗中普遍存在; 脱落率在跨研究间的结果差异很大, 并受到脱落的操作性定义和研究设计类型的重要影响。传统的静态的变量在预测脱落时存在明显局限, 治疗同盟等治疗过程预测变量近年来得到更多重视, 并丰富了我们对来访者脱落的深入理解。为减少脱落, 研究者建议为来访者提供治疗前准备, 对治疗过程中的关键变量进行评估并根据具体情况采用合适的干预策略。未来研究需要完善脱落的操作性定义, 更多地在自然治疗设置下进行研究, 进一步深化脱落的预测变量研究, 并关注治疗外重要事件及文化背景对脱落的影响。     

Iraqi refugee men’s experiences of psychotherapy: clinical implications and the proposal of a pluralistic model

The psychotherapy experiences of a sample of Iraqi refugee men, in later stages of exile, were explored with the aim of shedding some light on how this client group can experience therapy. Ten adult male Iraqi refugees – who had lived in Sweden for at least five years and had been psychotherapy clients at some point during that time – were recruited for this study. Using individual semi-structured interviews (in Arabic), three main areas were explored with each participant: (1) reasons for seeking psychotherapy; (2) perceptions of the psychotherapy professional; and (3) experiences of the psychotherapy process and outcome. The interviews were then translated into English, transcribed, and then analysed using Interpretative Phenomenological Analysis (IPA). Most participants/clients described exile-related stressors as their main reason for seeking psychotherapy, but some described distress due to a combination of pre-migration trauma and post-migration stress. They also found some aspects of therapy to be positive (mainly verbalising ones thoughts and feelings, and feeling less marginalised) and some negative (mainly experiencing racist or culturally insensitive treatment by therapists, and experiencing a lack of competence and transparency in therapists). The findings were explored in terms of clinical implications and a pluralistic model was proposed to address the identified needs.     

Symptom reduction and termination: client change and therapist identified reasons for saying goodbye

Empirical efforts have focused on predicting whether or not clients prematurely terminate therapy, with nonattendance of last session equated to premature termination. However, this fails to explore the relationship between clients’ distress reduction and reasons for termination. With this study, we aimed to understand how clients’ distress change relates to premature termination and examine clients’ distress change in conjunction with therapists’ perceptions of termination reasons. We collected data from 797 clients who prematurely terminated or attended termination but completed therapy a minimum of three individual sessions provided by 38 therapists. Clients completed an assessment of psychological symptoms before each session. At the end of treatment, therapists identified the reasons they believed termination occurred for all clients in the sample. Results demonstrate that total sessions attended and missed predict premature termination, whereas distress change does not. Additionally, clients who were believed to accomplish goals do show greater change. However, therapists’ indicated that over half of clients did not reach goals at termination and they did not perceive nonattendance at last session to equate to drop out in all cases. Implications are discussed with respect to understanding why clients’ terminate, therapeutic goal conceptualization, and review of goals during termination in time-limited psychotherapy.     

The Effectiveness of Collaborative/Therapeutic Assessment for Psychotherapy Consultation: A Pragmatic Replicated Single-Case Study

This pragmatic study evaluated the effectiveness of a collaborative assessment intervention as an approach to midtherapy consultation, which has yet to be empirically tested. Ten adult participants in ongoing psychotherapy with a variety of presenting concerns, primarily consisting of general mood and adjustment issues, received a brief assessment-based intervention based on Finn's (2007) Therapeutic Assessment model. Following the collection of assessment questions and the administration of a multimethod assessment battery, clients and therapists participated in a joint feedback session with the assessor. Clients were then followed as their psychotherapy continued. The results of idiographic and aggregate analytic approaches revealed significant reductions in client-reported symptomatic distress, as evidenced by a medium effect size (d = –.50) and a significant change in the trajectory of distress. Client reports of the process of psychotherapy revealed a significant increase in the clients’ ratings of the working alliance. The findings suggest that a midtherapy consultation using collaborative/therapeutic assessment methods is beneficial but that further rigorous investigation is needed.     

Expectations About Couple Therapy Over Time

One common factor of therapy, expectations, has been demonstrated to be a significant contributor to outcome in individual therapy. Despite this, little is known about expectations about couple therapy. This paper presents the qualitative results of a study exploring clients’ expectations before beginning couple therapy and after six sessions. Results indicate that clients form pre-therapy expectations about their therapist, the process of therapy, and their partner. Results also showed that after six sessions, clients’ expectations about therapy were often met or modified in ways that were positive. Implications for therapists and researchers are included.     

Evaluation of a Combined Cognitive Behavioural Therapy and Interpersonal Process Group in the Psychotherapy Training of Clinical Psychologists

It is now widely acknowledged that both content and process elements of psychotherapy play a part in client treatment outcomes. Despite this, there are pressures on Australian clinical psychology training programs to teach evidence‐based approaches in a relatively short time frame. Producing clinical psychology graduates who have an adequate level of competence in evidence‐based practice and meeting the demands of professional accreditation requirements can mean that less time is available to teach the process elements of psychotherapy. The aim of this study was to conduct a preliminary evaluation of a clinical psychology psychotherapy training program that combines an interpersonal process group with a cognitive behavioural therapy training model that incorporates self‐reflection and self‐practice. Eleven participants who participated in the training in 2008 completed the Counseling Self‐Estimate Inventory at pre‐ and post‐training. Significant improvements on the majority of the subscales of this inventory were found. A separate sample of nine trainees and clinical psychology registrars who also previously completed the program attended individual interviews in 2010 aimed at gaining their perspective regarding various aspects of the program. Self‐practice of cognitive behavioural therapy techniques was found to be important in the identification and management of trainees’ own core beliefs, and to their appreciation of how challenging this process may be for clients. The interpersonal process group was described by participants as enhancing their competency as psychotherapists. Common themes included the experience of anxiety and a high level of emotion, and understanding how this experience might be similar for clients; increased self‐awareness; and increased competence in process issues. Many participants believed the process and content components of training were equally important to their development as psychotherapists.     

When time stands still: fear-specific modulation of temporal bias due to threat

The current study was designed to test the fear-specific nature of temporal bias due to threat. A temporal bisection procedure was used in which participants (N = 46) were initially trained to recognize short (400 ms) and long (1,600 ms) standard durations. In the test phase, participants were asked to judge whether the duration of computer-generated faces drawn to appear threatening, fearful, and neutral, was closer to either the short or long duration they had learnt earlier. Past research was replicated-the durations of the arousing facial expressions were overestimated relative to a low arousal (neutral) expression. Overestimation for threat was positively correlated with individual differences in fearfulness, trait anxiety, and distress. Multiple regression analyses were carried out to test the hypothesis was that individual differences in anxiety and fearfulness but not other traits would uniquely predict temporal overestimation due to threat. The results showed that fearfulness but not other traits (trait anxiety, anger, distress, activity, and sociability) was a unique and strong (partial r = .47) predictor of increased overestimation for both threatening and fearful expressions. The findings support the hypothesis that threat-related expressions activate a fear-specific system (?hman & Mineka, 2001) or fear representations (Beck & Clark, 1997) in fearful individuals.     

Beyond Mindfulness: Buddha Nature and the Four Postures in Psychotherapy

We propose to incorporate the contextual view of the Buddhist teachings of the Three Turnings into applications of mindfulness in psychotherapy; specifically by applying the teaching of the Four Postures, which are expressions of innate health in ordinary life activities. This practice may expand understanding of the core mechanisms of different modalities of mindfulness and psychotherapy, thereby supporting clinicians in guiding clients on a healing path that is in natural alignment with each individual. By its allegiance to inherent wakefulness (Buddha Nature), this teaching supports clients in appreciating their own inherent health and the health of the world around them.     

Group Psychotherapy and Existential Concerns: An Interview with Irvin Yalom

Group psychotherapy can be used to help clients deal with most forms of emotional distress or problems with interpersonal functioning. Also, group therapy can be useful when helping clients to confront existential concerns such as isolation or meaning in ones life. During a recent interview, Irvin Yalom discussed a variety of issues related to group processes and existential matters that are involved in effective psychotherapy.     

The relationship between clients' conformity to masculine norms and their perceptions of helpful therapist actions

T. J. G. Tracey et al.'s (2003) common factors model derived from therapists and psychotherapy researchers has provided a parsimonious structure to inform research and practice. Accordingly, the current authors used the 14 common factor categories identified in Tracey et al.'s model as a guide to code clients' perceptions of helpful therapist actions (e.g., intervention, way of being) in short-term psychotherapy. Next, they conducted a cluster analysis to establish meaningful subgroups of clients based on clients' perceptions of helpful therapist actions. Finally, they explored if clients in these subgroups differed in their report of conformity to masculine norms. Clients (N = 161) from a university counseling center were recruited for the current study. Results revealed 3 clusters of clients based on their perceptions of helpful therapist actions: Insight (44%), Relationship (30%), and Information (26%). In contrast, Tracey et al. found 3 clusters: Bond (which includes Insight and Relationship), Information, and Structure of therapy (not found in the current study). Clients in the Insight and Relationship clusters reported more conformity to masculine norms as compared with clients in the Information cluster. There were no sex differences across clusters.     

Exploring Associations Between Therapy Factors and Post-therapy Development After Naturalistic Psychotherapies

Earlier research on what contributes to long-term outcome after psychotherapy is scarce and scattered. Responding to this, the current study explores potential associations between therapy factors reported as salient by clients in naturalistic psychotherapy and variation in post-therapy-movement. Material from different codes and categories derived from an earlier content analysis was explored in relation to post-therapy-changes on OQ-45. In the first part of the study, two overarching themes (relational aspects and therapeutic operations) were included in a regression analysis of data from 32 clients. In the second part, more nuanced associations between material from different change- or process categories and post-therapy-movement were explored using data from 20 clients that showed reliable improvement at treatment termination but varied in later development. Reports of material related to relational aspects were recurrently associated with post-therapy improvement. Material suggesting that therapy was experienced as not fully complete (e.g., changes being superficial or wish for more treatment), as well as reports of more positive affect, correlated with later deterioration after improvement at termination. Different processes and changes appreciated by clients during therapy seem to vary as predictors of lasting gains.     

Client Perspectives on Spirituality in the Therapeutic Relationship

There has been increasing interest in the integration of spirituality into psychotherapy in the last 10 years, yet we have very little in-depth information about clients' perspectives on spirituality in the counseling relationship to help guide this integration. Using a narrative methodology to explore the counseling experiences of 12 spiritually-committed clients in detail, this study suggests that clients who may not identify as traditionally religious may still view the entire process of psychotherapy through a spiritual lens. Furthermore, their spirituality may guide their interpretation of therapy, their expectations of the therapist, and their choice to engage in or terminate treatment in complex ways. By exploring the experiences of this growing breed of spiritually-committed clients, the results shed new light on the dimensions that deserve consideration as we think about how to respond to a client's spiritual needs in psychotherapy.     

Healthy and unhealthy forms of religiousness manifested by psychotherapy clients: An empirical investigation

This study investigated whether 49 Mormon psychotherapy clients and 51 Mormon nonclients differed on a number of religious and psychological variables. The data were analyzed using analysis of covariance, controlling for social desirability, education level, and occupation status. Clients scored higher than nonclients on shame and lower on existential well-being. There were no significant differences between clients and nonclients on religious orientation, religious wellbeing, moral reasoning, and guilt. Females scored much higher on guilt, and female clients scored much higher on shame; there were no other gender differences. Subjects showed a preference for Stage 4 moral reasoning, and 92% were intrinsically motivated in their religious worship. The psychotherapy clients' religious beliefs and motivations appeared healthy and functional and could be an asset during therapy. The clients manifested some psychological issues which could predispose them to unhealthy reactions to some of the doctrines and influences of their religion. The gender differences observed were also discussed.     

Psychological Distress in Australian Clients Seeking Family and Relationship Counselling and Mediation Services

There is little published data on the prevalence of psychological distress among individuals and couples seeking counselling and mediation services from non‐government organisations (NGOs). This national cross‐sectional study establishes the prevalence of psychological distress among clients seeking family and relationship counselling and mediation services from Relationships Australia. A national sample of 1,365 clients attending services in April to May 2012 completed the 10‐item Kessler Psychological Distress Scale (K10) after their first counselling or mediation session. Individual counselling (M = 23.01, SD = 8.97, 95% CI [22.05–23.97]) and couple counselling (M = 21.63, SD = 8.10, [20.86–22.41]) clients reported a mean K10 score comparable to those reported by clinical studies of clients with anxiety or affective disorders. One quarter to one fifth of these clients reported very high psychological distress. Clients accessing mediation services had a mean score of 18.13 (SD = 7.76; [17.51–18.75]), and one tenth of clients reported very high distress. These elevated rates of very high psychological distress suggest that mental health issues may be a significant problem for a large proportion of clients accessing counselling and mediation NGO services provided under Family Support Programs (FSP) funding. Implications for screening for mental health and appropriate treatment planning are discussed.     

Changes in meaning in life across the course of psychodynamic psychotherapy

Using the Meaning in Life Questionnaire (MLQ), we studied Presence and Search for meaning for 34 adult clients in psychodynamic psychotherapy. Clients completed the MLQ and Outcome Questionnaire (OQ) before intake and after every eight sessions. Variance in Presence scores was mostly attributable to clients; variance in Search scores was mostly attributable to clients and therapists. Clients initially high in Presence decreased and then increased back to initial levels; clients initially low in Presence increased and then decreased back to initial levels. Clients initially low in Search increased and then leveled off; clients initially high in Search decreased and then leveled off. In lagged cross panel analyses, when clients decreased in psychological distress during one eight-week time period, they increased in Presence during the next eight-week time period; when they increased in psychological distress during one eight-week time period, they increased in search in the next time period. Excerpts from post-therapy interviews illustrate the process of working with meaning in life in psychotherapy. Implications for practice and training are discussed.