Integrating spiritual direction into psychotherapy: ethical issues and guidelines.
Integrating spirituality and religion into psychotherapy (Tan, 1996b, 1999c, 2001b) has become a significant area of interest and emphasis in the mental health field in general (e.g., Akhtar & Parens, 2001; Becvar, 1997; Canda & Furman, 1999; Cornett, 1998; Fukuyama & Sevig, 1999; Genia, 1995; Griffith & Griffith, 2001; Kelly, 1995; Lovinger, 1984, 1990; G. Miller, 2003; W. R. Miller, 1999; Nielsen, Johnson, & Ellis, 2001; Richards & Bergin, 1997, 2000, in press; Shafranske, 1996; Steere, 1997; Walsh, 1999; West, 2000), as well as in Christian counseling in particular (e.g., Anderson, Zuehlke, & Zuehlke, 2000; Benner, 1988, 1998; McMinn, 1996). A more specific focus that is receiving greater attention recently is integrating spiritual direction into psychotherapy and counseling (see Benner, 1998). These recent developments are part of a larger movement in the mental health and health arenas that has emphasized the significant relationship, often positive (though not always), between religion and health (e.g., Koenig, 1998, 1999; Koenig & Cohen, 2002; Koenig, McCullough, & Larson, 2001; Larson, Swyers, & McCullough, 1998; Plante & Sherman, 2001; also see Francis & Kaldor, 2002; Mills, 2002), although there are critics of this movement (see Sloan & Bagiella, 2002).
The literature on spiritual direction itself has mushroomed especially in recent years. Anderson and Reese (1999) reviewed contemporary definitions of spiritual mentoring or spiritual direction by Barry and Connolly (1982), Coombs and Nemeck (1984), Edwards (1980), Foster (1988), Guenther (1992), Jones (1982), Laplace (1988), Leech (1977), Merton (1960), and Peterson (1989). They also recommended a bibliography for spiritual mentoring or direction that further included Allen (1994), Gratton (1992), Hausherr (1990), and Kelsey (1983). More recently, several other significant books on spiritual direction have been published (e.g., Benner, 2002; Rosage, 1999; Ruffing, 2000; Stairs, 2000; also see Crabb, 1997, 1999; Moon, 1997a), including a more comprehensive text covering 12 biblical and practical approaches to spiritual formation (Boa, 2001).
A well-known definition of Christian spiritual direction is the following provided by Barry and Connolly (1982): "We define Christian spiritual direction, then, as help given by one Christian to another which enables that person to pay attention to God's personal communication to him or her, to respond to this personally communicating God, to grow in intimacy with this God, and to live out the consequences of the relationship" (p. 8).
Benner (2002) most recently defined spiritual direction as a "prayer process in which a person seeking help in cultivating a deeper personal relationship with God meets another for prayer and conversation that is focused on increasing awareness of God in the midst of life experiences and facilitating surrender to God's will" (p. 94). He further pointed out that spiritual direction is not new, is not authoritarian, is not giving advice, is not discipling, is not preaching, is not moral guidance, is not teaching, and is not counseling, although it shares several common features with counseling or psychotherapy. Spiritual direction differs from counseling in at least three major ways, according to Benner: (a) counseling is problem centered whereas spiritual direction is Spirit centered; (b) counselors seek to be empathic to the inner experience of those seeking help from them, whereas spiritual directors make their empathic focus not so much on the directee but more on the Spirit of God; and (c) counselors engag e in note-taking and record-keeping whereas spiritual directors usually do not (also see Moon, 1994).
West (2000, p. 127) compared psychotherapy and spiritual direction as follows:
1. Features of psychotherapy and counseling: helping and supportive relationship in a professional or agency context; one-to-one or group; client has emotional or psychological distress; clinic or office based; can be seen as helping client adjust to society; focus on emotional and mental dimensions; aims to strengthen client's autonomy; and often formal hourly sessions over weeks, months, or years.
2. Features of spiritual direction: helping and supportive relationship in a faith context; one-to-one or group; client may not have a crisis; based in a community of faith; helps clients lead a life of faith; focus on spiritual issues such as prayer life, religious experiences, and relationship with God; aims to self-surrender to the will of God; sometimes informal, periodic, and intensive (e.g., retreats).
In spiritual direction thus defined, it is not uncommon for the spiritual director and directee to engage in the practice of spiritual disciplines such as prayer, Scripture meditation, and silence during the time of spiritual direction. This can also take place in Christian counseling and psychotherapy where appropriate (Tan, 1996a, 1996b, 1998; also see Eck, 2002; Hall & Hall, 1997; Willard, 1996). Moon, Willis, Bailey, and Kwasny (1993) found that consistent with previous research, the most frequently used spiritual guidance techniques (out of a list of 20) by Christian psychotherapists, pastoral counselors, and spiritual directors were: spiritual history, discernment, forgiveness, solitude or silence, intercessory prayer, and teaching from Scripture. An earlier study by Ganje-Fling and McCarthy (1991) showed that spiritual directors were more likely than psychotherapists to incorporate techniques and topics from the other discipline into their practice, although significant overlap between the two discipli nes was also suggested by the results obtained.
It may be interesting to note that Benner (1998) recently changed his earlier view of Christian psychotherapy and spiritual direction as being so different in their role demands and focus that they cannot be integrated or combined (see Benner, 1988). His current view is that they can be combined although we have little experience or few models for doing such integration (also see May, 1992). He described two examples of combining spiritual direction and psychotherapy: Bernard Tyrell's Christotherapy (1982) and Benner's own intervention called an intensive soul care retreat (Benner, 1998). In both these examples, psychotherapeutic techniques as well as spiritual exercises or spiritual direction are employed. Integrating spiritual direction into psychotherapy, especially Christian psychotherapy can therefore be an important part of professional integration (Tan, 2001b), or what Hall & Hall (1997) have called "integration in the therapy room" (p. 86). However, it is essential to practice such integration in an e thical and helpful way. The present article, therefore, focuses on ethical issues and guidelines for integrating spiritual direction into psychotherapy.
ETHICAL ISSUES AND GUIDELINES FOR INTEGRATING SPIRITUAL DIRECTION INTO PSYCHOTHERAPY
Books have been published on legal (Levicoff, 1991; Ohlschlager & Mosgofian, 1992) and ethical (Sanders, 1997; also see Tjeltveit, 1999) issues pertinent to Christian counseling and psychotherapy. Ethical issues and guidelines that are more specific to the integrating of spiritual direction into psychotherapy will now be covered.
It should first be pointed out that Christian counseling or psychotherapy often aims at the ultimate goal of facilitating the spiritual growth of clients, and not just the alleviation of symptoms and resolution of problems. Integrating spiritual direction, including the use of spiritual disciplines and other religious resources, into psychotherapy is therefore often seen as an integral part of such religiously oriented, Christian counseling. Spiritual direction, pastoral counseling, and Christian psychotherapy can be viewed as greatly overlapping though not synonymous areas of people helping. Bufford (1997) summarized the following distinctives of Christian counseling: "The counselor has a deep faith; counsels with excellence; holds a Christian world view; is guided by Christian values in choosing the means, goals, and motivations of counseling; actively seeks the presence and work of God; and actively utilizes spiritual interventions and resources within ethical guidelines" (p. 120).
Christian counselors and psychotherapists, however, differ as to how explicitly they would integrate spiritual direction, including the use of spiritual disciplines, directly into the therapy session. While some have advocated more explicit integration in clinical practice where appropriate (see Tan, 1996a, 1996b, 1998, 1999b, 1999c; Tan & Dong, 2001) others have suggested caution but not censure (e.g., McMinn & McRay, 1997).
Caution to an extent is appropriate because of the dangers of abusing or misusing spiritual direction in psychotherapy. Richards and Bergin (1997) devoted an entire chapter to ethical issues and guidelines in their well-known text on a spiritual strategy for counseling and psychotherapy published by the American Psychological Association. They covered the following potentially difficult ethical questions and challenges (see Richards & Bergin, 1997, pp. 143-169): dual relationships (religious and professional), displacing or usurping religious authority, imposing religious values on clients, violating work-setting (church-state) boundaries, and practicing outside the boundaries of professional competence. Two other significant concerns that they raised regarding the use of spiritual interventions in psychotherapy are: becoming enmeshed in superstition and trivializing the sacred or numinous.
Tan (1994) summarized the following potential pitfalls or dangers of religious psychotherapy that are also relevant to integrating more specifically spiritual direction into psychotherapy:
1. Imposing the therapist's religious beliefs or values on the client, thus reducing client freedom to choose.
2. Failing to provide sufficient information regarding therapy to the client.
3. Violating the therapeutic contract by focusing mainly or only on religious goals rather than therapeutic goals, and thus obtaining third-party reimbursement inappropriately. (It is, however, difficult sometimes to clearly differentiate between spiritual and therapeutic goals because they tend to overlap for religious clients.)
4. Lacking competence as a therapist in the area of converting client values ethically or conducting religious psychotherapy appropriately.
5. Arguing over doctrinal issues rather than clarifying them.
6. Misusing or abusing spiritual resources like prayer and the Scriptures, thus avoiding dealing with painful issues in therapy.
7. Blurring important boundaries or parameters necessary for the therapeutic relationship to be maintained.
8. Assuming ecclesiastical authority and performing ecclesiastical functions inappropriately, when referral to ecclesiastical leaders may be warranted.
9. Applying only religious interventions to problems that may require medication or other medical or psychological treatments. (p.390)
A particular ethical concern raised by McMinn and McRay (1997; also see Tjelrveit, 1986) has to do with charging fees and receiving third-party reimbursement for spiritual interventions in psychotherapy:
More generally, the fee for service practices of most psychologists introduce a number of challenges when using spiritual disciplines as part of psychotherapy. Is it legitimate to charge for work that has historically been given away as part of pastoral care? What information should be given to insurance companies who pay part of the client's bill? Is spiritual development a legitimate goal of psychotherapy in an era where time-limited interventions are increasingly the standard of care? These are troubling matters that warrant careful consideration in the years ahead. (p. 108)
McMinn and McRay also underscored the need to empirically demonstrate the efficacy of spiritual interventions or methodologies, especially in the context of the recent emphasis on using empirically supported therapies, which have most recently grown to a list of 145, 108 for adults and 37 for children (Chambless & Ollendick, 2001; Tan 2001a). However, this recent emphasis on using empirically supported therapies has also been critiqued (see Tan, 2001a, 2002), with Beutler (2000) in particular proposing going beyond empirically supported treatments to empirically informed principles of treatment selection (also see Beutler, Clarkin, & Bongar, 2000; Beutler & Harwood, 2000). More recently, Norcross (2002) has emphasized the need to pay greater attention to empirically supported therapeutic relationships (ESRs) or psychotherapy relationships that work (see Tan, in press).
The ethical issues just reviewed are not exhaustive but they do include the major potential pitfalls inherent in any religious or spiritual approach to psychotherapy, including integrating spiritual direction into psychotherapy. These ethical dangers can be minimized or avoided by following a number of ethical guidelines for the proper practice of religious psychotherapy that incorporates spiritual direction.
Richards and Bergin (1997, pp. 143-169) have provided a long list of ethical recommendations or guidelines for dealing with the five major ethical issues they raised for psychotherapists who follow a theistic, spiritual strategy in their practice.
In the first area of avoiding dual relationships, Richards and Bergin (1997) included the following ethical guidelines (see pp. 147-148): Therapist-religious leader/associate dual relationships should be avoided. If a therapist carefully decides that a dual relationship may be in a client's best interest, the therapist should consult with a supervisor or professional colleagues to see if they agree before entering into such a relationship. If agreement is found, the therapist should clearly define and explain the limits and risks of the dual relationship to the client. Frequent consultation should be sought by the therapist, and the dual relationship should be terminated and an appropriate referral made if it is believed that the client is being harmed by such a relationship, with careful documentation made.
In the second area of the danger of displacing or usurping religious authority, Richards and Bergin (1997) recommended ethical guidelines for collaborating with religious authorities, which included (see pp. 151-153): Therapists should determine clients' religious or denominational tradition, if any, and whether they see their religious leaders as possible sources of support or help. If clients agree, therapists should obtain their informed consent in writing to contact the client's religious leaders in order to consult and cooperate with such leaders to help the client. Therapists should be clear, respectful, and courteous in communicating with the client's religious leaders where appropriate, and thank them for their assistance. Prior to using spiritual interventions (including spiritual direction or spiritual guidance techniques) therapists should make explicitly clear to their clients that they have no ecclesiastical authority over their clients and they cannot act or speak officially for their clients' r eligious leaders or institution. Therapists should not perform ecclesiastical functions limited only to their clients' religious leaders (e.g., hearing confessions and absolving or pardoning sins). Therapists should explain where their therapeutic role overlaps with that of their clients' religious leaders who may also provide some form of pastoral counseling and care. Therapists should make sure that clients feel it is appropriate for them to use a specific spiritual intervention, such as religious imagery and prayer, before using such an intervention. Therapists should not put down or ridicule their clients' religious leaders, and should let their clients know that they generally see religious leaders and communities as potential sources of support and assistance (also see Brantley & Brantley, 2001; McRay, McMinn, Wrightsman, Burnett, & Ho, 2001).
In the third area of the danger of therapists imposing their religious values on clients, Richards and Bergin (1997) provided the following ethical recommendations or guidelines for respecting client values (see pp. 158-159): Therapists should respect their clients' right to have religious convictions that are different from their own. Therapists should not attempt to convert or proselytize clients to their own religious faith or denomination. Therapists should not arrogantly condemn their clients' behaviors or choices that run counter to their own convictions or beliefs, but they can engage in open exploration and discussion of the spiritual and moral aspects and consequences of their clients' value choices and behaviors if their clients want to do so. When value conflicts occur between therapists and clients, therapists can express their own views while preserving their clients' right to have different values, and decide whether their disagreement in values could negatively affect therapy, and therefore whe ther referral to another therapist may be warranted. Therapists should include spiritual and religious goals and interventions (including spiritual direction and other spiritual guidance techniques) only when proper informed consent is obtained from clients who have clearly expressed their interest in pursuing such goals and participating in such interventions, after an explicit and brief description has been provided.
In the fourth area of the danger of violating work-setting (church-state) boundaries, Richards and Bergin (1997) included the following ethical guidelines for respecting church-state boundaries (see pp. 162-163): Therapists in civic settings must follow policies and laws regarding the separation of church and state in such work-settings. Therapists in civic and other settings should not employ spiritual interventions to impose a specific religious tradition on clients but should always work within the clients' value system (as far as possible). Therapists in civic settings should get written consent from both client and supervisor prior to using spiritual or religious interventions, and in the case of conducting therapy with children and adolescents written parental permission should be obtained. Therapists working in public schools or other civic settings with children and adolescents as clients are advised not to engage in spiritual or religious interventions such as praying with clients, using Scriptures w ith them, or giving out religious bibliotherapy literature.
Finally, in the fifth area of the danger of practicing outside the boundaries of competence, Richards and Bergin (1997), following APA ethical guidelines, proposed the following ethical recommendations for education and training standards for professional psychotherapists wanting to use a theistic, spiritual strategy in their practice (see p. 166): Therapists should be trained in foundational multicultural counseling attitudes and skills (also see Sue & Sue, 2003; Tan, 1999a; Tan & Dong, 2000). Therapists should read relevant and helpful scholarly literature (journals) and books on religious and spiritual issues in counseling and psychotherapy, as well as on the psychology and sociology of religion. Therapists should attend at least one workshop or course on religion and mental health and spiritual issues in psychotherapy, and take a class or read one or two good books on world religions. Therapists should obtain more specific knowledge of particular religions and spiritual traditions that they often encounte r in therapy (for a helpful book, see Richards & Bergin, 2000). Therapists should seek supervision and/or consultation when they first see clients from a particular religious or spiritual tradition, especially with issues the therapist has not dealt with before, or when they first start using religious and spiritual interventions or new, untried ones, in their therapeutic work with clients.
Richards and Bergin (1997) have therefore provided a comprehensive, conservative, and cautious list of ethical recommendations or guidelines for conducting religiously oriented or spiritually oriented psychotherapy that can include integrating spiritual direction into psychotherapy.
Moon (1997b) also reviewed a number of guidelines and considerations for ethical practice with regard to using spiritual interventions in psychotherapy, including spiritual direction and spiritual disciplines (see p. 287). He summarized several ethical guidelines from Richards and Potts (1995): Use spiritual interventions only when led or prompted by the Spirit to do so. Prior to using such interventions, make sure that there is first a relationship of trust with the client. Informed consent from the client should be obtained, and the client's religious beliefs should be assessed, before initiating any spiritual interventions. Work within the client's level of spirituality and value system. Spiritual interventions should be used sparingly and carefully. Spiritual interventions may be less effective with severely disturbed clients and therefore referral may be warranted in such situations. Use spiritual interventions cautiously if religion appears to be part of the client's problems. Moon also listed the follo wing ethical guidelines from Tan (1994) based on Nelson and Wilson (1984): The client should share the therapist's basic religious or spiritual belief system; the client has asked for religious and spiritual input into psychotherapy and therefore has given informed consent; and there is a good reason for using a particular spiritual intervention--it is relevant to the clinical problem and it is expected to ameliorate psychological distress. Finally, Moon mentioned two ethical recommendations from McMinn (1996): Guidelines for informed consent must be carefully followed, and in the near future it will be safer for psychologists to use specific techniques, including spiritual interventions, that have received empirical support, preferably from two independent, double-blind studies.
Moon (1997b, pp. 291-292) himself offered 12 specific goals or recommendations for the formal training of psychotherapists to practice religiously oriented or spiritually oriented psychotherapy that can include integrating spiritual direction:
1. Following Sorenson (1996), more theologians should be recruited as faculty members and journal contributors, so that we can have better applied theology.
2. Instructors should be willing to model interventions that come from religious/Christian spirituality practices, and use competency-based training methods in training and supervising students.
3. Training programs should emphasize the methodology of the three disciplines (psychology, theology, and spiritual formation)--statistics and research skills, hermeneutics, critical thinking, and honest introspection.
4. Courses and activities aimed at developing Christian character traits in students (through instruction and practice of the Christian disciplines) seem very appropriate.
5. Require a year of personal psychotherapy.
6. Require another year of spiritual direction.
7. Require a course on the history of classic pastoral care/counseling.
8. The church should be considered as a site for service delivery (not just as a source for client referrals).
9. Integration training programs should take seriously the need to include spiritual formation training for the students.
10. Much more empirical outcome research is needed (with well-controlled studies that meet the criteria for empirically supported therapies).
11. The ethics of providing services to people with diverse religious values and backgrounds must be covered with the students.
12. Finally, there should be much more discussion across the boundaries between psychotherapy, pastoral counseling, and spiritual direction, with an appreciation of the differences between them.
Other recommendations for training mental health professionals in religion and spirituality in clinical practice are also available (Bowman, 1998; W. R. Miller, 1999; Tan, 1993, l999c; West, 2000), including a model curriculum for the training of psychiatric residents (Larson, Lu, & Swyers, 1996).
Much more work needs to be done in the formal training of mental health professionals in the use of spiritual interventions in psychotherapy, including integrating spiritual direction and spiritual disciplines in therapy sessions. It is important, however, to still keep the goals of psychotherapy that include the amelioration of symptoms or reduction of psychological distress intact in therapeutic work. Spiritual direction that aims more at spiritual growth and the development of one's relationship with God has a valid place in psychotherapy that is more wholistic and integrated. However, spiritual direction should not completely replace psychotherapy in the therapy session. If and when the goals of psychotherapy per se are achieved, and only spiritual direction is desired, then psychotherapy should be terminated. When a client wants only spiritual direction, a referral to a spiritual director or pastor/clergy person may be more appropriate. Potential ethical problems related to charging fees and especially r eceiving third-party reimbursement for doing only spiritual direction without any reference to psychotherapeutic work and goals related to symptoms and psychological distress or problems, can thus be avoided (cf. McMinn & McRay, 1997). In this context, it may be simpler to integrate spiritual direction, including the use of spiritual disciplines, into Christian lay counseling where fees are not charged (see Tan 1991, 1997).
However, if a client chooses with full informed consent to continue to see a Christian therapist for only spiritual direction (instead of accepting a referral to a pastor/clergy person or a spiritual director), after the goals of therapy have been achieved and symptoms substantially ameliorated, then the Christian therapist has a number of ethical options to select from: (a) agree with the client to continue sessions for spiritual direction, with the client paying for the sessions without third party payments; (b) provide services or sessions pro bono (free) to the client; or (c) switch to a suggested donation arrangement with the client making the donation, without any third party payments.
Formal training programs, especially at the doctoral level, may need to pay particular attention to developing a more effective curriculum for training students in more explicit integration in the therapy room (Tan, 1996a, 1996b, 1998, 1999b, 1999c; also see Eck, 2002; Hall & Hall, 1997), including integrating spiritual direction into psychotherapy. Moon et al. (1993) found that doctoral level religious mental health practitioners were less likely to use explicit spiritual guidance techniques (e.g., prayer and quoting or teaching Scripture) than were master's level practitioners. They also noted that such spiritual interventions were not often included in a course syllabus or given much formal lecture time. They therefore suggested that it might be time to seriously develop specialized education and certification in religious counseling or psychotherapy. An attempt in this direction has been made by Moon and his colleagues at the Psychological Studies Institute in Atlanta, Georgia, through the Institute of Cl inical Theology (see Moon, 1997b).
Integrating spiritual direction into psychotherapy, especially Christian psychotherapy, is a valid and exciting undertaking. It will further the development of practical, professional integration or integration in the therapy room. The field of spiritual direction has grown significantly in recent years, with a mushrooming literature including many books on the topic, as well as more training programs at the certificate, master's, and even doctoral levels being offered at various seminaries and universities. Formal training programs in the mental health professions at the graduate level, especially Christian doctoral level programs, need to incorporate some of the training recommendations reviewed in this article for more comprehensive and effective training in integrating spiritual direction and the use of spiritual disciplines into Christian psychotherapy. There are of course several ethical issues and dangers inherent in such integration, but following the ethical guidelines and recommendations covered in this article will help therapists to minimize or avoid potential ethical problems and pitfalls. Ultimately, integrating spiritual direction into psychotherapy from a biblical, Christian perspective requires dependence on the Holy Spirit (see Tan 1999b) and a prayer-filled life yielded to the Lordship of Christ, including the regular practice of the spiritual disciplines (Tan & Gregg, 1997; also see Foster, 1988; Willard, 1988) on the part of the therapist (Tan, 1987). The potential is great for deep blessing and greater wholeness and shalom for the client who freely chooses such a psychospiritual therapy that aims toward both psychological and spiritual growth as well as the reduction of psychological distress.
Rose, Westefeld, and Ansley (2001), in a recent study using actual clients (rather than potential clients as in previous analogue studies), found that clients believed religious concerns were appropriate for discussion in counseling and they had a preference for discussing spiritual and religious issues in counseling or therapy. Rose et al. (2001) concluded: Clearly, many clients, especially the highly spiritual, believe that religious and spiritual issues not only are acceptable and preferable for discussion in therapy but also are important therapeutic factors, central to the formation of worldview and personality and impacting human behavior. Psychologists who provide psychotherapeutic services need to be sensitive to client's needs to address religious and spiritual issues; those who provide training to future counseling psychologists need to prepare students to deal with these issues; and researchers need to identify the therapeutic aspects of religion and spirituality in counseling. (p. 69)
Integrating spirituality, including spiritual direction, into psychotherapy and counseling in an ethical and helpful way is therefore crucial to and preferred by many clients. More and better training and research are needed before more definitive conclusions can be made regarding the efficacy of such an integrated psychospiritual approach to psychotherapy (see McCullough, 1999; Worthington, Kurusu, McCullough, & Sandage, 1996), although a recent review of nine empirical studies of religiously accommodative Christian (n = 6) and Muslim (n = 3) psychotherapy concluded that there is some limited support for its efficacy, particularly with depressed clients (see Worthington & Sandage, 2001).
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TAN, SIANG-YANG. Address: Graduate School of Psychology, Fuller Theological Seminary, 180 N. Oakland Avenue, Pasadena, CA 91101. Title: Professor of Psychology. Degrees: BA, PhD, McGill University. Specializations: Cognitive-behavior therapy; religious psychotherapy; intrapersonal integration and spirituality; lay counseling; pain; epilepsy; and cross-cultural counseling, especially with Asian Americans.
This article is an expanded version of the William C. Bier Award (Division 36- Psychology of Religion) Address presented by the author at the 110th Annual Convention of the American Psychological Association in Chicago, IL, on August 23,2002. Requests for reprints should be sent to Siang-Yang Tan, PhD, Graduate School of Psychology, Fuller Theological Seminary, 180 N. Oakland Avenue, Pasadena, CA 91101.