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Moral and ethical features regarding integrating religion and spirituality in psychotherapy.

"We have been concerned with the act of knowledge, with mental or spiritual activity that generates knowledge ... It has always been believed that one starts from zero, from natural darkness, towards the direct light through metaphysical intuition, through religious revelation or progressively, through the development of intelligence up to a knowledge in continuous progress" (Stefan Lupascu) (1).

Out of a desire of explanation and understanding of the mechanisms underlying the operation of mental activity, there have been various theories over time, which supported the intervention of the divinity, of reason or of moral. Human status can be seen in a much broader context, which includes in addition to its bio-psycho-social three-dimensional feature a spiritual side. In this regard, in his work "Cunoastere si stiinta" (Knowledge and Science) Academician C. Balaceanu- Stolnici sees the spiritual world as an ideal-objective world, and not necessarily as a purely spiritual world, without a material component (2). Thus, all religious systems admit the existence of a spiritual, transcendental reality, which along with the material one define the Cartesian dualism characteristic to most theological systems and the two worlds are intertwined and influence each other. When we speak of the human soul, its spiritual component is actually the divine aspect that was instilled by God into the material body, according to Genesis (3). But unlike the actual psychological component, this component cannot be known through a scientific approach. Beyond all philosophical, religious or medical concepts the soul remains a topic indecisive and fascinating as it is indefinable, as Prof. C. Romanescu, who does not think there will ever be a "science of the soul" because the soul should not be understood but felt, sensed and intuited, says (2).

The concepts of spirituality and religion are often mistaken for one another and are not used with the same intention; for mental health professionals they are two totally different concepts. According to Walsh, the concept of religion is defined as a well-organized system of ideas and beliefs, which includes a number of moral values that are shared to the others, in an institutionalized way, as well as faith in God and the involvement in religious communities, and the concept of spirituality as a personal set of values, a personal, intimate own way of being, as well as the achievement of an appropriate relationship with others (4). Thus, according to Blando, the idea of spirituality is based on our relationship with what surrounds us, the compassion for others and the willingness to help and support the well being of others. Thus, the idea of religion can be understood in terms of a social experience, whereas spirituality is understood in terms of an individual experience (5).

Over time, mental disorders have been situated for a long time between religious-divine or spiritual-moral landmarks and the patient suffering from a mental condition was closed or isolated, far from scientific observation, being a subject of dispute between theologians and philosophers. The eminent theologian St. Augustine believed that "mental health is the link between logic life and emotional life" and Italian moralist Tomasso Go dazzini, at the end of the 13 th century, considered "insanity as a downright sin against wisdom"(6).

It is very difficult to enumerate the factors that determine patients' preference for religious or spiritual psychotherapy, sometimes to the detriment of the classic one, because initially, these new therapeutic directions were included in the classical forms of therapy. Thus, in the studies performed by Morrison, Clutter, Pritchet and Demmitt in 2009, it was found that 68.5% of the people who benefited from psychotherapy sessions discussed with their therapist religious issues as well, and that, in general, people were therefore the ones who initiated these discussions. Also, 73.5% of those who discussed religious issues with their psychotherapists, considered that these topics were very useful in terms of achieving the goals specific of therapy, 16.3% have considered them moderately useful and 10.2% were indifferent to this aspect of therapy (7).

The well-known dictum "mens sana in corpore sano" suggests the importance of the psychic in human life. But beyond what we call mind, there is something much deep and more subtle, so treating the mind can only be done through the care of the soul, of our transcendental self. Psychiatry is a domain that forms a distinct shape only at the end of the XVIII century, although it existed in various forms for thousands of years. Over time, a long journey has been done and huge progress took place so through pharmacotherapy development we were able to get amazing results in treating patients with mental disorders. In the third Millennium, we are wondering if this domain which deals with mental suffering is in need of a change or maybe an addition. The path followed by psychiatry is well delimited but there may be additions on even alternatives science of medicinal products; so mental suffering can also benefit from other approaches that complete the pharmacological one. If we come to think of the etymology of the word psychiatry, than we should deal with the soul's approach. Considering the philosophical problem of the reality based approach path of intuition, of globallity, intuition becomes synonym with wisdom and spiritual awakening, but to get on this path it is necessary to renounce the operational categories. That leads to the need for an opening of psychiatry to meditation, prayer so towards other therapeutic modalities. Any therapeutic process will consider dialogue with divinity, not necessarily in terms of the communication between the suffering one and God, but especially taking into account the therapeutic attitude. Should not be forgotten that since the earliest times the art of healing was associated with religious activity because the real healers were priests and the administration of the medical drugs was only made by invoking the Creator (3).

But the question that stood over time "what is the soul?" still has no answer yet. Some see it as an adapted energy based on the intellect through which take on the self-knowledge and the surrounding reality, willpower, through which accomplishes what knows, feels and sense, through which feels everything he knows and makes. The ensemble of spiritual manifestations is determined by the consciousness with the three aspects of its: conscious, unconscious and subconscious. In turn, the whole structure and spiritual manifestations result in individuality, meaning temperament and character, which influence, modify and control each other forming self. The so called raw material of soul is represented by thoughts that come before acts and desires. Budha said: "We are what we think", so the man could be good or bad, healthy or ill depending on his thoughts (8). It can be asserted that a condition to achieve an ample and rich spirit is represented by faith. In general, faith means the trust that the soul grants knowledge deemed absolute, definitely real and necessary. Therefore religious belief is the absolute confidence of the soul by the spirit in Deity, as the supreme principle of existence. There are pros and cons reviews regarding the existence of divinity, but perhaps what we should always bear in our minds are Blaise Pascal words: "If you say that God does not exist, you will be punished in your next life. If you say He exists and truly believe, this life and the next one will be happy. If God does not exist and you still believe, this life will be happy thinking He exists"(6). One of the aggravating factors of mental disorder or of disease in general is the feeling of loneliness, of abandonment, even when one is surrounded by friends; faith could give one the certainty that one is never alone; therefore Divinity reduces the aggressiveness of this factor. The second complicating factor is the fear of death, but faith brings the conviction that earthly life is but a tiny episode of eternal life. Juan de la Cruz said that "confidence in the immortality of the soul is the way in which the soul can be preserved" and Francois Mauriac said "When I die I will not say goodbye to God, but I shall head towards Him"(1). Thus, the dialogue with the divine is achieved through faith, prayer, meditation, thoughts and deeds. The prayer must be simple, short and without conditions, even the sense of the presence of divinity in everything around us is a prayer, "there is no need for words, it is enough to raise hands to heaven" says St. Macarius (6). In its complexity human personality incorporates a system of religious beliefs. Religion, as a form of social consciousness, which establishes a transcendent direction on human destiny is a phenomenon accompanying cultural development of mankind from the beginning of times until these days. It focuses on the ontological position of the supernatural which becomes part of a being (9). Mircea Eliade considered the sacred an important, defining factor of the human being, "it is an element in the structure of consciousness and not a stage in the history of consciousness"(10). All religions are based on confession, whose main purpose is sacralization and alternatively the catharsis, namely a relief; a hope of forgiveness and of healing through faith is obtained. Any religion has a set of rituals and rules of worship, which conditions the relationship between man and divinity.

Spiritual and religious therapy is part of the life of the society and is complementary to the methods of medical treatment, which have a scientific support. But we have to admit the limits of science, beyond which remains a broad spectrum of human suffering, where religious faith can act. Therefore, most psychiatric hospitals have places of meditation and prayer, and the priests provide religious assistance. Even in case of a separate category of patients with mental disorders who have committed various crimes and are admitted to psychiatric hospitals under special care, the medical team who assists them will not be able to abandon the human dimension of their mission. Thus, in case of the Native Americans the different mental disorders and physical conditions could be solved only by invoking the Great Spirit, and in Malaysia or Indonesia, Kari had to be reconciled by means of a healing process because the disease was considered a consequence of the human action against the Supreme Being (11). In Greece and ancient Rome, any curative activity had to be preceded by the research of astral signs that indicated whether the gods were favourable or not. Of course, the dialogue with the Creator could not be an ordinary one, and therefore, the ecstasy practiced by shamans in Asia, Pacific and America was the first way of communicating with the Almighty (12). Gradually, they came to the need for an active detachment from the time-spatial reality and they came to meditation, a state in which one could perceive better what was happening around one, but in which one paid attention to one's soul as well. As different as religious traditions may be, through meditation and Christian prayer one can obtain a communication with the Absolute. Of course, modern man is far from the necessary state of detachment, but even the most concrete healing activities have an improved prognosis if the specialist tries to pray before the initiation of the intervention in question. Also, in this regard, ever since 1995, DSM IV The American Manual for the Diagnostic and Statistical of the Psychiatric Disorders added the concept of religious and spiritual issue, regarding a situation that requires counselling and attention from mental health specialists (13). Also, both the American Counselling Association as well as the American Psychological Association show several mea sures to be followed regarding the ethical aspects of the use of religion in psychotherapy. Thus, they designed a series of evaluation scales that try to help the clinicians who use religious psychotherapy, namely:

--Spiritual Assessment Inventory (SAI, Hall and Edwards, 1996) the scale that assesses the psychological and spiritual aspects of spiritual maturity in terms of Judeo-Christianity;

--The Index of Core Spiritual Experiences (INSPIRIT, Kass, Friedman, Leserman, Zuttermeister, Benson, 1991) the scale that assesses the personal experiences of individuals on the existence of God and His embodiment in each of us, being a quick way to stimulate discussions about God;

--The Spiritual Well-Being Scale (SWBS, Ellison, 1983) the scale that assesses a person's wellbeing from an existential and religious point of view, in case we assume that trust in God is part of human well-being;

--The Spiritual Health Inventory (SHI, Veach and Chappel, 1992) the scale that assesses the factors that contribute to the well-being of a person and the biological, psychological, social and spiritual dimensions that cause this condition are identified;

--The Spirituality Assessment Scale (SAS, Howden, 1992) the scale that assesses patients' religiosity using four primary concepts, namely the purpose and meaning of life, transcedentality, own internal resources and interconnecting networking, and which can be used on a wider group of population as in its conception it does not have a religious background (14).

By using these methods of assessment, the therapist will be able to effectively implement the techniques and principles of religion in the principles of psychotherapy, but he/she will have to be open and not judge the religious beliefs of the client. Religious ideas can be implemented explicitly or implicitly by the therapist on the patient.

Based on the etiology of the word psychotherapy, it would mean the healing of the soul and it has been used ever since ancient times, in a syncretic form, by the healer of all peoples. For centuries on end, the approach of the human soul was the attribute of priests and in the nineteenth century one can notice the update of hypnosis and its wider application in the medical field. Today, there is a tremendous diversity of all forms of therapy, especially of those which do not use drugs or the scalpel and which apparently act only through the words and voice of the therapist (15). Thus, due to the various forms of psychotherapy the concept has gradually changed its meaning and has returned to what the medicine men or priests once understood it represented. The framework conditions expressed by Carl Rogers empathy, congruence and unconditional acceptance can be found in another form in the wisdom of great religions of mankind. Jesus said "Love thy neighbour as thyself", synthesizing the facilitating atmosphere which assumes that people come as close as possible to each other. Christian love, as it is preached by Apostle Paul means to wholly understand and communicate with the other, namely exactly the elements of psychotherapy (16).

Religious psychotherapy is part of the group of cathartic psychotherapies, which is based on the therapeutic effect of the confession of psycho-emotional experiences. Thus, based on a different kind of therapeutic relationship a genuine affective discharge, namely the catharsis is achieved. The catharsis becomes a spiritual act of enlightenment, of cleansing the spirit of passion and has even a strong moral effect by transposing the subject of everyday life. The celebration of religion, which mediates the relationship of mortals with the divinity is conducted by priests who play the psychotherapist's role and has the necessary means to mediate the relationship with the divine. Orthodox psychotherapy may be defined by the words of the Apostle James "Confess your trespasses to one another" because it is not enough for man to confess before God by means of the mystery of repentance, but man feels the need to open before another man (17).

As long as religious beliefs are part of our own being, of external or internal reality, it can become a source of great conflicts or of great achievements and accomplishments. But when religion becomes part of psychotherapy, we must consider all its elements, even those with negative consequences. Thus, religion can have consequences on the therapist him/herself, determining emotional reactions and changes at the cognitive level, some changes being even automatic, unconscious, including countertransference reactions. This countertransference is not necessarily related to an overreaction in relation to the therapist's own beliefs, but with a reduced reaction related to the fear of being misunderstood by the client. In general, the therapist has certain limits of his/her powers, thus he/she has to augment his/her knowledge and skills in relation to each client, in order to work from a religious perspective with the client, sometimes discussing the case with other experts in this area (18).

The theme of death is a topic often avoided in medicine and psychology, but for a Christian the remembrance of death is one of the main things of life. Therefore, for a psychotherapist is important to have their own religious values to define his/her work with patients. Of course, the doctor cannot replace the priest, but only precedes it and thus they will work together to care for the souls. In Orthodox psychotherapy, consultation is primarily an encounter with God and its action must consider the soothing and instilling of confidence up to the inner growth and development, the return to the everlasting values of life. Thus, some authors believe that the process of psychotherapeutic discussions can be compared with a forward movement. The map that we use to check the correctness of our course is the Gospel, and the aim is our Lord Jesus Christ. The beginning of the movement is the place and condition in which the patient came to the visit (19). By means of Orthodox psychotherapy the patient is led to accept the thesis according to which "man's happiness depends on his spirituality." Orthodox anthropology as stated by O. Siropiatov is diametrically opposed to the usual human psychotherapeutic approach because whereas some types of psychotherapy are characterized by the transformation of personality, according to religious concepts, man never loses his personality in his path to God (20).

Thus, it is very important to properly consider not only the complaints of the patient with psychiatric problems, but his/her state of mind, the context of the circumstances of life. Therefore, one of the most important tasks of Orthodox psychotherapy is the work with the patient in the process of awareness of the disorder psychological mechanisms. Opponents of this type of psychotherapy say that the orthodox doctor should not instil his/her religious beliefs on other people, followers of other religious doctrines. But, like any other form of psychotherapy this is a specific way of healthcare that focuses on the human soul and one even can even recognize a new moral-religious orientation of medicine (21).

The prayer is a formula by which we address the Deity; it is designed in advance or on the spot, under the influence of powerful, special moods, being uttered with all sincerity and conviction. It is a breath of the soul, which maintains the spirit. But it is not just a formula by which we address the Deity, but a general mood generated by its text, a possibility of communication with God and it is not just an act characteristic of the weak, as Nietzsche claimed (22). The act of prayer involves a kind of self-forgetfulness, of separation from the usual mental agitation; therefore St. Dominic believed that God was found at the meeting place of the body with the soul of man, in the house of prayer. Prayer can be a request for help and a serene contemplation, so that it can be delivered at any place or in any circumstance (3).

Meditation is a means of spiritual strengthening, but it also becomes a therapeutic tool because the spirit can influence, strengthened by the divine energy, the development of mental disorders. But any meditation must have an emotional involvement with the participation of the mystical feeling; otherwise it remains only an intellectual act. If prayer is seen as a correspondence, meditation is a true dialogue with the divinity and instead of words addressed by man to God, it uses images. Through meditation, man achieves a kind of liberation, on a higher plane from his own soul with the help of the spirit, having access to the knowledge unknown to senses (23).

Self-therapy through goods thoughts and deeds requires a daily concern for their implementation, by refusing any kind of reward. Father Dumitru Staniloaie said that people could not have good thoughts and actions all the time if their will was not strengthened by a strong faith in God that was shown to us through Christ (12). All good thoughts can provide one a good psycho-moral balance, it keeps one's physical vigour and good deeds are the basis of good thoughts. Good deeds and thoughts are a first step towards a separation of the biological and structure a higher ego, which shall promote the dialogue with the divine; they shall put their mark not only on man's spirit and soul, but also on his/her face. Father George Calcium Dumitreasa said that "spontaneous generosity is the evidence of the existence of the spirit in us" (24). Self-therapy through good thoughts and deeds involves a material sacrifice, time or effort and its perseverant application may generate the following results (25):

--forms or strengthens the moral sense, taking into account the idea that a positive thought generates a positive thing, just as a positive deed, or rather a way of life based on positive facts gives rise to positive thoughts;

--negative autosuggestion is avoided because when one is dealing with the troubles of others forgets one's own problems;

--the positive thinking of the one who is helped may have a beneficial effect on the health of the other.

By this self-therapy one will get positive skills that mark the entire activity of man. This form of therapy applied daily, with patience and perseverance will become a way of life, a skill that will generate positive feelings. For example, in case of large consumers of alcohol, negative habits can be eliminated by (26):

--the elimination of all negative factors, namely people should avoid entering a restaurant, talking about alcohol, friends who are big consumers of alcohol, etc.;

--awareness of the adverse effect of this habit and potentiation by autosuggestion repeated several times a day, for example "Alcohol makes me sick and I will not drink again", repeated 30-50 times per day;

--the use of a replacement that will generate new satisfactions, namely self-therapy through creation or self-therapy through good deeds and thoughts.

This form of self-therapy can become a way of life only when it has a spiritual support, a superior ego through which a dialogue with the divinity is achieved. Mother Teresa, who founded the order of Missionaries of Charity in India in 1928 said: "Many years have passed since I picked up a man from the street. Had I not done it then, I could not have helped later 42,000 people gathered with sisters from the streets of Calcutta. This is why I think we should start with less, with a man"(27).

As psychotherapy addresses the soul, the therapy of the spirit aims at enriching the spirit, namely to strengthen certain energies, which by acting on the other level of the human will lead to the improvement of his/her mental disorders. This therapy is not complete and will not remove the others, but it is an alternative, an adjuvant. Man should not have in mind only the idea that he lives in a mechanical universe, that he is just a physical-chemical organization, but we have to think that the universe is created by Divinity. Faith cannot be imposed because in order to be accepted a certain psycho-moral pattern is needed, therefore the therapy of the spirit apparently addresses a limited number of people, but Mahatma Gandhi said that religions are different paths to the same target, therefore one has to simply plead for faith in God, as a means, purpose, target and source of help and healing (28).

All these spiritual remedies may not be suggested unless a number of measures that have to remove the causes of these disorders are recommended. Any belief can ensure its practitioners the role of psychological support, of an element of safety and harmonization of the human being. This support should be encouraged and can help any therapeutic approach and should be a continuation of the medical treatment. The complete treatment of any patient should present four levels biological, individual psychological, psychosocial and spiritual. The spiritual treatment is considered the highest level of treatment and aims at the reintegration of the individual into the harmony of his culture. Thus, existence may take on a new meaning, according to a set of accessible values in accordance with the new situation created by the disease in relation to the values of culture in which the individual lives (29).

One of the operational ethic concepts in psychiatry is the concept of competence, which involves in its assessment the concepts of understanding, deliberation and decision. In reality, psychopathology can offer situations that can often be confusing because there may be patients who have the ability to understand, deliberate and even conclude, but they cannot be considered fully competent (30). Thus, this may be the case of psychotic patients with systematized delusional ideation or of those with a low IQ, a particular case being that of people with fanatical religious beliefs. Hence the problem related to the best therapeutic modality that would be in patients' best interests, especially in situations where the opinions physician versus patient are contradictory.

Issues related to abuse, manipulation, competence, respect for human dignity will require complex approaches and appropriate regulations, especially considering that all forms of psychiatric treatment are focused on the human mind. Thus, ethics plays an increasingly more important role in the field of psychiatry and proves its opportunity for the entire psychiatric medical act (31).

Nowadays, religion and spirituality have a very important role in terms of mental health and mental disorders, both in terms of clinical activity, as well as in psychotherapy or counselling. But there are some authors who recommend caution regarding the integration of spirituality in psychotherapy, due to the possibility of its abusive use or misuse in psychotherapy. Since 1997, Richards and Bergin have devoted an entire chapter in the manual published by the American Psychological Association regarding the moral and ethical issues of using spirituality in counselling and psychotherapy (32). Thus, they identified a number of difficulties regarding this type of psychotherapy, which refers to the duality of relations from a religious perspective versus a professional perspective, the encroachment or replacement of religious authority, the imposition of religious values on the client, the application of measures beyond those in the therapist's area of competence. Also, they notice the risk of increase of the number of superstitions in the life of the patient and the trivialization of the concept of sacred in a person's life. Consequently, they have developed a series of measures, rules to be observed when we think about the ethical aspects of religious therapy. Thus, the therapist must respect the client's religious beliefs; he/she should not do prozeletism, nor criticize the religious beliefs of the patient. When necessary, the therapist can contact the patient's confessor or recommend another therapist, if his/her beliefs are in total contradiction with that of the patient's. The authors assert that, the therapist will always need to have a multicultural training when he/she addresses such a spiritual direction in psychotherapy (33).

In 1994, Tan summarized a number of risks of spiritual therapeutic directions, namely (34):

--the therapist imposing the patient certain religious beliefs and values, thus limiting his/her freedom of choice;

--providing insufficient information about this type of therapy;

--focusing on the religious goals of therapy rather than on the therapy itself;

--the absence of an appropriate competence of the therapist regarding the achievement of an adequate religious therapy;

--focusing the therapy on the discussion and argumentation of religious doctrines rather than on their clarification;

--misuse and even an abusive use of the religious way such as the prayers over other therapeutic modalities, either pharmacological, medical or psychological;

--the incorrect assumption of an ecclesiastical authority by the therapist.

McMinn and McRay present another ethical feature associated to these directions in psychotherapy, related to the fact that the therapist may unduly require an additional fee for the discussions focused on religion in addition to the standard cost of the actual psychotherapy sessions, as long as pastoral care has always been offered to people (35).

In conclusion, there are many things to be done regarding the integration of spiritual and religious issues in therapy and especially in terms of the training of mental health professionals. However, the important point is that the target of any therapy is the improvement of symptoms and spirituality will not completely replace the role any psychotherapy session has. In a 2001 study conducted by Rose, Westefeld and Ansley on a batch of clients who received psychotherapy, they discovered that patients, especially those with high spiritual faith, wanted to discuss about their religious beliefs during psychotherapy sessions and considered them therapeutic factors with an important role on the behaviour and personality of each person (36). On the other hand, other research is needed regarding the role of spirituality and religion in psychotherapy as a recent review of 9 empirical studies that included both Christian clients as well as Muslim clients, showed some limitations in terms of the role of this type of psychotherapy in depressed patients (Worthington and Sandage, 2001) (37).

The therapy of every patient envisages a set of medical and socio-therapeutic measures, which, after the removal of the acute psychopathological phenomena, can ensure an adequate recovery and social reintegration through the participation of an entire therapeutic team. Pascal said: "Knowing God and not knowing one's own misery gives rise to pride, not knowing God and knowing one's misery gives rise to self-contempt and knowing God and one's own misery offers peace and reconciliation"(1).


The authors state that they are no declared conflicts of interest regarding this paper


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Alexandra Bolos--MD--PhD, senior psychiatrist, lecturer, Gr.T.Popa University of Medicine and Pharmacy Iasi, Romania

Loredana Catrinescu--MD, residency training in psychiatry, Socola Institute of Psychiatry, Iasi, Romania Georgiana Macovei--PhD, lecturer, Gr.T.Popa University of Medicine and Pharmacy Iasi, Romania Roxana Chirifa--MD, PhD, senior psychiatrist, professor, Gr.T.Popa University of Medicine and Pharmacy Iasi, Romania

Andreea Silvana Szalontay--MD, PhD, senior psychiatrist, associate professor, Gr.T.Popa University of Medicine and Pharmacy Iasi, Romania


Georgiana Macovei, PhD, lecturer, Gr.T.Popa University of Medicine and Pharmacy Iasi, Romania, str. Universitatii 16, 700115,

Submission: 20 feb 2018

Acceptance: 22 may 2018
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Author:Bolos, Alexandra; Catrinescu, Loredana; Macovei, Georgiana; Chirifa, Roxana; Szalontay, Andreea Silv
Publication:Bulletin of Integrative Psychiatry
Article Type:Report
Date:Jun 1, 2018
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