The following article considers from the empirical, psychological "end", the relationship between psychotherapy and spirituality in historical perspective, the concept of "healthy religiosity" and practical results and issues in the implementation of religiously sensitive psychotherapy in different religious cultures
1. An overview of the relationship of psychotherapy and religion
The views on the relationship of spirituality and psychotherapy which dominated the first half of the last century, and continued to linger in the ensuing decades were markedly polarized. There was dismissal of religion and the spiritual from psychotherapy, and dismissal of psychotherapy, psychiatry – all the “psychs” – by religious spokespeople.
The best-known of the psychotherapeutic antagonists to religion was, of course, Freud.He had complex and often profound views on religion, which were usually seen as negative to religion - such as describing religion as resemblingl obsessional neurosis, or as a system of wishful illusions.” Mowrer articulated the common view that mental problems are the result of guilt, caused by an awareness of sin. This guilt, he thought, destroyed personal integrity and the relatedness of the community. All of this was the fault of religion. Ellis, the initiator of rational-emotive therapy, and a reputed atheist, expressed views similar to that of Mowrer - religion causes guilt, leading to psychological distress. These - anti-religious - founders of modern psychotherapeutic trends generally claimed that religion causes distress and psychological problems.
In the religious camp, the dislike was mutual. Foskett noted the “… history of discord” between psychiatry and religion. Esau thought that “…evangelical Christians may feel that the …psychological perspective of Freud…was outside the realm of faith. It was viewed…as the enemy of faith and of the believer…spiritual counsel was the means of …deliverance…The emotionally disturbed had sinned in some way”. In Amsel’s book claiming that religious methods should be sufficient for treating psychological distress, about half the endorsements are negative about psychology, psychiatry and psychotherapy: “… psychological theory is far more anti-[religion] than any of the [other] sciences”, and that “…Psychoanalysis effected no cures…caused aggravation of mental disorders…Freud and his cohorts…[are] charlatans and vampires that prey upon society” .
At the same time, beginning in the mid-twentieth century and extending to the present, there are also strands of reconciliation between the two. Jung suggested that acknowledging and dealing with the unconscious, dark side of ourselves – which is of course a psychoanalytic venture - is parallel to dealing with the paradox of good and evil in the world. The latter is both a psychological and a spiritual journey “to the centre of self”. Individuation, a developmental process first described by Jung, involves a sense of mystical unity and harmony.
Viktor Frankl, the “father of existential psychology” was a survivor of deportation and concentration camps. After the second world war, in the United States, he described noogenic neurosis – a condition characterised by the feeling that there is no purpose in life. Frankl argued that the search for meaning is essential to our human condition, and he highlighted the role of the therapist in supporting and facilitating this search, and suggested that meaning may involve ideas of religious or spiritual significance.
I was introduced to the work of Gordon Allport many years ago by a senior colleague, Monica Lawlor. She believed that Allport had risked his academic career and flew in the face of academic anti-religious convention by choosing to research and write about the psychological processes involved in personal belief. This was certainly something that Monica herself had done, in her book Out of This World: A Study of Catholic Values, a pioneering application of scientific methods of enquiry to the study of religious behaviour. In The Individual and his Religion, A Psychological Interpretation, Allport looked at developmental changes in personal belief systems, and the movement from “immature” (egocentric, self-serving) beliefs, to “mature” (humane, tolerant, compassionate) beliefs. Later this distinction was developed into the distinction between extrinsic and intrinsic religiosity. These orientations to religion have been a major focus of research attention, and their relations to mental health and social cognitions have been widely investigated. We shall return to this. Another moderate - and reasonable - view was that religious and spiritual care was outside the professional competence of psychotherapists and related professionals. “The task of psychotherapy is...psychological healing…the aim of spiritual care…purely and solely spiritual help”. Neeleman & Persaud thought this could have been a widespread belief, as they suggested in their article “Why do psychiatrists neglect religion?”.
Thus, the climate was changing, and it was becoming increasingly possible to publish studies of religious behaviour and belief, and studies of religious issues in psychotherapy. Rizzutto and Spero are object-relations theorists, who have shown how the image of G-d in the person, and the relationship with G-d, may be healed in the course of psychotherapy, just as other relationships may be healed. Frankl described how in the course of psychotherapy, blocked-up primary belief (unconscious religiosity) may be released, even though this is not the intention of psychotherapy - just a common outcome. Religious issues did come up in therapy and clinical work, and thought needed to be given to how these might best be dealt with.
This brings us to the present, and some personal observations. First, some research-based observations on how lay people see psychotherapy, and how they compare it with religious and spiritual ways of coping. In one series of studies, we collected qualitative and quantitative data from lay people in the UK, from different religious traditions and cultural groups, including religiously non-active. We asked how they rated the effectiveness of a large range of interventions for psychological illnesses, including accepting medication, going on holiday, consulting a religious leader (minister, priest, rabbi, imam etc.), accepting help from friends, and praying. We also asked whether they would consider using these different interventions. Generally, prayer was the most popular and believed-to-be-effective of the religious interventions, and in one study, more people thought it might be helpful for depression compared to psychotherapy, or medication. Another study compared direct ratings of the helpfulness of religious and other interventions, and looked at whether people would actually use these different forms of help. For depression, religious interventions were seen as somewhat helpful, but not to the same extent as professional help and social support, and fewer people thought they would actually use religious interventions – this held even when we only considered the religiously active. This is a mixed bag of findings, but it leaves us, or at least me, with the conclusion that religious methods of coping are quite well-regarded. The most popular method, prayer, can be tried privately, without anyone knowing about the individual’s disturbance: G-d was sometimes described a terrific confidant, one to whom one can tell everything, and trust completely. And of course free of charge. So religious coping is an easy, confidential, low-cost option – and according to current scientific consensus, some forms of religious coping may have (weak but) reliable beneficial effects. For most people, choices of health care are pragmatic and eclectic, not either/or choices taken from a moral high ground.
2. The issue of psychologically healthy religiosity
We all now use the term “spiritual” quite freely. Twenty years ago, this did not happen. The distinction between spirituality and religiosity may be enabling mental health practitioners to feel that, even if they are not entitle or qualified to have to professional views on religion, they may be entitled to have professional views on spirituality. In our individualistic era, spirituality can be claimed and owned by anyone. In the present time, an important question is, what can be done to ensure that humane and compassionate behaviour - to which most religions pay lip-service - is really part and parcel of religious up-bringing?
By way of coming to a consideration of psychologically healthy religiosity, how do I understand the terms "religion" and "mental health"? Of course there are many answers, and many thousands of words have been written by different authors (including me), but here I would like to offer simple definitions for each of these terms. For "religion" there are common themes in the major religious traditions. Additionally, many (sometimes all) of these beliefs are held by people who might not align themselves with a particular religious tradition. Such people might think of themselves as spiritual, or moral. These beliefs include:
the existence of non-material (i.e.spiritual) reality
a source of existence (i.e. G-d)
the purpose of life as increasing harmony in the world by doing good and avoiding evil
moral and social laws, for example laws prohibiting murder, governing sexual morality, laws to protect the helpless, to promote social justice and kindness.
Mental health could be defined rather pragmatically as the absence or reduction of psychiatric symptoms and the symptoms of distress, and the presence of positive well-being. We might want to go further, and not just consider mental health as the absence of misery and the presence of contentment, but also as the promotion of goodness, kindness and psychological maturity. Of course goodness and maturity beg definition, but I shall come to some suggested definitions shortly.
Now the issue here is, given the validity and factual importance of the role of the spiritual within the concept of the person, what constitutes a healthy spirituality viewed especially in terms of the outcome, the kinds of behaviour and qualities in the person, which it produces. In particular, might religious belief help to reduce psychiatric symptoms and distress, promote positive well-being, and promote goodness? Or might it have the opposite effect? On balance, we now know that overall, religion does go along with somewhat better mental health. But there are some counter-effects, and we would all like to know how the effects and the counter-effects work. To focus on one fairly specific line of enquiry: when and how might religion promote kindness, tolerance, a human view of others and compassion, and when might it promote fanaticism, persecution, and horrors such as those of 9/ll? One line of fruitful and fascinating enquiry was suggested by Gordon Allport, whose work I alluded to earlier. Among Allport's suggestions, which resonate strongly for most of us, was his observation that while many people could not always relate to organised religion, nearly everyone had a felt need for some kind of spiritual, religious and moral beliefs. Then Allport went on to suggest that we could distinguish between mature, humane beliefs, which were linked with compassionate views of others, and compassionate behaviour, and immature, egocentric beliefs, which were not associated with humane and compassionate views and behaviour. Allport went on in his later work to distinguish between intrinsic and extrinsic religiosity, and these in turn have been the objects of extensive scientific investigation. However there are still gaps in our knowledge. But we can make reasonable informed guesses about some of the causes and effects of humane (intrinsic/internalised) religion, and immature/fanatical religiosity.
We can be fairly sure that humane religiosity does go with more compassionate views of other people, and more compassionate, kindly behaviour, higher standards of honesty and moral behaviour, as well as higher personal well-being and lower distress. Immature, "extrinsic" religiosity and fanaticism are often associated with self-righteousness, unpleasant prejudiced views of others, and lower personal happiness.
Two classic accounts by psychiatrists are Aliens and Alienists and Sanity and Sanctity. Many of the clients described in these fascinating books are more seriously disturbed than those who co-operate with psychotherapists. Often psychotic, often hospitalised, and often convinced that their symptoms have spiritual origins, the patients of Littlewood, Lipsedge, Greenberg and Witztum have benefited from careful co-operation between mental health professionals, and members or leaders of religious groups. One message from these books is that it is sometimes difficult for a psychiatrist to tell whether a piece of behaviour is mad, or holy: “It occurred to (the psychiatrist) that this might be speaking in tongues…her fellow-church members said, no doctor this is not speaking, she is sick in the head”.
Pargamentand others in their studies of religious methods of coping with difficulties, have identified religious “red flags” (such as believing that “G-d is angry with me”) – beliefs that are associated with poor emotional outcomes. They have also identified Clinically Significant Religious Impairment (CSRI). This significant development raises questions about whether mental health professionals are ethically and professionally competent to make decisions and prescriptions about which religious beliefs are “better” than others.
There are take-home lessons. Probably the most important is that carrying out the externals of religious behaviour - belonging to a group, keeping to the group norms of adherence, saying the right prayers and so on - are just a beginning, and are certainly not a cause for complacency. They do not in themselves guarantee mental health, maturity or descendants who will carry on the tradition. A great deal of care, work, thought, indeed study and self-examination are needed in addition. And possibly, sometimes, psychotherapy might be helpful. As suggested earlier, some theorists and practitioners have suggested that repairing psychological damage can go along with the repair of spiritual damage. Of course, it is a shame that this is necessary. Religion is about love of others, moral, right and compassionate behaviour - the practical integration of these virtues into religious thinking and practice is devoutly to be wished.
3. Results and issues in the implementation of religious perspectives
Nowadays, the integration of religious and psychotherapeutic perspectives has a number of institutionalized forms. One can go to Muslim therapy centres, or Christian counsellors, or rabbinically-vetted orthodox-Jewish counsellors, taking our pick of the now-politically-correct culturally and religiously-sensitive service provision that is available in many communities. Would we choose this? Or would we go to a “neutral” therapist or psychiatrist?
Some professionals would not go for this kind of culture-sensitive kind of work: “I would never practice in my own community. I could not cope with the problems, especially if child protection issues come up…”. And, as we shall see, many clients and potential clients have their reservations.
How do these culturally and religiously-sensitive service provisions work? To illustrate some of the range, here is a description of some service provision groups, their histories, strengths and difficulties: I will describe some features of three groups, involving respectively Muslim, orthodox-Jewish and Christian clients.
First, some observations involving psychotherapy – and other support services – in the Muslim community. These observations were made in doing collaborative work with Ravinder Barn, Michelle Lee and Sidra Muntaha. We had been asked to evaluate a particular intervention project in London’s East End. There have been a number of attempts to introduce culturally and religiously sensitive therapy in the UK Muslim community. This one was pioneered by a Muslim working for the statutory services. Not all the professionals involved were South Asians/Muslims. The MAP (Multi-Agency Prevention) project used social workers, youth workers, clinical psychologists and link workers (teachers). It targeted at-risk adolescent boys (Bangladeshi, in London’s East End), identified by schools and made known to the project, which was able to respond to needs rapidly and flexibly. Possible interventions included family support, one-to-one sessions, group psychotherapy, outings and other group activities. Problems included uncertain funding, short-term staff, and general lack of resources. Both qualitative and quantitative data reflected that the interventions were generally seen to be helping. For example, clients
Felt better about selves (quantitative support) and were
Trying to improve school attendance (some quantitative evidence)
Trying to keep better company
Trying to give up drugs
Quantitatively, there were statistically significant changes in self-image after group psychotherapy.
Turning to a Jewish group, Chizuk. This Hebrew term means strengthening, or encouragement. I have had several connections with this group. I serve on its management committee, I have included it in a study of several support groups, examining how culture-sensitive service provision works, and I am currently involved in running an intervention project with this group.
The London strictly-orthodox Jewish community has many groups, offering practical, social and psychological support for religiously- and culturally-specific needs. Some of these groups focus on psychological support and counselling.
Chizuk’s services include
group psychotherapy (called “a drop-in circle”) which includes many volunteers. No-one is identified as paid staff, volunteer, or client
individual and family psychotherapy (called counselling) by professionals who are also Orthodox Jewish, and clients are asked if they are willing to see the named professional.
group activities: outings, drama, creative writing, arts and crafts
other forms of help, including family support, and referral to other services.
In common with other services, Chizuk’s work is appreciated by users and by the community. They are seen as
culturally and religiously-sensitive (“feel understood”)
showing respect for confidentiality (“people know that you can’t tell who is volunteer and who is not”),
financially affordable (clients are not charged for most services),
helpful (“very helpful”, “Look forward to it the whole week”)
But there remain important issues, particularly those of stigma and confidentiality: “I wonder what type of families need this? Is it just those who can’t cope? I might feel ashamed to ask for such help”. ”I would think that many people would prefer something more confidential than an open meeting”. “We live in a goldfish bowl”.
Professionals working for Chizuk and other organisations realise that they may have a better understanding of their clients than outside agencies, but confidentiality is an issue - and so (for the organisers) is finance. “People feel comfortable - they feel at home - they may have feelings and problems to which other (outside the community) could not relate.” “One problem is stigma, and the related problem of confidentiality. In a small closed community like this, these are difficult issues. There is a lack of suitable venues. It is important that clients do not have to go buildings where it is obvious why they are going.” “Our account book is a joke”. “I spend too much time trying to raise money”.
Finally, a brief report on one aspect of a Christian counselling venture. Protestant Christianity is dominant religious tradition in the UK, with a church in every village. Pastoral counselling has a long and distinguished history. Additionally, many ordained Christian ministers are professional psychotherapists/counsellors. I was involved in advising for a series of studies of the development of a form of counselling suitable for Christian clients, which was based in orthodox counselling and psychotherapy theory and practice. The author was both an ordained minister, and a professional psychotherapist. A special feature was a series of questions about preferred coping strategies, and an aspect of therapy included getting clients to consider all options. A training course, was developed, validated by a respected British university, and leading to a professionally recognised qualification. The course was well-attended, and well-run. After some time, the course ran out of recruits. All those within the particular Christian group who wished to train had done so.
Our other work on members of different religious groups and their views on seeking psychotherapy from someone within their own group, suggest that conflicting feelings - of reluctance, or relief in being able, to consult fellow members - are both important.
We are still left with questions, which include (a) Whether professional psychotherapists deal with religious issues? (b) Can religious groups train and provide their own psychotherapeutic services? (c) Which is the first port of call, psychiatry or religious guidance and in which circumstances? (d) What solutions to we have to the recurrent problems of stigma and confidentiality?
Psychology Department, Royal Holloway, University of LondonGrateful thanks to many collaborators, including: Vivienne Goldblatt, Esther Spitzer, Miriam Herzog, Caroline Lindsey, June Jackson, Tabassum Aslam, Ravinder Barn, Michelle Lee, Marco Cinnirella, Andy MacLeod, Guy Lubitsh, Stephen Frosh... So also to funding bodies, including those funding the following projects Support groups: how they are seen by their providers,by the community, and by statutory professionals (Leverhulme Trust); Religious coping beliefs and their efficacy (Wellcome Trust); Beliefs about different forms of help for psychological problems (Central Research Fund); Post-natal depression: service provision, monitoring and effectiveness (Sure Start).
The Future of an Illusion. London: Hogarth Press, 1927; Totem and Taboo: Resemblances between the Psychic Lives of Savages and Neurotics. New York: Dodd, 1928; Civilisation and its Discontents. London: Hogarth Press, 1930; Moses and Monotheism. London: Hogarth Press and the Institute of Psychoanalysis, 1939
Freud, S. "Obsessive acts and religious practices", Collected Papers 1907-1924. London: Hogarth Press. The Future of an Illuision. London: Hogarth Press, 1927.
Mowrer, O.H. The Crisis in Psychiatry and Religion. New York: Van Nostrand, 1961.
Ellis, A.., "The case against religion: a Psychotherapist’s view" in B. Ard (ed), Counselling and Psychotherapy, Palo Alto, California: Science and Behaviour Books, 1975
Foskett, J., "Christianity and psychiatry" in D. Bhugra (ed), Psychiatry and Religion: Context, Consensus, and Controversies. London: Routledge, 1996 [p. 51-64]
Esau, T.G., "The evangelical Christian in psychotherapy", American Journal of Psychotherapy, 52, (1998), pp. 28-36.
Amsel, A., Rational Irrational Man: Torah Psychology 2nd. Edition, New York, Feldheim, 1984.
Jung, C.G., Psychology and Religion: East and West. London: Routledge & Kegan Paul, 1958.
Frankl, V. From Death Camps to Existentialism: Man’s Search for Meaning. Boston, Massachusetts: Beacon, 1959; "Psychotherapy and religious counselling", translated by L.Kosma. Journal of Judaism and Civilisation, 2 (1999), 14-21. "Ten theses concerning a 'person'", translated by S. Cowen. Journal of Judaism and Civilisation, 3 (2001), 1-11.
London: Sheed and Ward, 1965.
New York: MacMillan, 1950.
Frankl, "Psychotherapy and religious counselling", p. 19.
Neeleman J & Persaud Why do psychiatrists neglect religion? British Journal of Medical Psychology, 68 (1995), 169-78.
Rizzuto, A.M. The Birth of the Living G-d. Chicago: University of Chicago Press, 1979.
Spero, M.H., Religious Objects as Psychological Structures: a Critical Integration of Object Relations Theory, Psychotherapy and Judaism. Chicago and London: University of Chicago Press, 1992.
Frankl, "Psychotherapy and religious counselling", p. 19.
Loewenthal, K.M. & Cinnirella, M., "Beliefs about the efficacy of religious, medical and psychotherapeutic interventions for depression and schizophrenia among women from different cultural-religious groups in Great Britain", Transcultural Psychiatry, 36 (1999), 491-504, 1999.
K.M.Loewenthal, M.Cinnirella, G. Evdoka & P.Murphy: "Faith conquers all? Beliefs about the role of religious factors in coping with depression among different cultural-religious groups in the UK", British Journal of Medical Psychology, 74 (2001), pp. 293-303.
See Loewenthal, K.M. The Psychology of Religion: A Short Introduction. Oxford: One World, 2000; Pargament, K.I., The Psychology of Religious Coping: Theory, Research and Practice. New York: Guilford Press, 1997.
Zinnbauer, B.J., Pargament, K.I., Cole, B., Rye, M.S., Butter, E.M., Belavich, T.G., Hipp, K.M., Scott, A.B. & Kadar, J.L. "Religion and spirituality: Unfuzzying the fuzzy" in Journal for the Scientific Study of Religion, 36 (1997) , 549-564.
Littlewood, R. & Lipsedge, M., Aliens and Alienists: Ethnic Minorities and Psychiatry (3rd edition). London: Routledge, 1989.
Greenberg, D. & Witztum, E. , Sanity and Sanctity: Mental Health Work among the Ultra-Orthodox in Jerusalem. New Haven: Yale University Press, 2001.
Littlewood, R. & Lipsedge, M., Aliens and Alienists: Ethnic Minorities and Psychiatry (3rd edition). London: Routledge, 1989, p173.
Pargament, The Psychology of Religious Coping.
Hathaway, W. Clinically Significant Religious Impairment (CSRI). Mental Health, Religion and Culture, (in press).
Barn, R., Lee, M.J. & Loewenthal, K.M. "The multi-agency intervention project among Bangladeshi adolescents in Tower Hamlets", Trust for the Study of Adolescence, London, November 2001.
K.M. Loewenthal, M.Cinnirella, G. Evdoka & P.Murphy: "Faith conquers all? Beliefs about the role of religious factors in coping with depression among different cultural-religious groups in the UK", op. cit.
Loewenthal, K.M. & Cinnirella, M., "Beliefs about the efficacy of religious, medical and psychotherapeutic interventions for depression and schizophrenia among women from different cultural-religious groups in Great Britain", loc. cit..