Religious consultation can accelerate symptom improvement.
Originally Posted Dec 26, 2020
Religion and the science of psychology traditionally don’t get along, but science says religion is good for psychology. I found myself reflecting on this irony after a conversation with a very religious good friend who had struggled with emotional turmoil. He shared how his family learned to meld faith consultation with clinical intervention for a much more solid outcome in their case.
A Google Scholar search delivers numerous studies about the mental benefits of religion and spirituality. The National Alliance on Mental Illness has this page devoted to it. Books like Spirit In Session: Working With Your Client’s Spirituality in Psychotherapy by therapist Russel Siler Jones are increasingly common. Clearly there is a symbiotic relationship here, and it occurred to me it’s an underutilized tool in our clinical work.
While not unusual for patients to say their religious community is a support, how often do we capitalize on this? I admittedly never explored this potential goldmine further than encouraging people to find more time for prayer if it helped, especially as mindfulness practice. I’d quickly change gears from religion to more clinical, “Now, let’s get back to helping you challenge that thought process.”
I have come to realize that, similar to, “I’m not a psychiatrist, therefore I don’t provide guidance on medications,” I’d draw such a line with religion. So why not explore enlisting collaboration, as I do with psychiatrists, of religious or spiritual leaders if faith is important to a patient? Consider the case of Samuel (disguised):
Samuel’s wife, Jess, insisted they attend couples counseling for communication. “He just shuts down for days. I get scared. I don’t know what’s happening,” Jess shared.
Samuel confessed it’s hard to let Jess in. “She wasn’t raised in a rigidly traditional Jewish family. Your problems are your problems. I guess it’s a sign of strength to be able to contain them. Part of me wants Jess to know me more, but I also feel I’d be breaking a sacred code of some kind.”
Soon, Jess asked if I could meet with only Samuel. “He actually exposed a bit, like the ‘code.’ Sam said he was somewhat comfortable talking to another male, especially in a confidential setting.”
Alone, Samuel confessed worrying about being called crazy as he described bouts of depression. “These are the ‘shut downs’ Jess needs communication about” he confessed. I also learned he was prone to worry and panic.
Samuel shared his family was disappointed in him. “School was tough. I joined the service instead of college, and ended up at war. There was finger-wagging that I’d not tried hard enough, and ‘look what you got into.’ They couldn’t even be proud of me for serving.” Samuel berated himself for being a family outsider. When the war ended, he experienced combat guilt, worrying about his moral character and how God might view him.
Samuel’s internalized guilt and shame fueled his growing depressive spells and stoked the background anxiety. It was time for action:
“Sam, from what I’m hearing, you’ve kept it all to yourself long enough and are ready for relief if we can be respectful of your sensitivities.” He agreed he bottomed out and feared losing his wife if he didn’t better himself emotionally.
Remembering the conversation with my friend, I swooped in:
“Here are my thoughts. I know Judaism remains important to you, and a large part of what’s driving your bad mood is a belief you’ve been amoral, what that means to God, and, essentially, your soul. Honestly, I’m seeing this more as soul sickness than someone who’s crazy.” I continued, “You’ve mentioned you’re active in the synagogue. How well do you know your rabbi?” Samuel replied, “We’re not friends, but we chat and he’s always warm towards us.”
“Great! Now, my guess is, your rabbi would be versed in being empathic about your concerns from cultural and faith standpoints. Plus, religious leaders are usually versed in counselling to help their followers with just such things. Since you know him and he’s of a warm demeanor, I’d like to propose working with your rabbi to sort out this soul sickness component. Meanwhile, you and I can continue to work on communication and managing panic and worry.”
Samuel brightened at realizing there was someone in the know he could connect with in confidence about faith and culture. He not only minimized shame and guilt, but became more active at synagogue and gained a sense of belonging missing from his nuclear family.
It is up to therapists to broach the idea—patients may not realize spiritual examination is formally available—but to also explore appropriateness. For example, some feel that openly sharing their darkness to a priest or pastor could encourage judgment if sin is a focus of their religion, and be more damaging.
In these cases, therapists can focus on what the patient feels must occur to feel redeemed, and help them work towards that vision. Other times a referral to a psychotherapist versed in faith, such as a Christian counselor, might be most appropriate.
Like with any patient, exploration is key. My friend and Samuel illustrated that therapists can do well to explore the role of religion and spirituality in someone’s life and capitalize on this adjunctive intervention if deemed appropriate. For some really stuck patients, like Samuel, who felt he didn’t have a prayer, it may just be the one they were looking for.
Pies, R.W. (2020, December). Psychiatry and the dark night of the soul. Psychiatric Times, 37 (12). Retrieved from https://www.psychiatrictimes.com/view/psychiatry-dark-night-soul
Despite their differences, all good therapies share certain qualities.
Originally Posted Mar 04, 2016
Many approaches to therapy have been developed in the decades since Freud first began his experimentation with the talking cure. Psychotherapy today comes in many varieties: The psychoanalyst will probe your unconscious; the behaviorist will rearrange your reinforcement contingencies; the cognitive therapist will challenge your irrational thoughts; the humanist will provide a safe space within which you may activate your self-actualization tendency; the existentialist will encourage your find meaning in the desert of existence; the reality therapist will guide you toward choosing behaviors that facilitate your connection to others; the feminist therapist may show you how your personal problems could be manifestations of patriarchal oppression, and so forth, on and on.
In this rich ecology, no single therapy theory or technique holds a monopoly on healing. Depending on the particular context—when, where, how, and with whom they are used—multiple approaches, explanations, and interventions may prove effective and helpful, or, alternately, ineffective and harmful. Given this, and the endless array of choices, how can potential clients tell good therapy from bad?
Well, just as all wines—despite their great diversity in taste, price, and presentation—share the same active ingredient (grapes), so it is with therapy: Underneath the surface diversity, all good therapies share several underlying principles. These common factors are in fact responsible for most of the healing that takes place in therapy.
Here’s a list (based on my own reading of the research, and my clinical experience) of 10 basic, common ingredients of good therapy:
There are several differences between friendship and therapy. First, you may have multiple relationships with your friends. You can go into business with them, borrow money from them, have sex with them. With your therapist, you can only do therapy. Your therapist may be friendly, but she is not your friend. If your therapist is your friend, then she is not your therapist.
Second, friendship doesn’t need to have a plan, goal, or purpose beyond its own existence. You can hang out with your friends for no good reason other than that you enjoy it, are used to it, or have nothing better to do. You don’t hang with your therapist. Therapy is purposeful and pragmatic, moving deliberately toward one or more mutually negotiated goals. Therapy is not an end in itself.
Third, you and your friends have a mutual, equal claim on your encounter. Your interests, needs, and concerns are as important as your friends’ concerns and issues. Therapy is not like that. By design it is one-sided; it is about the client. Every action of the therapist can legitimately be directed only toward one goal—helping the client. The therapist cannot use therapy time, or the therapeutic relations, to take care of their own needs. If your therapist uses therapy time for any purpose other than to help you, then what they’re doing is not good therapy.
2. Good therapy is evidence-based.
Good therapy involves keeping good records, connecting anecdotes into patterns, generating hypotheses, and testing them. Good therapy is responsive to new knowledge. It admits and corrects its mistakes. While good therapy seeks to foster hope and nourish the expectation of change, its promises are tethered to facts. If your therapist guarantees success or promises to change your personality, walk away.
There is an art to good therapy, since it is an intentional human encounter, and as such is inherently dynamic, creative, and unique. But the art of good therapy must align with science in the way that the art of architectural design must align with the principles of sound engineering. What the therapist suggests to the client—the course of action, the explanations and interventions—should be based on scientific research, to the extent that such research exists. Good therapy does not contradict or ignore sound scientific data, knowledge, or evidence. Good therapy recognizes the simple truth—simple, yet not easy—that the evidence wins out in the end.
3. Good therapy affirms the client’s basic human dignity and worth.
Good therapy looks to facilitate sound mental health. Mental health, however, is not a destination, not an end in itself, not a place you arrive at, pearly-gates style, to be ushered into bliss. Rather, mental health is a process you adopt and use in the pursuit of your chosen goals. In other words, mental health is your driving skill, not the destination of your trip. The therapist, therefore, is not a chauffeur but a driving instructor.
Good therapy concerns itself with judgments, but it is not about judging people, in the same way that a church must concern itself with finances, but should not be about money. Most people who come to therapy have been judged harshly enough for their troubles—by themselves, their peers, spouses, employers, neighbors, and, often, society at large. They have also been given plenty of advice. Therefore, unlike media therapists, good therapists go light on both judgment and advice. And by and large, that’s not what people come to therapy to find. They come for an experience—a healing, corrective experience. What they require is understanding, empathy, attention, acceptance, and encouragement.
Just as a surgeon has a duty to operate regardless of the patient’s ideology, moral character, wealth, or ethnicity, so must a therapist accept, listen, and seek to understand, respond appropriately to, and honor the humanity of every client, regardless of how much the therapist “likes” or approves of the individual. And needless to say, good therapy does not condescend, patronize, abuse, abandon, manipulate, lie, or cheat.
4. Good therapy encourages and models accurate, honest, and timely feedback and communication.
Video games are hugely popular. One reason is that people who play a lot can improve a lot. They improve because the video game environment provides timely, consistent, unflinching, and accurate feedback: You kill the bad guy, you move to level 2; the bad guy kills you, you repeat level 1. Likewise, clients improve when they receive timely, accurate feedback in therapy.
Many of our encounters with people outside the therapy room are mannered, circumspect, or shallow. Many are touched by deceit, or plagued by inattention. Our communications in the world often seek to obscure rather than reveal our true intents, to avoid the truth rather than confront it. We are often afraid to say what we truly feel and think; afraid to hurt and be hurt; afraid that our secrets will leak out and be used against us. Truth may set us free. But more than we want to be free, we want to belong and get along, because that’s how we survive and keep safe. What is the right to privacy, if not the right to withhold truth, to maintain a distance between how we present ourselves and who we are, to keep our truths to ourselves? Out there in the social world, truth can be dangerous.
Truth is safe in good therapy. Therapy creates a space that invites, expects, and is quite purposely designed for frank, probing, and revealing dialogue. It’s a safe space for clients to express themselves honestly, get to understand their true feelings, and work with the therapist to figure out how to use that information in their journey toward healing.
5. Good therapy = a good therapeutic alliance.
Generally, the best predictor of success in therapy is rapport—feelings of trust and respect between the participants; a therapeutic alliance. When there’s no rapport, there’s no therapy. Thus, while a therapist may look good on paper—experienced, well trained, etc.—if upon meeting them (within the first few sessions) you feel no chemistry, no trust, no warmth, then it’s probably best (for both of you) if you move on.
6. Good therapy encourages the client’s independence and competence.
If the therapy process is not moving in the direction of improving client resilience, independence, decision-making, and life competence, then therapy is not taking place. If your admiration for the therapist rises in tandem with your self-doubt, then you’re probably not in good therapy. A good sign of therapy at the brink of failure, or of therapy that’s not legitimate, is when your dependence on the therapist increases over time. Therapy is not about handing out solutions to problems; it’s about teaching the client to problem solve.
7. Good therapy considers the client’s history and biography.
Some therapy approaches focus mostly on the here and now, or on the future, while others focus mainly on re-envisioning past experiences. Either way, good therapy makes room for biography. The past is not the only key, but is often one key to the present. We may not focus on it, but acknowledge it we must. We all come from somewhere. And where we come from has implications for where we are and who we are. A person’s biography provides a map of their experiential field; it’s a context within which their behavior can be usefully understood. The past may not determine the present, but it certainly informs it. And it informs good therapy.
8. Good therapy takes into account the client’s subjective experience and inner world.
People experience life through their senses. Our individual sensory experiences—while rooted in the common soil of our evolutionary heritage—are shaped by our genetic makeup and life experiences, both of which are unique. Thus, while on some level we are all in this together, on another, to paraphrase Lilly Tomlin, we are all in this alone. Which is to say, how you represent and process the phenomena of the world may be quite different from how I do so. Good therapists know that to understand the client, they must understand her subjective experience. Not just her circumstances, but what the circumstances mean to her. Good therapy is curious about the client’s inner grammar. Good therapy honors, maps, and works within the client’s subjective experience. In other words, good therapy accepts that while, for example, your mother is in all likelihood an average person by objective measurements, she is special to you, because of how she is represented in your subjective world.
9. Good therapy happens when the client does the work.
Like parents do with their children, therapists tend to take too much credit for their clients’ success (and too much blame for failure). In fact, both parents and therapists are less powerful than they (and the world) believe they are. Client factors such as hope, motivation, resources, social support, and grit account for far more than the therapist’s ability and characteristics in determining the therapy’s outcome. The client’s experience of the therapy also matters more than the objective measurement of therapy ingredients. All therapy, in a fundamental sense, is self-therapy. If therapy is to work for the client, the client has to work for the therapy. As the old joke goes: How many therapists does it take to change a light bulb? Answer: Two or three, but the light bulb has to want to change. (And yes, humor belongs in good therapy).
10. Good therapy offers support, requires learning, and facilitates action.
Good therapy engages clients on multiple levels. It involves clients’ emotions, cognition, and behavior. Often, the effort in therapy will focus first on an emphatic understanding of the client, establishing alliance, and becoming aware of the client’s inner architecture, life circumstances, and personal narrative. Then, good therapy will also facilitate learning—new insights, new ways of thinking, communicating with others, and managing emotion. Finally, good therapy includes a focus on the clients’ actions in the world—practicing new skills, adopting new habits, and new ways of moving in the world.
If you are in therapy feeling alone and unsupported, if you haven’t learned anything new, and if your behavior has not changed at all, then you’re not in therapy, at least not in therapy that’s any good.