Journal of Religion and Health, Vol. 24, No. 1, Spring 1985
Religious Issues in Psychotherapy J O S E P H M. SACKS ABSTRACT." Religious belief is i m p o r t a n t to a large proportion of our population. It has been found to be a potent neutralizer of death anxiety. Religion and psychotherapy share values relating to self-actualization. It is the responsibility of psychotherapists to be aware of their own ambivalences and biases; to assess the significance of religious belief in the lives of their clients; to clarify conflicting views and values of client and therapist; to t r e a t the client's psychodynamic problems; and respectfully to refer spiritual problems outside the domain of psychotherapy to the client's minister. An illustrative example from the a u t h o r ' s practice is included.
Religion and psychotherapy were once closely allied, and most psychiatric disorders were considered to indicate a disturbance in the person's spiritual life. The modern era of psychotherapy has marked a split in this alliance, and at times an antithetic relationship between practitioners of religion and psychotherapy has existed. Freud depreciated religion as an infantile dependency and blind faith in God, an illusion used as a defense against humanity's helplessness before the external forces of nature and its own uncontrolled instincts.I Contemporary therapists tend to agree with Freud with respect to a fundamentalist concept of the deity as a being endowed with h u m a n attributes who directs and controls our destinies. Ostow followed Freud in holding t h a t obedience to doctrinal religious commandments is derived from an original need for parental love and/or fear of parental punishment. 2 However, he pointed out that in therapy we see disturbed individuals in a regressed relationship to society as a parental surrogate. He does not regard these regressed relationships as characteristic of well-integrated individuals who grow up in a religious framework and who are not seen in therapy. There remains among some therapists considerable ambivalence regarding more liberal and sophisticated religious beliefs whose validity can be neither proved nor disproved. When such beliefs are brought up as issues in connection with problems in living, therapists who have not resolved their own ambiguities are likely to depreciate them, to ignore them, or to interpret them routinely as immature defensive operations. For some therapists there m a y be a strong pull to influence the client toward their own type of belief or disbelief. Peteet discussed a number of problems encountered in the treatment of religious persons: resistance, guilt, trust and dependence on authority, countertransference, and ethical issues. 3 Based in part on a paper presented at the annual meeting of the California State Psychological Association, San Francisco, California, February 4, 1983. Dr. Sacks is Associate Dean E m e r i t u s of the California School of Professional Psychology, Fresno. He has been in the private practice of psychotherapy for more t h a n 30 years. 26
{~1985Institutes of Religionand Health
Joseph M. Sacks
27
Significance of religious commitment Pruyser advises careful assessment of the client's religiosity and its social and dynamic implications at the beginning of therapy as part of the case history. 4 In the course of gathering information about the client's background in connection with the presenting problems, religious affiliation of client and family and their commitment to it are often mentioned. At times the religious affiliation of the therapist may be questioned. It is important at this point to clarify the meaning of this to the client. When a client affirms that only a therapist with a particular religious orientation could deal with his or her problems, it is prudent to make a referral to such a therapist. Otherwise, once this question has been clarified, one can go on from there. Brooner describes some of the difficulties of working with religious patients when the therapist is nonreligious. 5 Beit-Hallahmi admits openly to his religious clients that he cannot share their views, b u t he assures them that this should not preclude their working together on other problems. However, he unwittingly expressed devaluation in saying of one client, "I attempted to help him go beyond the religious view to a more personal way of experiencing his relationship to his parents." 6 It is a delicate matter, then, to rule out one's own bias in assessing a client's religious conflict as truly neurotic, that is, one in which unresolved love, anger, and fear toward parental figures are projected onto a punitive, nonforgiving, depriving image of God, and to direct treatment accordingly; or to use the client's religious belief as a resource for coping and growth. This decision is especially relevant in view of the large proportion of individuals of all ages for whom religious identification is of major importance. In a survey of 213 undergraduates at Western Kentucky University, Templer and Dotson found that 84 of the students expressed strong attachment to their religious belief, 110 moderate attachment, and only 19 weak attachment. 7 In an identity study by Rosenberg of over 2000 high-school juniors and seniors in New York State, 54 percent rated their religion as very important to them; only 9 percent rated it as not very important. In a similar study of over 1200 black children in Baltimore, 48 percent rated their religion almost as important to them as their race. 8 It is apparent that religious identification is a major component of self-concept for many people that some therapists may tend to minimize. It is useful to consider a significant religious commitment in terms of its positive value to the individual's well-being. For example, Templer 9 and others, Young and Daniels, 1~and Gibbs and Achterberg-Lawles 11 have found that highly religious persons have a lower degree of death anxiety than those who are nonreligious. Tansey found lower levels of general anxiety in persons with high religious commitment who have available to them relatively fewer other ego-strength resources. 12 The significance of religion in the lives of so many people can be understood if we consider religion in its broadest sense to include a system of beliefs, practices, customs, and ceremonies rooted in a culture; a view of the individual's relationship to the universe; a moral and ethical code; and a community of adherents providing social relationships.13 If
Journal of Religion and Health
28
we grant that these components of religion meet some of mankind's fundamental needs, we shall be wary of stripping away or even of depreciating this resource.
Religious and psychotherapeutic values Religion and psychotherapy hold in common values relating actualization:
to self-
a commitment to growth toward one's potential; being productive; respect for the dignity and well-being of others as for one's own; responsibility for one's behavior; being in touch with one's self; a sense of relationship to the universe; and participation with others in sharing one's deepest emotional experiences. Therapists acknowledge the value of ceremonies and rituals in life cycle events from birth to death and of relating to a community that provides resources for sharing and support. It is also important to confront areas in which there are conflicting values between therapist and client. There are, for example, a number of sexual behaviors explicitly prohibited b y the Bible, such as adultery, incest, sodomy, masturbation, animalism, and homosexuality. With some of these, psychotherapists may have little difficulty in terms of value conflict. With others, there m a y be clear conflict, for example, with religious attitudes toward abortion. It is helpful to clarify areas of disagreement with a client holding strong religious convictions without implying that either perception is right or wrong and with respect for those convictions with which we don't agree. It is not helpful to become involved in discussions of the religious issues as such. The patient should be referred to his or her minister to clarify such issues from the religious standpoint.
Guilt There is a popular view of psychoanalysis, and b y extension of psychotherapy, as the advocate of complete individual freedom to express instinctual impulses with minimal restriction. This is not consistent with Freud's references to creative guilt and ethics as a therapeutic a t t e m p t to deal with what he viewed as the greatest hindrance to civilization--the constitutional inclination of human beings to be aggressive toward one another. It is the excessive and tyrannical aspects of superego for which Freud saw the need for therapeutic intervention. 14 Guilt is an area in which options for collaboration with clergy are available. In general, religious atonement, which has been interpreted to mean at-one-
Joseph M. Sacks
29
m e n t w i t h God, self, a n d fellow m a n , r e q u i r e s confession, sincere r e p e n t a n c e , a n d r e s t i t u t i o n . F o u r t y p e s of guilt m a y be d i s t i n g u i s h e d . T h e first t w o are a m e n a b l e to religious or p s y c h o t h e r a p e u t i c i n t e r v e n t i o n or both: realistic guilt, which is a p p r o p r i a t e to t h e d a m a g e one h a s done to a n o t h e r , a n d existential guilt, arising f r o m failure to live u p to o n e ' s p o t e n t i a l s . T h e t h i r d t y p e , n e u r o t i c guilt, which is a r e a c t i o n e x c e s s i v e in p r o p o r t i o n to t h e act, or r e p r e s e n t s a d i s p l a c e m e n t , is m o r e p r o p e r l y in t h e p r o v i n c e of p s y c h o t h e r a p y . F o r the f o u r t h t y p e , sins a g a i n s t God, as p e r c e i v e d b y t h e religious person, aft e r careful e x p l o r a t i o n of this issue, t h e p a t i e n t n e e d s to be r e f e r r e d to his c l e r g y m a n for resolution.
Case example The father of a woman in her thirties, married, with four children, is a fundamentalist minister who dominated his family by his dogmatism and wrath. She feels that he has made her mother a mindless nonperson. He pressured the patient to break up a youthful romance and to marry a man of religious views similar to his own. During the 18 years of their marriage, she has rebelled against her husband's religious views and practices. She comes to therapy because of chronic severe headaches and outbursts of rage, which at times are expressed in suicidal gestures. She has left home several times but always returns. Her husband, parents, and siblings insist that if she could see the light and share her burdens with the Lord, her troubles would vanish. She simply cannot buy this, but she is confused and ambivalent. As she has learned to recognize the transference elements of her relationship with her husband, she has become able to assert herself more appropriately with him. She found a church compatible with her convictions. Communication between therapist and minister established consistency in our approach. Family relationships improved, and she has become free of her headaches and rage reactions.
Summary I t is p r o p o s e d t h a t religious issues in p s y c h o t h e r a p y can be r e s o l v e d eff e c t i v e l y b y t h e e m p a t h i c c o l l a b o r a t i v e i n t e r v e n t i o n of t h e r a p i s t s w h o recognize the s t r e n g t h a n d g r o w t h - p r o v i d i n g a s p e c t s of religious c o m m i t m e n t a n d of clergy who can d i f f e r e n t i a t e r a t i o n a l religious c o n c e r n s f r o m n e u r o t i c conflict.
References 1. Freud, S., The Future of an Illusion. London, Hogarth, 1927. 2. Ostow, M., "The Nature of Religious Controls." Amer. Psychologist, 1958, 13, 571-574. 3. Peteet, J.R., "Issues in the Treatment of Religious Patients," Amer. J. Psychotherapy, 1981, 35, 559-564. 4. Pruyser, P.W., "Assessment of the Patient's Religious Attitudes in the Psychiatric Case Study," Bulletin of the Menninger Clinic, 1971, 35, 272-291. 5. Brooner, A., "Psychotherapy with Religious Patients," Amer. J. Psychotherapy, 1964, 18, 475-487.
30
Journal of Religion and Health
6. Beit-Hallahmi, B., "Encountering Orthodox Religion in Psychotherapy," Psychotherapy: Theory, Practice and Research, 1975, 12, 357-359. 7. Templer, D.I., and Dotson, E., "Religious Correlates of Death Anxiety," Psychological Reports, 1970, 26, 895-897. 8. Rosenberg, M., Conceiving the Self New York, Basic Books, 1979. 9. Templer, D.I., "Death Anxiety in Religiously Very Involved Persons," Psychological Reports, 1972,31, 361-362. 10. Young, M., and Daniels, S., "Born Again Status as a Factor in Death Anxiety," PsychologicalReports, 1980, 47, 367-370. 11. Gibbs, H.W., and Achterberg-Lawles, J., "Spiritual Values and Death Anxiety: Implications for Counseling with Terminal Cancer Patients," J. Counseling Psychology, 1978, 25, 563569. 12. Tansey, M., "Religious Commitment and Anxiety Level as Functions of Ego Strength," Doctoral Dissertation, California School of Professional Psychology, 1980. 13. Cox, R.H., ed., Religious Systems and Psychotherapy. Springfield, Ill., Charles Thomas, 1973. 14. Freud, S., Civilization and its Discontents. New York, Norton, 1930.
Religious Issues in Psychotherapy J O S E P H M. SACKS ABSTRACT." Religious belief is i m p o r t a n t to a large proportion of our population. It has been found to be a potent neutralizer of death anxiety. Religion and psychotherapy share values relating to self-actualization. It is the responsibility of psychotherapists to be aware of their own ambivalences and biases; to assess the significance of religious belief in the lives of their clients; to clarify conflicting views and values of client and therapist; to t r e a t the client's psychodynamic problems; and respectfully to refer spiritual problems outside the domain of psychotherapy to the client's minister. An illustrative example from the a u t h o r ' s practice is included.
Religion and psychotherapy were once closely allied, and most psychiatric disorders were considered to indicate a disturbance in the person's spiritual life. The modern era of psychotherapy has marked a split in this alliance, and at times an antithetic relationship between practitioners of religion and psychotherapy has existed. Freud depreciated religion as an infantile dependency and blind faith in God, an illusion used as a defense against humanity's helplessness before the external forces of nature and its own uncontrolled instincts.I Contemporary therapists tend to agree with Freud with respect to a fundamentalist concept of the deity as a being endowed with h u m a n attributes who directs and controls our destinies. Ostow followed Freud in holding t h a t obedience to doctrinal religious commandments is derived from an original need for parental love and/or fear of parental punishment. 2 However, he pointed out that in therapy we see disturbed individuals in a regressed relationship to society as a parental surrogate. He does not regard these regressed relationships as characteristic of well-integrated individuals who grow up in a religious framework and who are not seen in therapy. There remains among some therapists considerable ambivalence regarding more liberal and sophisticated religious beliefs whose validity can be neither proved nor disproved. When such beliefs are brought up as issues in connection with problems in living, therapists who have not resolved their own ambiguities are likely to depreciate them, to ignore them, or to interpret them routinely as immature defensive operations. For some therapists there m a y be a strong pull to influence the client toward their own type of belief or disbelief. Peteet discussed a number of problems encountered in the treatment of religious persons: resistance, guilt, trust and dependence on authority, countertransference, and ethical issues. 3 Based in part on a paper presented at the annual meeting of the California State Psychological Association, San Francisco, California, February 4, 1983. Dr. Sacks is Associate Dean E m e r i t u s of the California School of Professional Psychology, Fresno. He has been in the private practice of psychotherapy for more t h a n 30 years. 26
{~1985Institutes of Religionand Health
Joseph M. Sacks
27
Significance of religious commitment Pruyser advises careful assessment of the client's religiosity and its social and dynamic implications at the beginning of therapy as part of the case history. 4 In the course of gathering information about the client's background in connection with the presenting problems, religious affiliation of client and family and their commitment to it are often mentioned. At times the religious affiliation of the therapist may be questioned. It is important at this point to clarify the meaning of this to the client. When a client affirms that only a therapist with a particular religious orientation could deal with his or her problems, it is prudent to make a referral to such a therapist. Otherwise, once this question has been clarified, one can go on from there. Brooner describes some of the difficulties of working with religious patients when the therapist is nonreligious. 5 Beit-Hallahmi admits openly to his religious clients that he cannot share their views, b u t he assures them that this should not preclude their working together on other problems. However, he unwittingly expressed devaluation in saying of one client, "I attempted to help him go beyond the religious view to a more personal way of experiencing his relationship to his parents." 6 It is a delicate matter, then, to rule out one's own bias in assessing a client's religious conflict as truly neurotic, that is, one in which unresolved love, anger, and fear toward parental figures are projected onto a punitive, nonforgiving, depriving image of God, and to direct treatment accordingly; or to use the client's religious belief as a resource for coping and growth. This decision is especially relevant in view of the large proportion of individuals of all ages for whom religious identification is of major importance. In a survey of 213 undergraduates at Western Kentucky University, Templer and Dotson found that 84 of the students expressed strong attachment to their religious belief, 110 moderate attachment, and only 19 weak attachment. 7 In an identity study by Rosenberg of over 2000 high-school juniors and seniors in New York State, 54 percent rated their religion as very important to them; only 9 percent rated it as not very important. In a similar study of over 1200 black children in Baltimore, 48 percent rated their religion almost as important to them as their race. 8 It is apparent that religious identification is a major component of self-concept for many people that some therapists may tend to minimize. It is useful to consider a significant religious commitment in terms of its positive value to the individual's well-being. For example, Templer 9 and others, Young and Daniels, 1~and Gibbs and Achterberg-Lawles 11 have found that highly religious persons have a lower degree of death anxiety than those who are nonreligious. Tansey found lower levels of general anxiety in persons with high religious commitment who have available to them relatively fewer other ego-strength resources. 12 The significance of religion in the lives of so many people can be understood if we consider religion in its broadest sense to include a system of beliefs, practices, customs, and ceremonies rooted in a culture; a view of the individual's relationship to the universe; a moral and ethical code; and a community of adherents providing social relationships.13 If
Journal of Religion and Health
28
we grant that these components of religion meet some of mankind's fundamental needs, we shall be wary of stripping away or even of depreciating this resource.
Religious and psychotherapeutic values Religion and psychotherapy hold in common values relating actualization:
to self-
a commitment to growth toward one's potential; being productive; respect for the dignity and well-being of others as for one's own; responsibility for one's behavior; being in touch with one's self; a sense of relationship to the universe; and participation with others in sharing one's deepest emotional experiences. Therapists acknowledge the value of ceremonies and rituals in life cycle events from birth to death and of relating to a community that provides resources for sharing and support. It is also important to confront areas in which there are conflicting values between therapist and client. There are, for example, a number of sexual behaviors explicitly prohibited b y the Bible, such as adultery, incest, sodomy, masturbation, animalism, and homosexuality. With some of these, psychotherapists may have little difficulty in terms of value conflict. With others, there m a y be clear conflict, for example, with religious attitudes toward abortion. It is helpful to clarify areas of disagreement with a client holding strong religious convictions without implying that either perception is right or wrong and with respect for those convictions with which we don't agree. It is not helpful to become involved in discussions of the religious issues as such. The patient should be referred to his or her minister to clarify such issues from the religious standpoint.
Guilt There is a popular view of psychoanalysis, and b y extension of psychotherapy, as the advocate of complete individual freedom to express instinctual impulses with minimal restriction. This is not consistent with Freud's references to creative guilt and ethics as a therapeutic a t t e m p t to deal with what he viewed as the greatest hindrance to civilization--the constitutional inclination of human beings to be aggressive toward one another. It is the excessive and tyrannical aspects of superego for which Freud saw the need for therapeutic intervention. 14 Guilt is an area in which options for collaboration with clergy are available. In general, religious atonement, which has been interpreted to mean at-one-
Joseph M. Sacks
29
m e n t w i t h God, self, a n d fellow m a n , r e q u i r e s confession, sincere r e p e n t a n c e , a n d r e s t i t u t i o n . F o u r t y p e s of guilt m a y be d i s t i n g u i s h e d . T h e first t w o are a m e n a b l e to religious or p s y c h o t h e r a p e u t i c i n t e r v e n t i o n or both: realistic guilt, which is a p p r o p r i a t e to t h e d a m a g e one h a s done to a n o t h e r , a n d existential guilt, arising f r o m failure to live u p to o n e ' s p o t e n t i a l s . T h e t h i r d t y p e , n e u r o t i c guilt, which is a r e a c t i o n e x c e s s i v e in p r o p o r t i o n to t h e act, or r e p r e s e n t s a d i s p l a c e m e n t , is m o r e p r o p e r l y in t h e p r o v i n c e of p s y c h o t h e r a p y . F o r the f o u r t h t y p e , sins a g a i n s t God, as p e r c e i v e d b y t h e religious person, aft e r careful e x p l o r a t i o n of this issue, t h e p a t i e n t n e e d s to be r e f e r r e d to his c l e r g y m a n for resolution.
Case example The father of a woman in her thirties, married, with four children, is a fundamentalist minister who dominated his family by his dogmatism and wrath. She feels that he has made her mother a mindless nonperson. He pressured the patient to break up a youthful romance and to marry a man of religious views similar to his own. During the 18 years of their marriage, she has rebelled against her husband's religious views and practices. She comes to therapy because of chronic severe headaches and outbursts of rage, which at times are expressed in suicidal gestures. She has left home several times but always returns. Her husband, parents, and siblings insist that if she could see the light and share her burdens with the Lord, her troubles would vanish. She simply cannot buy this, but she is confused and ambivalent. As she has learned to recognize the transference elements of her relationship with her husband, she has become able to assert herself more appropriately with him. She found a church compatible with her convictions. Communication between therapist and minister established consistency in our approach. Family relationships improved, and she has become free of her headaches and rage reactions.
Summary I t is p r o p o s e d t h a t religious issues in p s y c h o t h e r a p y can be r e s o l v e d eff e c t i v e l y b y t h e e m p a t h i c c o l l a b o r a t i v e i n t e r v e n t i o n of t h e r a p i s t s w h o recognize the s t r e n g t h a n d g r o w t h - p r o v i d i n g a s p e c t s of religious c o m m i t m e n t a n d of clergy who can d i f f e r e n t i a t e r a t i o n a l religious c o n c e r n s f r o m n e u r o t i c conflict.
References 1. Freud, S., The Future of an Illusion. London, Hogarth, 1927. 2. Ostow, M., "The Nature of Religious Controls." Amer. Psychologist, 1958, 13, 571-574. 3. Peteet, J.R., "Issues in the Treatment of Religious Patients," Amer. J. Psychotherapy, 1981, 35, 559-564. 4. Pruyser, P.W., "Assessment of the Patient's Religious Attitudes in the Psychiatric Case Study," Bulletin of the Menninger Clinic, 1971, 35, 272-291. 5. Brooner, A., "Psychotherapy with Religious Patients," Amer. J. Psychotherapy, 1964, 18, 475-487.
30
Journal of Religion and Health
6. Beit-Hallahmi, B., "Encountering Orthodox Religion in Psychotherapy," Psychotherapy: Theory, Practice and Research, 1975, 12, 357-359. 7. Templer, D.I., and Dotson, E., "Religious Correlates of Death Anxiety," Psychological Reports, 1970, 26, 895-897. 8. Rosenberg, M., Conceiving the Self New York, Basic Books, 1979. 9. Templer, D.I., "Death Anxiety in Religiously Very Involved Persons," Psychological Reports, 1972,31, 361-362. 10. Young, M., and Daniels, S., "Born Again Status as a Factor in Death Anxiety," PsychologicalReports, 1980, 47, 367-370. 11. Gibbs, H.W., and Achterberg-Lawles, J., "Spiritual Values and Death Anxiety: Implications for Counseling with Terminal Cancer Patients," J. Counseling Psychology, 1978, 25, 563569. 12. Tansey, M., "Religious Commitment and Anxiety Level as Functions of Ego Strength," Doctoral Dissertation, California School of Professional Psychology, 1980. 13. Cox, R.H., ed., Religious Systems and Psychotherapy. Springfield, Ill., Charles Thomas, 1973. 14. Freud, S., Civilization and its Discontents. New York, Norton, 1930.
