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Book Forum: Psychotherapies   |    
Handbook of Psychotherapy and Religious Diversity
Am J Psychiatry 2002;159:883-a-885. doi:10.1176/appi.ajp.159.5.883-a
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Hartford, Conn.

Edited by P. Scott Richards and Allen E. Bergin. Washington, D.C., American Psychological Association, 2000, 516 pp., $39.95.

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The editors begin by stating that "the alienation that has existed between the mental health professions and religion for most of the 20th century is ending. The influence of the naturalistic, antireligious assumptions that once gripped the field have weakened, and there is now a more spiritually open Zeitgeist." Seizing the opportunity to respond to the Zeitgeist, the editors attempt to provide therapists (either secular or presumably ignorant of other creeds) with a core knowledge base of the world’s main religions. It is an ambitious task with the goal "to add our voices to those of other scholars and practitioners who, in recent years, have urged mental health professionals to acquire greater competency in religious and spiritual aspects of diversity."

In an attempt to educate their audience, the editors present statistical charts, diagrams, tables, and an extensive reference list. Anyone unfamiliar with their patients’ specific religious beliefs and faith community will find this tome worthwhile. It is no substitute, however, for empathy and good listening skills. It is hard to imagine any competent therapist not asking questions about his or her patient’s spirituality (it is mandated by the Joint Commission on Accreditation of Healthcare Organizations to assess a patient’s spiritual needs and develop a spiritual "treatment" plan as needed). This tome should not be used as a substitute for good therapeutic technique. Spiritual issues may arise anywhere along the continuum of psychotherapy and must be managed differently at each stage. Moreover, learning details about a specific religion’s credo and how a faith-based community operates tells us nothing about how our patients understand and live out their creed and relate to their faith community.

The danger of this book is that it may be taken too literally as a cookbook to treat problems that don’t exist for our patients. It also assumes that followers of Christian, Jewish, Muslim, or ethnic-centered faiths will know and live out all the details of their faith’s belief systems and rituals. This may be one of the most serious errors of the book, that is, not recognizing how individualized and idiosyncratic are an individual’s religious beliefs and practices within any religious context. Reading about a person’s faith is no substitute for listening to how our patients live out their faith, often in confusion and contradiction to some of their faith’s core belief structures.

Little attention is given to the ways organized religion and faith-based systems may originate or perpetuate mental illness through discouraging needed drugs or therapy. Moreover, many religious institutions may support patriarchal systems that dominate and subjugate women, may teach inaccurate, pseudo-scientific views of sexuality (or evolution), and may perpetuate damaging superstitions that encourage obedience and authoritarian rule when agency and personal response may be needed. During marital crises in which changing male and female roles are at issue, an institutional religious response may be harsh. Knowing that some of the core teachings of our patients’ religious belief structures may increase the severity of their symptoms, how are we to respond? Some of the case material in the handbook suggests that a correct therapeutic approach, even from a religious standpoint, may be in conflict with the core aspects of the religion.

Currently, religion and prayer are in vogue among some groups of therapists. Some therapists may be drawn to spiritual practices because of their frustration with ordinary therapeutic technique or a personal need to connect emotionally with their patients’ souls. When therapists reach this stage, the possibility of boundary crossings and violations increases. Some ministers and pastors may be drawn to psychological science and psychotherapeutic techniques because their personal experiences with parishioners led them to feel that their religious methods are inadequate to address psychopathology. Some of these ministers may incorporate psychological insights into their liturgy and sermons, while also looking for therapies that can be grafted onto religious texts. The psychological-religious landscape is complex, and the potential for doing harm to our patients by mixing spiritualism with psychotherapy should not be underestimated.

The warning in the final chapter of this book against the clinician’s becoming "overwhelmed or even confused" by the "breathtaking…religious landscape of North America" seems a bit patronizing. Actually, the summary tables in this chapter suggest a more monolithic view of the diverse religions in that landscape. Most religions share similar negative attitudes regarding the role of women, sexuality, contraception, premarital/ homosexual/extramarital sex, and divorce. Issues of abortion, suicide, and euthanasia are also viewed in a negative light. Religious intolerance of diversity is not discussed.

The summary table 19 will probably become the centerpiece of this tome, which would be unfortunate because of the way the belief systems of the different religions are oversimplified and stereotyped. A review of therapy recommendations listed in table 19 for religiously diverse groups is discouraging. Latinos, we are told, should not be treated in individual therapy because individualist intervention approaches are less congruent with the Latino collectivist world view. We are also told to use a developmental approach with Hindus, empathic understanding with African Americans, supportive meditative practices with Buddhists, cultural therapy with Muslims, spiritual prayer and spiritual self-disclosure with Latter-day Saints, relaxation training and rational emotive therapy with Seventh Day Adventists, motifs of healing and internalized God representations for Catholics, supportive spiritual growth for the Eastern Orthodox, collaboration with pastoral care and some secular approaches with mainstream Protestants, spiritual interventions and some secular therapy for Evangelical and Fundamentalist Protestants, no psychological interventions that are contrary to Pentecostal scriptural understandings, and, finally, psychodynamic and other cognitively oriented approaches with Conservative and Reform Jews, and spiritual interventions for Orthodox Jews, who are seen as having mixed feelings about psychodynamic therapy. Such a summarization is not only confusing but also misleading and stereotyping, wrongheaded, and possibly destructive. I tried to envision what a managed care treatment plan might look like as a result of these recommendations.

Given the way many faith communities have crossed or violated so many boundaries of their parishioners and how insensitive some organized religions have been to the victims of clergy abuse, it seems fair to say that before any rapprochement can be made between faith and psychotherapy, it is equally as important for faith traditions to become less paternalistic, authoritarian, xenophobic, and isolative in order to allow their parishioners access to the mental health care they need.

The mental health field is dominated by pleas from all sectors for competency in all areas of mental health. If the editors support specific competencies in religion for therapists, I suggest that they also support competencies for clerics who offer psychotherapy to their parishioners. For a dialogue to take place, there must be portals of entry into such a dialogue from all positions. The effort to deepen one’s spirituality and develop a sense of agency may eventually lead a patient either toward or away from mainstream religion. Either outcome must be acceptable (by both parties) if therapy is to have any meaning.

For the most part, we should not be giving our patients legal or financial advice and certainly not religious advice. Therapists who pray with their patients, read the Bible with them (for therapeutic purposes), use touch as a form of religious healing, and give sermons to their patients are probably treading on thin ice. When my religious patients are at a religious impasse we may reach out to their faith system and enjoin their minister to provide spiritual guidance. In many situations the impasse may still exist after the consultation. As psychotherapists we strive to maintain good boundaries in therapy. Our patients rely on our expertise and our ability to maintain good boundaries, to use good clinical judgment and diagnostic skills, and to do them no harm. Unfortunately, these issues are not fully addressed in the Handbook of Psychotherapy and Religious Diversity and are ignored with respect to Christianity (in the subject index, the word "Boundaries" is indexed only for African Americans, Buddhism, and Judaism). The strengths of this book are in the rich mixtures of facts and clinical vignettes that help clinicians question their hypotheses and listen more closely to their patients’ needs.




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