CASEBOOK FOR

A SPIRITUAL STRATEGY
IN COUNSELING
AND PSYCHOTHERAPY
 CASEBOOK FOR

A SPIRITUAL
STRATEGY
IN
COUNSELING
AND
PSYCHOTHERAPY

EDITED BY

P. SCOTT RICHARDS
AND
ALLEN E. BERGIN

AMERICAN PSYCHOLOGICAL ASSOCIATION

Washington, DC
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Library of Congress Cataloging-in-Publication Data

Casebook for a spiritual strategy in counseling and psychotherapy / edited by P. Scott

Richards and Allen E. Bergin.—1st ed.
p. cm.
Includes bibliographical references and indexes.
ISBN 1-59147-056-0
1. Psychotherapy—Religious aspects—Case studies. 2. Mental health counseling—
Religious aspects—Case studies. I. Richards, P. Scott. II. Bergin, Allen E., 1934-

RC489.S676C37 2003 2003014054

616.89—dc21

British Library Cataloguing-in-Publication Data

A CIP record is available from the British Library.

Printed in the United States of America

First Edition
 Dedicated to the late David B. Larson
and his wife Susan,
courageous leaders in the integration of spirituality and health.
 CONTENTS

Contributors xi
Preface xiii
Acknowledgments xv

I. Introduction 1
Chapter 1. A Theistic Spiritual Strategy for
Psychotherapy 3
P. Scott Richards and Allen E. Bergin

II. Programmatic, Group, and Marital Therapies 33

Chapter 2. A Theistic Approach to Therapeutic
Community: Non-Naturalism and the
Alldredge Academy 35
Brent D. Slife, L. Jay Mitchell, and
Matthew Whoolery
Chapter 3. A Theistic Inpatient Treatment Approach
for Eating-Disorder Patients: A Case Report 55
Randy K. Hardman, Michael E. Berrett,
and P. Scott Richards
Chapter 4- A Spiritual Formulation of Interpersonal Psychotherapy
for Depression in Pregnant Girls 75
Lisa Miller

vn
Chapter 5. Forgiveness in Marital Therapy 87
Mark]. Krejd

III. Individual Denominational Therapies (Within Faiths) .... 103

Chapter 6. Spiritual Interventions in the Treatment
of Dysthymia and Alcoholism 105
Richard Dobbins
Chapter 7. Judaic Therapeutic Spiritual Counseling:
Guiding Principles and Case Histories 119
Aaron Rabinowitz
Chapter 8. Integrative Spiritually Oriented Psychotherapy:
A Case Study of Spiritual and Psychological
Transformation 141
Len Sperry
Chapter 9. A Psychodynamic Case Study 153
Edward P. Shafranske

IV. Individual Ecumenical Therapies (Across Faiths) 171

Chapter 10. Crossing Traditions: Ignatian Prayer With
a Protestant African American
Counseling Dyad 173
Donelda A. Cook
Chapter 11. The Perilous Pranks of Paul: A Case of
Sexual Addiction 187
Carole A. Raybum
Chapter 12. Humanistic Integrative Spiritual Psychotherapy
With a Sufi Convert 201
William West
Chapter 13. A Mormon Rational Emotive Behavior
Therapist Attempts Qur'anic Rational
Emotive Behavior Therapy 213
Stevan Lars Nielsen
Chapter 14. A Psychobiological Link to Spiritual
Health 231
Zari Hedayat-Diba

viii CONTENTS
Chapter 15. Rational Emotive Behavior Therapy for
Disturbance About Sexual Orientation 247
W. Brad Johnson

Chapter 16. Religious Cross-Matches Between Therapists

and Clients 267
Robert]. Lovinger and Sophie L. Lovinger

V. Conclusion 285
Chapter 17. Theistic Perspectives in Psychotherapy:
Conclusions and Recommendations 287
P. Scott Richards and Allen E. Bergin

Author Index 309

Subject Index 315

About the Editors 329

CONTENTS ix
 CONTRIBUTORS

Allen E. Bergin, PhD, Emeritus, Department of Psychology, Brigham

Young University, Provo, UT
Michael E. Berrett, PhD, Center for Change, Provo, UT
Donelda A. Cook, PhD, Counseling Center, Loyola College, Baltimore,
MD
Richard Dobbins, PhD, EMERGE Ministries, Akron, OH
Randy K. Hardman, PhD, Center for Change, Provo, UT
Zari Hedayat-Diba, PhD, private practice; Adjunct Faculty, Antioch
University; Core Faculty, Infant Mental Health Interdisciplinary
Training Institute, Los Angeles, CA
W. Brad Johnson, PhD, Department of Leadership, Ethics, and Law,
United States Naval Academy, Annapolis, MD
Mark J. Krejci, PhD, Psychology Department, Concordia College,
Moorhead, MN
Robert J. Lovinger, PhD, ABPP, Professional Psychology Program,
Walden University, Minneapolis, MN
Sophie L. Lovinger, PhD, ABPP, Professional Psychology Program,
Walden University, Minneapolis, MN
Lisa Miller, PhD, Clinical Psychology Program, Teachers College,
Columbia University, New York
L. Jay Mitchell, LLD, Alldredge Academy, Davis, WV
Stevan Lars Nielsen, PhD, Brigham Young University, Provo, UT
Aaron Rabinowitz, PhD, Department of Psychology, Bar-Han University,
Ramat Gan, Israel
Carole A. Rayburn, PhD, private practice, Silver Spring, MD
P. Scott Richards, PhD, Department of Counseling Psychology, Brigham
Young University, Provo, UT
Edward P. Shafranske, PhD, ABPP, Graduate School of Education and
Psychology, Pepperdine University, Irvine, CA
Brent D. Slife, PhD, Department of Psychology, Brigham Young
University, Provo, UT
Len Sperry, MD, PhD, Department of Psychiatry and Behavioral
Medicine, Medical College of Wisconsin, Milwaukee, WI;
Department of Counseling, Florida Atlantic University, Boca Raton
William West, PhD, Faculty of Education, University of Manchester,
Manchester, England
Matthew Whoolery, MS, Department of Social Science and Education,
College of Southern Idaho, Twin Falls, ID

xii CONTRIBUTORS
 PREFACE

Not long after the publication of our book about psychotherapy and
religious diversity,1 our editors at the American Psychological Association
(APA) Books Department encouraged us to begin planning for the second
edition of our first APA book, A Spiritual Strategy for Counseling and Psycho-
therapy.1 As we contemplated this possibility, we decided that a third book
was needed to further assist practitioners—an applied book of spiritual strat'
egy case studies.
In A Spiritual Strategy for Counseling and Psychotherapy, we described a
theoretical framework and applied approach for implementing theistic spiri-
tual perspectives into mainstream psychology and psychotherapy. The Hand-
book of Psychotherapy and Religious Diversity provided many additional reli-
gious-cultural and clinical insights that can assist mainstream professionals
in working effectively with clients from a diversity of spiritual traditions.
This new volume, Casebook for a Spiritual Strategy in Counseling and Psy-
chotherapy, provides in-depth, applied insight into the diversity of ways that
theistic spiritual perspectives and interventions can positively influence the
processes and outcomes of psychological treatment. We believe that this case-
book will be especially helpful to practitioners and graduate students in the
mental health professions. As we have read the fascinating case reports in
this book, our own understandings about how spiritual perspectives can en-
hance clinical practice have broadened and deepened. We feel confident
that you will have a similar experience.

'Richards, P. S., & Bergin, A. E. (Eds.). (2000). Handbook of psychotherapy and religious diversity.
Washington, DC: American Psychological Association.
2
Richards, P. S., (Si Bergin, A. E. (1997). A spiritual strategy for counseling and psychotherapy.
Washington, DC: American Psychological Association.

Xlll
 ACKNOWLEDGMENTS

We are grateful to Susan Reynolds, our acquisitions editor at the Ameri-

can Psychological Association (APA). From the beginning, she recognized
that a book of case studies illustrating the application of theistic perspectives
in counseling and psychotherapy would be a valuable contribution to the
literature. Her support and advice in the formative stages of the book were
crucial.
We are grateful to Vanessa Downing and Tiffany Klaff, our editors at
APA, and to the rest of the APA Books development and production staff.
Their feedback and suggestions for refining the book manuscript were in-
valuable. We express our appreciation to two anonymous reviewers who of-
fered wise feedback and helpful encouragement.
We are grateful to the authors of the case reports for their courage in
publicly sharing their theistic treatment approaches. We regard them as our
colleagues and friends. We respect their work and appreciate the time they
gave in writing up their cases. We also appreciate the patience they demon-
strated as they responded to our suggestions for refining their case reports
and to our many requests for information and paperwork.
We express gratitude to several other professional colleagues, including
Melissa Allen, Ronald D. Bingham, Lane Fischer, Richard A. Heaps, Aaron
P. Jackson, Steven A. Smith, Timothy B. Smith, and James R. Young. Their
encouragement and friendship over the years have been a source of inspira-
tion and enjoyment.
We are grateful to several talented undergraduate psychology students
at Brigham Young University: Jeremy Bartz, Adam Froerer, Kari O'Grady,
and Coral Richards. Their insightful feedback about the book chapters and
enthusiasm for the topic were extremely helpful.
Finally, we express our profound gratitude to our wives, Marcia Richards
and Marian Bergin. Their love, support, and sacrifice on our behalf have
made all the difference in the world.
 I
INTRODUCTION
 A THEISTIC SPIRITUAL STRATEGY
1
FOR PSYCHOTHERAPY
P. SCOTT RICHARDS AND ALLEN E. BERGIN

The alienation that existed between psychology and religion during

most of the 20th century has ended. Hundreds of articles on religion and
mental health and spirituality and psychotherapy have been published in
professional journals. Numerous presentations have been given at professional
conferences. Many mainstream publishers have published books on these
topics. All of the major mental health organizations now explicitly recognize
that religion is one type of diversity that professionals are obligated to re-
spect. Clearly, a more spiritually open Zeitgeist or "spirit of the times" is upon
us (Richards & Bergin, 1997).
The rise of a spiritual Zeitgeist has opened the door to the development
and integration of spiritual perspectives and interventions into mainstream
psychological practice (Collins, 1977; Larson & Larson, 1994; Miller, 1999;
Peck, 1978; Richards & Bergin, 1997, 2000; Shafranske, 1996). During the
past decade, numerous spiritual psychotherapy approaches have been pro-
posed, including those conceptually grounded in Buddhist, Hindu, Chris-
tian, Jewish, and Muslim spiritual thought (Collins, 1988; Epstein, 1995;
Hedayat-Diba, 2000; Rabinowitz, 2001; Rubin, 1996; Sharma, 2000; Spero,
1985). Spiritual approaches based on Jungian, transpersonal, cognitive, and
humanistic psychologies have also been proposed (Elkins, 1995; Helminiak,
1996; Nielsen, Johnson, & Ellis, 2001; Vaughan, Wittine, & Walsh, 1996).
Several writers have also described multicultural psychotherapy approaches
that are not grounded in a particular spiritual tradition or psychological theory,
but that advocate respect for religious and spiritual diversity (Faiver, Ingersoll,
O'Brien, & McNally, 2001; Griffith & Griffith, 2002; Kelly, 1995; Lovinger,
1984; Sperry, 2001; Swinton, 2001; West, 2000).
We regard the development of a variety of spiritual psychotherapy ap-
proaches as a positive trend in the mental health professions. The diversity
of religious and spiritual beliefs and practices in the world is astonishing
(Keller, 2000; Richards & Bergin, 2000). It seems obvious that a variety of
spiritual approaches to psychotherapy will be needed to respond to this di-
versity. We hope that creative and competent theorists and practitioners
from diverse spiritual traditions will continue the effort to develop and evaluate
new and more effective spiritual psychotherapy approaches.
Although we think there is value in diversity, we have devoted our
efforts during the past 25 years to the development of a specific theistic spiri-
tual strategy for mainstream psychology and psychotherapy (Bergin, 1980a,
1983, 1985, 1988, 1991; Richards & Bergin, 1997). Given the fact that in
North America and Europe more than 80% of the population professes belief
in one of the theistic world religions (Barrett & Johnson, 1998), we think
such an approach is a vital ingredient in the multicultural spectrum (Bergin,
1980a; Richards & Bergin, 2000). Although we do not endorse all of the
teachings and practices advocated by the theistic world religions, there is
nevertheless much therapeutic potential in these traditions for individuals
and groups in need (Benson, 1996; Richards & Bergin, 1997), and we hope
to tap their healing resources.
As we have developed and shared our theistic spiritual strategy over the
years, we have had the opportunity to visit and correspond with mental health
professionals from many different religious and theoretical backgrounds who
have incorporated theistic perspectives into their professional work. These
experiences have helped us appreciate more fully the implications of such
perspectives for psychotherapy. A major purpose of the present book, Case-
book for a Spiritual Strategy in Counseling and Psychotherapy, is to demonstrate
the diverse and creative ways that theistic perspectives can influence clinical
theory and practice. Consider the following preview of some of the cases.1
Case I: Laura
Laura, a 16-year-old Caucasian woman, had no religious affiliation.
Laura's birth mother and father were drug addicts, and neither was cur-
rently involved in Laura's life. Laura's grandparents had custody of her.
Prior to her current treatment, Laura had been admitted to an inpatient

'In accordance with guidelines of the American Psychological Association, all cases in this book have
been disguised by changing clients' names and other identifying details.

RICHARDS AND BERGIN

 psychiatric ward for a number of problems, including running away, heavy
drug use, and misdemeanor convictions for shoplifting and truancy. She
had also been diagnosed with attention-deficit/hyperactivity disorder
(ADHD; with secondary depression) and placed on Prozac, but her prob-
lem behaviors continued. An educational consultant for the psychiatric
hospital with expertise in the special needs of youth had referred Laura
to Alldredge Academy, a residential adolescent treatment program lo-
cated in the mountains of West Virginia. Alldredge Community is based
on a nonnaturalistic, ecumenical theistic treatment philosophy that
among other things teaches adolescents spiritual values and helps them
learn to listen to the "Source" (the Alldredge term for God or Spirit).

Case 2: Paul
Paul, a 52-year-old Caucasian man, was a Southern Baptist of moderate
devoutness. Paul was experiencing much concern about why his family
and friends had not accepted his most recent extramarital lover of 3 years,
Fritzi. Paul was still married to Cathy, 51, his wife of 34 years, although he
lived with Fritzi. Paul and Fritzi were experiencing conflict when Paul started
therapy because Paul had become impotent, perhaps due to some heart
medications he was taking. Fritzi had begun insulting Paul at every oppor-
tunity and criticizing his sexual prowess and appearance. Despite his extra-
marital relationship with Fritzi and many other extramarital affairs, Paul
considered himself to be a religious and spiritual person, attended church
services on a fairly regular basis, and professed his belief in God and Jesus
Christ. Paul presented for individual therapy with Dr. Carole Rayburn, a
Seventh-day Adventist woman, whose therapeutic approach is heavily
influenced by a theistic, God and Christ-centered worldview.

Case 3: Grace
Grace, a 39-year-old, single African American woman, was affiliated
with an African American Baptist church. Grace had a master's degree in
school counseling and was employed in a high school as the head of the
counseling department. Grace was also a recently licensed minister in her
church. Grace was experiencing considerable stress trying to meet the de-
mands of her life, including full-time employment, church ministry, and
seminary. Grace had little time for herself because she was putting forth as
much effort and energy in her part-time unpaid church ministry as in her
full-time employment, because of her passion for ministry and her need for
approval from her pastor. Grace also had unresolved issues because she
had not yet married or had children. Grace sought therapy from Dr. Donelda
Cook after participating in a weekend Scripture-based meditative prayer
retreat conducted by Dr. Cook. Multicultural psychology and an ecumeni-
cal, theistic spiritual perspective inform Dr. Cook's therapeutic approach.

Case 4: Renee
Renee, a 16-year-old African American young woman, was a Chris-
tian with no current denominational affiliation. Renee was 5 months

A THEISTIC SPIRITUAL STRATEGY

 pregnant. Renee was experiencing severe depression and met diagnostic
criteria according to the Diagnostic and Statistical Manual of Mental Disor-
ders (4th ed.; DSM-IV; American Psychiatric Association, 1994) for major
depressive disorder. Renee's depression stemmed from issues of abandon-
ment and loss. Her mother had died within the past year, leaving her
without a family or home. Renee's biological father would not allow her
to live with him and his new wife, and he refused to speak to Renee
because of her pregnancy. Renee's boyfriend, the father of her baby, had
turned against Renee and disowned the baby when Renee refused to have
an abortion. Renee was referred for group psychotherapy in a public high
school in New York City. Dr. Lisa Miller, a Caucasian Jewish woman
whose therapeutic orientation is influenced by a theistic spiritual per-
spective of pathology, resilience, and renewal, led the group.

In addition to illustrating the diverse ways that theistic perspectives can

influence clinical practice, another major purpose of the Casebook for a Spiri-
tual Strategy in Counseling and Psychotherapy, is to help mental health profes-
sionals more fully understand how to effectively implement theistic perspec-
tives and interventions in their work. There is still much to be learned about
implementing spiritual interventions in psychotherapy, and we think the case
studies described in this book offer many valuable insights for clinicians.
A final purpose of this book is to help mental health professionals who
would like to more fully incorporate theistic perspectives into their theoreti-
cal framework and therapy approach gain additional insight into how they
might do so. Most mental health professionals are trained in secular psycho-
therapy traditions, and we suspect that they, like us, may find it easier to
think and practice consistent with their secular training. Incorporating the-
istic perspectives into one's therapeutic orientation in a philosophically and
theoretically sound manner is not necessarily easy. We hope that the Case-
book for a Spiritual Strategy in Counseling and Psychotherapy helps mental health
professionals more fully succeed at this challenging task.
The following is a brief summary of our theistic spiritual strategy for
psychotherapy. We hope that this information will help you more fully un-
derstand and appreciate the case studies presented in the book. We also hope
it helps make clear that our strategy provides a broad framework that psycho-
therapists of diverse theistic backgrounds and orientations can use to con-
ceptualize, guide, and evaluate their work. We conclude this chapter by briefly
describing the plan of the book.

A THEISTIC SPIRITUAL STRATEGY

In A Spiritual Strategy for Counseling and Psychotherapy (Richards &

Bergin, 1997), we described an approach to psychotherapy that comprises
two separate but related parts. First, it contains a new psychotherapy orienta-

6 RICHARDS AND BERGIN

tion—an orientation we have decided to call Theistic Psychotherapy. This ori-
entation includes a theoretical framework for psychotherapy as well as a va-
riety of spiritual therapeutic interventions. No other mainstream psycho-
therapy tradition has adequately incorporated theistic spiritual perspectives
and practices into its approach, and so our orientation fills a void in the field
(Bergin, 1980a, 1988). Although our orientation is stated broadly so as to
make it suitable for therapists and clients from a variety of theistic religious
traditions, including many branches within Judaism, Islam, and Christian-
ity, it does not incorporate Eastern, transpersonal, or humanistic spiritual
perspectives. Without prejudice, we have left the task of developing spiritual
therapies based on these perspectives to those who are more familiar with
and committed to them.
Second, our spiritual strategy describes an applied process for imple-
menting spiritual perspectives in psychotherapy in an ethically appropriate
and culturally sensitive manner. We offer process guidelines and recommen-
dations concerning (a) multicultural spiritual sensitivity, (b) establishing a
spiritually open and safe therapeutic relationship, (c) setting spiritual goals
in psychotherapy, (d) conducting religious and spiritual assessments, (e) at-
tending to ethical concerns in spiritual psychotherapy, and (f) implementing
spiritual interventions appropriately in therapy.
As we have explained in more detail elsewhere (Richards & Bergin,
1997), our spiritual strategy is integrative in that we advocate that spiritual
interventions should be combined in a treatment-tailoring fashion with a
variety of standard mainstream techniques, including psychodynamic, be-
havioral, humanistic, cognitive, and systemic ones. The strategy is empirical
in that it is grounded in current research about psychotherapy and spiritual-
ity, and will continue to submit its claims to empirical scrutiny. The strategy
is ecumenical in that it can be applied sensitively to people from diverse
theistic religious traditions. Finally, our strategy is denominational in that it
leaves room for psychotherapists to tailor treatment to the fine nuances of
specific religious denominations. In our view, these four characteristics are
essential for any viable spiritual approach to psychotherapy. We now sum-
marize both our theoretical orientation and the process for implementing it.

Conceptual Framework for Theistic Psychotherapy

Theological and Philosophical Foundations

The core assumptions of our theistic psychotherapy orientation are that

"God exists, . . . human beings are the creations of God, and . . . there are
unseen spiritual processes by which the link between God and humanity is
maintained" (Bergin, 1980a, p. 99). These core assumptions are grounded
firmly in the worldview of the five major theistic world religions: Judaism,
Christianity, Islam, Sikhism, and Zoroastrianism (Smart, 1994).

A THEISTIC SPIRITUAL STRATEGY 7

 Although there is great diversity between and within these five world
religions in terms of specific beliefs and practices, at a more general level
they share a common global worldview. According to the theistic worldview,
God exists, human beings are the creations of God, there is a divine purpose
to life, human beings can communicate with God through prayer and other
spiritual practices, God has revealed moral truths to guide human behavior,
and the human spirit or soul continues to exist after mortal death (Richards
& Bergin, 1997).
Table 1.1 briefly compares the theistic spiritual worldview with the
modernistic naturalistic-atheistic worldview on which all other mainstream
theories of psychotherapy are grounded. It can be seen that the metaphysical
assumptions of these two worldviews are almost diametrically opposed across
all six dimensions in this table, including how they view deity, human na-
ture, purpose of life, spirituality, morality, and death. The naturalistic-athe-
istic view excludes all reference to God and transcendent spiritual realities
and assumes that the universe, life, and human nature can all be explained
completely through natural forces and processes such as the Big Bang theory,
the theory of evolution, and related perspectives. The theistic view focusing
on God as creator and redeemer, therefore, provides a dramatically different
position (Bergin, 1980a, 1980b).
To more fully understand the conceptual foundations of our theistic
orientation, one may find it helpful to examine some additional underlying
philosophical assumptions of our view and contrast them further with the
assumptions of the modernistic, naturalistic-atheistic worldview. Table 1.2
reveals that the philosophical assumptions underlying our orientation starkly
conflict with the deterministic, reductionistic, mechanistic, relativistic, and
hedonistic assumptions adopted by scientists and behavioral scientists in the
late 19th and early 20th centuries. We prefer theistically based alternatives
such as agency, holism, contextuality, altruism, theistic realism, and episte-
mological pluralism (Richards & Bergin, 1997). It is interesting that con-
temporary postmodern views in science and the philosophy of science are
now more compatible with these theistic perspectives than was the case in
previous decades (Griffin, 2000, 2001; Jones, 1994; Richards & Bergin, 1997;
Slife, 2003; Slife, Hope, & Nebeker, 1999).
There are several reasons why we ground our therapeutic orientation in
the theistic worldview and reject the modernistic naturalistic-atheistic
worldview. First, we believe in God and in spiritual realities. We are con-
vinced that the naturalistic-atheistic worldview does not adequately account
for the complexities and mysteries of life and of the universe (Barbour, 1990,
1997; Eccles & Robinson, 1984; Griffin, 2000). We agree with many other
scientists and philosophers who have argued that spiritual perspectives are
needed to enrich scientific understandings of human beings and of the ori-
gins and operations of the universe (Barbour, 1997; Griffin, 2000; Jones, 1994;
Schroeder, 2001; Templeton & Herrmann, 1994).

8 RICHARDS AND BERGIN

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A THEIST1C SPIRITUAL STRATEGY

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10 RICHARDS AND BERGJN

 TABLE 1.2
Conflicting Philosophical Assumptions of Naturalistic-Atheistic
Science and Theistic Psychotherapy

Naturalistic-atheistic science
and psychology Theistic psychotherapy
Determinism: Human behavior is Free will: Human beings have agency and
completely caused by forces outside of the capacity to choose and regulate their
human control. behavior, although biological and
environmental influences may set some
limits.
Universalism: Natural laws, including laws Contextuality: While there are natural laws
of human behavior, are context free; they that may be context free, there may also
apply across time, space, and persons. A be some that are context bound; that is,
phenomenon is not real if it is not they apply in some contexts but not
generalizable and repeatable. others. There are real phenomena that
are contextual, invisible, and private. They
are not empirically observable,
generalizable or repeatable (e.g.,
transcendent spiritual experiences).
Reductionism/atomism: All of human Holism: Humans are more than the sum of
behavior can be reduced or divided into their parts. They cannot be adequately
smaller parts or units. understood by reducing or dividing them
into smaller units.
Materialism/mechanism: Human beings Transcendent spirit/soul: Humans are
are like a machine; composed of material composed of a spirit or soul and physical
or biological parts working together. body; they cannot be reduced simply to
physiology or biology.
Ethical relativism: There are no universal Universals/absolutes: There are universal
or absolute moral or ethical principles. moral and ethical principles that regulate
Values are culture-bound. What is right healthy psychological and spiritual
and good varies across social and development. Some values are more
individual situations. healthy and moral than others.
Ethical hedonism: Human beings always Altruism: Human beings often forego their
seek rewards (pleasure) and avoid own rewards (pleasure) for the welfare of
punishments (pain). This is the basic others. Responsibility, self-sacrifice,
valuing process built into human behavior. suffering, love, and altruistic service are
valued above personal gratification.
Classical realism/positivism: The universe Theistic realism: God is the ultimate
is real and can be accurately perceived creative and controlling force in the
and understood by human beings. universe and the ultimate reality. God and
Science provides the only valid the universe can only be partially and
knowledge. Scientific theories can be imperfectly understood by human beings.
proven true on the basis of empirical Scientific methods can approximate some
evidence. aspects of reality but must be
transcended by spiritual ways of knowing
in many realms.

continues

A THEISTIC SPIRITUAL STRATEGY 11

 TABLE 1.2 (Continued)

Naturalistic-atheistic science
and psychology Theistic psychotherapy

Empiricism: Sensory experience provides Epistemological pluralism: Human beings

human beings with the only reliable can learn truth in a variety of ways,
source of knowledge. Nothing is true or including authority, reason, sensory
real save that which is observable through experience, and intuition/inspiration,
our sensory experience or measuring Inspiration from God is a valid source of
instruments. knowledge and truth.
Note. From A Spiritual Strategy for Counseling and Psychotherapy (pp. 30-31), by P. S. Richards & A. E.
Bergin, 1997, Washington, DC: American Psychological Association. Copyright 1997 by the American
Psychological Association. Adapted with permission of the authors and publisher.

Second, we think the modernistic naturalistic-atheistic worldview is

philosophically and empirically problematic, for scientists in general, and
behavioral scientists and mental health practitioners in particular (Bergin,
1980b; Griffin, 2000, 2001; Richards & Bergin, 1997; Slife, 2003; Slife et al.,
1999). If mental health professionals accept the naturalistic-atheistic
worldview, to be logically consistent, they are then compelled to accept sev-
eral other problematic viewpoints commonly linked to the modern scientific
worldview, including sensationism, mechanism, materialism, determinism,
and reductionism (Griffin, 2000; Slife, 2003; Slife et al., 1999). The implica-
tions of this worldview were clearly stated by William Provine (1988), a
historian of science:
Modern science directly implies that the world is organized strictly in
accordance with deterministic principles or chance. . . . There are no
purposive principles whatsoever in nature. There are no gods and no
designing forces that are rationally detectable. . . . Second, modern sci-
ence directly implies that there are no inherent moral or ethical laws.
.. . Third, human beings are marvelously complex machines. The indi-
vidual human becomes an ethical person by means of only two mecha-
nisms: deterministic heredity interacting with deterministic environmen-
tal influences. That is all there is.
Fourth, we must conclude that when we die, we die and that is the
end of us. There is no hope of life everlasting.... [F]ree will, as tradition-
ally conceived, the freedom to make uncoerced and unpredictable choices
among alternative possible courses of action, simply does not exist. . . .
[T]he evolutionary process cannot produce a being that is truly free to
make choices... . The universe cares nothing for us. ... Humans are as
nothing even in the evolutionary process on earth. . . . There is no ulti-
mate meaning for humans, (pp. 64-66, 70)
Philosopher David Griffin (2000) has argued that the modernistic, natu-
ralistic-atheistic worldview not only provides an impoverished view of hu-
man nature but also is inconsistent with the empirical evidence and with
what he calls "hard-core common sense beliefs" or, in other words, beliefs
that are "inevitably presupposed in practice" by both laypersons and scien-

12 RICHARDS AND BERGIN

tists (p. 99). We agree with these critiques of the naturalistic-atheistic
worldview. We think the theistic worldview provides a more adequate foun-
dation on which to construct theories of human nature, personality, and thera-
peutic change.
Third, we reject the modernistic naturalistic-atheistic worldview as a
foundation for our approach to psychotherapy because it fails to provide a
culturally and spiritually sensitive framework for the large numbers of people
in North America who believe in God and who are religiously committed.
Bergin (1980a) argued that mainstream psychological theories and treatment
approaches based on naturalistic assumptions "are not sufficient to cover the
spectrum of values pertinent to human beings and the frameworks within
which they function. Noticeably absent are theistically based values" (p. 98).
He further wrote:
Other alternatives are thus needed. Just as psychotherapy has been en-
hanced by the adoption of multiple techniques, so also in the values realm
our frameworks can be improved by the use of additional perspectives.
The alternative 1 wish to put forward is a spiritual one. It might be
called theistic realism. I propose to show that this alternative is neces-
sary for ethical and effective help among religious people, who consti-
tute 30% to 90% of the U. S. population.... I also argue that the values
on which this alternative is based are important ingredients in reforming
and rejuvenating our society, (p. 99)

Theistic View of Personality

A concept of fundamental importance for the theistic, spiritual view of

human personality is that of the eternal spiritual identity of human beings.
Consistent with the teachings of most of the theistic world religions, we
theorized that human beings are composed of both a mortal body and an
eternal spirit, soul, or energy source that continues to exist beyond the death
of the mortal body. This eternal spirit or soul is of divine creation and worth
and constitutes the lasting or eternal identity of the individual. The spirit or
soul "interacts with other aspects of the person to produce what is normally
referred to as personality and behavior" (Richards & Bergin, 1997, p. 98).
Our theoretical views about human nature, personality, and therapeu-
tic change are summarized in Table 1.3. Human development and personal-
ity is influenced by a variety of systems and processes (e.g., biological, cogni-
tive, social, psychological), but the core essence of identity and personality is
spiritual. People who believe in their eternal spiritual identity, follow the
influence of God's spirit, and live in harmony with universal moral prin-
ciples are more likely to develop in a healthy manner socially and psycho-
logically. Spiritually mature people have the capacity to enjoy loving, affirm-
ing relationships with others, have a clear sense of identity and values, and
their external behavior is in harmony with their value system (Bergin, 1980a;

A THE/STIC SPIRITUAL STRATEGY 13

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14 RICHARDS AND BERGIN

Malony, 1985). They also feel a sense of closeness and harmony with God
and experience a sense of strength, meaning, and fulfillment from their spiri-
tual beliefs. People who neglect their spiritual growth and well-being, or who
consistently choose to ignore the influence of God's spirit and do evil, are
more likely to suffer poor mental health and disturbed, unfulfilling interper-
sonal relationships.
Therapeutic change and healing can be facilitated through a variety of
means, including physiological, psychological, social, educational, and spiri-
tual interventions. But complete healing and change requires a spiritual pro-
cess. Therapeutic change is facilitated, and is often more profound and last-
ing, when people heal and grow spiritually through God's inspiration in their
lives. Spiritual practices such as prayer, meditation, reading sacred writings,
worship and ritual, repentance and forgiveness, altruistic service, and seek-
ing spiritual direction can give people added hope and power to cope, heal,
and change (Benson, 1996; Richards & Bergin, 1997).

Theistic View of Psychotherapy

The sacred writings of all of the major theistic religious traditions af-
firm God's power to inspire, comfort, and heal. Our theistic orientation as-
sumes that clients who have faith in God's healing power and draw on the
spiritual resources in their lives during psychological treatment will receive
added strength and power to cope, heal, and grow (Richards & Bergin, 1997,
p. 100). Theistic psychotherapists, therefore, may encourage their clients to
explore how their faith in God and personal spirituality may assist them dur-
ing treatment and recovery. In this sense, our theistic orientation offers a
unique view of psychotherapy. No other mainstream psychotherapy orienta-
tion makes faith in God's loving and healing influence the foundation of its
theory and approach (Bergin, 1980a; Jones, 1994).
Another distinctive view of our orientation is that it asserts that a the-
istic moral framework for psychotherapy is possible and desirable. By a moral
framework, we do not mean a detailed list of moral instructions. We mean
that there are general moral values and principles that influence healthy
human development and functioning and that can be used to guide and evalu-
ate psychotherapy (Bergin, 1980a, 1985, 1991). Theistic psychotherapists
appeal to the world's great religious traditions for insight into what are these
moral values and principles. They also seek to cross-validate and deepen their
understanding of health and human welfare values by gleaning insights from
mental health professionals, ethicists, moral philosophers, and behavioral
scientists (Bergin, 1985, 1991; Richards, Rector, & Tjeltveit, 1999).
Although there is great diversity between and within the theistic reli-
gious traditions regarding their beliefs and practices, they agree that human
beings can and should transcend hedonistic and selfish tendencies to grow
spiritually and to promote the welfare of others. There is also general agree-
ment among the world religions about what moral principles and values pro-

A THEISTIC SPIRITUAL STRATEGY 15

mote spiritual enlightenment and personal and social harmony. According
to Ninian Smart (1983), a respected world religion scholar, "The major faiths
have much in common as far as moral conduct goes. Not to steal, not to lie,
not to kill, not to have certain kinds of sexual relations—such prescriptions
are found across the world" (p. 117).
A variety of moral values and principles grounded in the theistic reli-
gious traditions are associated with better mental and physical health and har-
monious interpersonal relationships. These include values and principles such
as integrity, honesty, forgiveness, repentance, humility, love, spirituality, reli-
gious devoutness, marital commitment, sexual fidelity, family loyalty and kin-
ship, benevolent use of power, and respect for human agency (Bergin, 1985,
2002; Richards & Bergin, 1997). These theistically based moral values provide
theistic psychotherapists with a framework for evaluating whether their cli-
ents' lifestyles are healthy and mature and for deciding what therapeutic goals
to endorse. We think it is noteworthy that there is substantial overlap of these
theistically based values with health values endorsed by most mental health
professionals, ethicists, and moral philosophers (Jensen & Bergin, 1988).
Although there are moral values that do more than others to promote
mental health, harmonious relationships, and spiritual growth, the applica-
tion and prioritization of these values may vary somewhat depending on the
time, context, and other competing values. For example, even a seemingly
absolute value such as "It is wrong to kill another human being" may depend
on the context for its application and validity. Thus, in endorsing the idea
that certain values are moral and beneficial, and that therapists should share
their understanding with clients about these values, this does not mean thera-
pists should tell their clients how to apply them in a given situation. Ulti-
mately, therapists must permit clients to make their own choices about what
they value and how they will apply these values in their lives, but it would be
irresponsible for therapists not to share what wisdom they can about values
when it is relevant to clients' problems (Bergin, 1991; Richards et al., 1999).
A third contribution of our theistic orientation is that it provides a
body of spiritual interventions that psychotherapists can use to intervene in
the spiritual dimension of their clients' lives. No mainstream psychotherapy
tradition has interventions designed for this purpose. Spiritual interventions
that may be used by theistic psychotherapists include praying for clients,
encouraging clients to pray, discussing theological concepts, making refer-
ence to scriptures, using spiritual relaxation and imagery techniques, encourag-
ing repentance and forgiveness, helping clients live congruently with their
spiritual values, self-disclosing spiritual beliefs or experiences, consulting with
religious leaders, and recommending religious bibliotherapy (Ball & Goodyear,
1991; Kelly, 1995; Richards & Bergin, 1997; Richards & Potts, 1995). Most of
these spiritual interventions are actually practices that have been engaged in
for centuries by religious believers. They have endured because they express
and respond to the deepest needs, concerns, and problems of human beings.

16 RICHARDS AND BERGIN

 Research evidence indicates that there is significant healing potential
in many spiritual practices (e.g., Benson, 1996; Borysenko & Borysenko, 1994;
Miller, 1999; Richards & Bergin, 1997, 2000). Benson (1996) concluded
that interventions for promoting the relaxation response are more powerful
when they draw on people's deepest spiritual convictions. He referred to this
as the "faith factor" and indicated that it appears that people's faith in an
"eternal or life-transcending force" enhances "the average effects of the re-
laxation response" (pp. 151, 155). Spiritual interventions that help clients
access the resources of their faith in God and personal spirituality may en-
hance the effects of other forms of medical and psychological treatment. Bergin
(1991) suggested that
some religious influences have a modest impact, whereas another por-
tion seems like the mental equivalent of nuclear energy . . . the more
powerful portion can provide transcendent conviction or commitment
and is sometimes manifested in dramatic personal healing or transforma-
tion. When this kind of experience is also linked with social forces, its
effect can be extraordinary, (p. 401)

Such experiences often alter people's worldviews, positively change their

sense of identity, heal their feelings of shame, and reorient their values from
materialistic to spiritual ones (Bergin et al., 1994; Emmons, 1999; Miller &
C'deBaca, 1994; Richards, 1999). These inner changes in beliefs and values
can lead to outer changes in lifestyle, which can thereby lead to healthier
behaviors and reductions in psychological and physical symptoms and prob-
lems. Thus, spiritual interventions may help set people on a path that is more
conducive to physical and mental health.
A fourth element of our viewpoint is that both therapists and clients
may seek, and on occasion obtain, spiritual enlightenment to assist in treat-
ment and recovery (Chamberlain, Richards, & Scharman, 1996; Richards &
Bergin, 1997). By entering into meditative or prayerful moments before, dur-
ing, or after sessions, therapists and clients may experience inspired insights.
These experiences are usually not dramatic but may come as quiet, gentle
impressions to the mind and heart of the therapist and client. Genuine spiri-
tual impressions can give therapists and clients important insight into prob-
lems as well as ideas for interventions or healing strategies that may be effec-
tive. If heeded, such impressions can facilitate clients' therapeutic growth.
Some of the most powerful healing moments in therapy happen when this
occurs. Table 1.4 provides a summary overview of some of the important
components and processes of our theistic psychotherapy approach.

Process Guidelines for Theistic Psychotherapy

A variety of important process issues and principles need to be kept in

mind when implementing spiritual interventions in treatment. The follow-

A THEISTIC SPIRITUAL STRATEGY 17

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A THEISTJC SPIRITUAL STRATEGY 19

ing process recommendations are summarized from our book (Richards &
Bergin, 1997).

Multicultural Spiritual Sensitivity

The capacity to adopt an ecumenical therapeutic stance—one that is
sensitive and open to diverse spiritual perspectives—is essential for thera-
pists who work with religious and spiritual clients. The foundations of an
ecumenical therapeutic stance are the attitudes and skills of effective
multicultural therapists (e.g., Sue & Sue, 1990; Sue, Zane, & Young, 1994),
but it goes beyond most contemporary multicultural approaches to include
training and competency in working with religious and spiritual issues.
Therapists with good ecumenical skills are aware of their own religious
and spiritual heritage and values and are sensitive to how they could affect
their work with clients from different religious and spiritual traditions. They
are capable of communicating interest, understanding, and respect to clients
who have spiritual beliefs that are different from their own. They seek to
learn more about the spiritual beliefs and cultures of clients with whom they
work. They make efforts to establish trusting relationships with members
and leaders in their clients' religious communities and seek to draw on these
sources of social support when it seems appropriate. They use spiritual re-
sources and interventions that are in harmony with their clients' beliefs when
it appears that this could help their clients cope, heal, and change. Thera-
pists should use an ecumenical therapeutic approach during the early stages
of therapy with all clients and over the entire course of therapy with clients
whose religious affiliation or beliefs differ significantly from their own.
Therapists may also adopt a denominational therapeutic stance with
some clients. A denominational stance is one that is tailored for clients who
are members of a specific religious denomination. A denominational approach
builds on the foundation laid earlier in therapy by the therapist's ecumenical
stance but differs from it in that the therapist uses assessment methods and
interventions that are tailored more specifically to the client's unique de-
nominational beliefs and practices. Therapists should use a denominational
approach only with clients who view them as able to deeply understand and
respect their spiritual beliefs. Such an approach can give therapists added
leverage to help clients because it can help them more fully address the fine
nuances of a client's religious and spiritual issues as well as tap into the spiri-
tual resources of the client's spiritual tradition.

Establish a Spiritually Open and Safe Relationship

Establishing a spiritually safe and open therapeutic relationship is cru-
cial for the effective and ethical exploration of religious and spiritual issues.
Spiritual beliefs and feelings are often very private and sacred to people. If
clients do not feel a great deal of trust for their therapists, they are unlikely to
freely discuss and work through such sensitive matters. In addition, because

20 RICHARDS AND BERGIN

many psychotherapists have traditionally been reluctant to discuss religious
and spiritual issues (Bergin, 1980a; Henning & Tirrell, 1982), clients may
not believe it is appropriate to do so.
We recommend that therapists explicitly let their clients know it is
permissible and appropriate to explore spiritual issues should they so desire.
Therapists can do this in the written informed consent documents they give
clients at the beginning of treatment or they can do so verbally at appropri-
ate times during the course of therapy. Fears that clients may have that the
therapist might view their spiritual beliefs as pathological could also be al-
layed in the informed consent document. Therapists can also open the door
to discussions about spirituality by including questions about clients' reli-
gious and spiritual backgrounds on an intake questionnaire.
In therapeutic settings where clients from a diversity of religious tradi-
tions receive treatment, therapists should usually avoid disclosing details about
their religious beliefs unless clients directly ask for such information. Prema-
turely disclosing details about one's affiliation or beliefs may "turn off cli-
ents whose religious affiliation and beliefs are different. By communicating
willingness to explore spiritual issues without prematurely disclosing specific
details about their own religious beliefs, therapists will probably be more suc-
cessful at establishing trust with a wider range of clients.
Psychotherapists should communicate interest and respect when cli-
ents self-disclose information about their religious tradition and spiritual
beliefs. Therapists may also sometimes acknowledge that it is not necessarily
easy to discuss spiritual matters, and that they respect the client for having
the courage to do so. Letting clients know that you do not view them as
foolish or disturbed for having such beliefs might also be appropriate and
necessary on some occasions, even including those where the beliefs may be
psychologically dysfunctional.
Therapists should also deal with religious differences and value con-
flicts with clients in a respectful and tolerant manner. Differences in reli-
gious affiliation and disagreements about specific religious doctrines or moral
behaviors can threaten the therapeutic alliance if they are prematurely dis-
closed or inappropriately addressed. When such value conflicts become sa-
lient during therapy, it is important for therapists to openly acknowledge
their values while also explicitly affirming clients' rights to differ from thera-
pists without having their intelligence or morality questioned. Therapists
should also openly discuss with clients whether the belief or value conflict is
so threatening that referral is advisable.

Attend to Potential EtKical Concerns

Psychotherapists who implement a spiritual perspective in their profes-
sional practices are faced with several potentially difficult ethical questions
and challenges. Dual relationships (religious and professional), displacing or
usurping religious authority, imposing religious values on clients, violating

A THEISTJC SPIRITUAL STRATEGY 2J

work setting (church-state) boundaries, and practicing outside of the bound-
aries of professional competence are all potential ethical pitfalls.
It is beyond the scope of this chapter to specifically discuss each of
these ethical issues, however this has been done in other publications (Bergin,
Payne, & Richards, 1996; Richards 6k Bergin, 1997; Richards & Potts, 1995;
Tjeltveit, 1986; Younggren, 1993). We encourage therapists to read these
publications so that they can keep these ethical dangers in mind and take
steps to minimize and avoid them. We also encourage therapists to always
consult with professional colleagues when these or other ethical or legal di-
lemmas and issues arise. This will not only help safeguard therapists from
lapses in judgment or ethical oversights but also may lessen their legal liabil-
ity should they get sued. Most important, it will help protect clients from
harm.
We do not believe that therapists who use a spiritual approach are more
likely to violate ethical or legal guidelines than are other therapists, and in
some ways they may be less likely to do so. Nevertheless, therapists face addi-
tional ethical complexities when integrating spiritual perspectives into their
work. Thus, it is crucial for them to be aware of these complexities and do all
that they can to implement spirituality into treatment in an ethical and ef-
fective manner.

Conducting a Religious and Spiritual Assessment

A religious-spiritual assessment should be imbedded in a multisystemic
assessment strategy. We recommend that when therapists first begin working
with clients that they quickly and globally assess the following systems or
dimensions of human functioning: physical, social, behavioral, intellectual,
educational-occupational, psychological-emotional, and religious-spiritual.
During this phase of the assessment process, therapists can rely primarily on
client self-descriptions and their own clinical impressions about how clients
are functioning in each system.
Depending on clients' presenting problems and goals, and the informa-
tion obtained during the initial global phase of assessment, therapists can
then proceed with more in-depth assessments of only those systems where it
seems clinically warranted. More focused, probing questions can be asked
during clinical interviews, and therapists might also wish to have clients com-
plete some standardized assessment measures. During this second phase of
the assessment process, therapists need not rely primarily on clients' self-
descriptions of their problems and functioning, but they can draw more heavily
on objective assessment measures, diagnostic criteria, and clinical theory.
During the initial global phase of the assessment process, we recom-
mend that therapists collect only that information which will help them
understand whether their clients' spiritual background and status may be rel-
evant to their presenting problems and treatment planning. Seeking insight
into the following questions may help therapists make such a determination.

22 RICHARDS AND BERGIN

 1. Is the client willing to discuss religious and spiritual issues
during treatment? If not, this must be respected, although the
issue may be revisited if new information warrants it.
2. If the client is willing to discuss religious and spiritual issues
during treatment, then what is the client's current religious-
spiritual affiliation? How important is this affiliation to the
client?
3. What were the client's childhood religious-spiritual back-
ground and experiences?
4. Does the client believe his or her spiritual beliefs and lifestyle
are contributing to his or her presenting problems and con-
cerns in any way?
5. Does the client have any religious and spiritual concerns and
needs?
6. Is the client willing to participate in spiritual interventions if
it appears that they may be helpful?
7. Does the client perceive that his or her religious and spiritual
beliefs or community are a potential source of strength and
assistance?

Generally speaking, a more in-depth assessment of religious and spiri-

tual issues is indicated for clients who are religious or spiritual, perceive that
their spiritual beliefs are relevant to treatment, and wish to explore spiritual
issues during treatment. The objective of a second phase spiritual assessment
is to determine whether a client's spiritual orientation is healthy or unhealthy,
and what impact, if any, it is having on his or her presenting problems and
psychological functioning. Listed below are some specific assessment ques-
tions that we have found are often clinically useful to pursue during the sec-
ond phase of a spiritual assessment.

1. How orthodox is the client in his or her religious beliefs and

behavior?
2. What is the client's religious problem-solving style (i.e., de-
ferring, collaborative, self-directing)?
3. How does the client perceive God (e.g., loving and forgiving
vs. impersonal and wrathful)?
4. Does the client have a sound understanding of the important
doctrines and teachings of his or her religious tradition?
5. Is the client's lifestyle and behavior congruent with his or her
religious and spiritual beliefs and values?
6. What stage of faith development is the client in?
7. Does the client feel a sense of spiritual well-being (e.g., is the
client's relationship with God a source of comfort and
strength)?

A THEISTIC SPIRITUAL STRATEGY 23

 8. Is the client's religious orientation predominantly intrinsic,
healthy, and mature, or is it extrinsic, unhealthy, and imma-
ture (and in what ways)?
9. In what ways, if any, are the client's religious and spiritual
background, beliefs, and lifestyle impacting her or his pre-
senting problems and disturbance?
The most viable method for seeking insight into second-phase assess-
ment questions is the clinical interview. There are also a growing number of
objective religious and spiritual research measures that have been developed,
mostly from within a Christian theological framework (Hill & Hood, 1999).
Because most of these research measures have not been validated in clinical
situations, therapists should only use them after they have carefully exam-
ined them and verified in their own minds that they are suitable for their
clients. Even then, therapists should interpret these measures tentatively.

Set Appropriate Spiritual Therapy Goals

The overall purpose of psychotherapy is to help clients cope with and
resolve their presenting problems and concerns and to promote their heal-
ing, growth, and long-term well-being. Although not all clients wish to ex-
plore religious issues or pursue spiritual goals, many do. We think there are
five general spiritual goals that may be appropriate for therapy, depending on
the unique concerns and issues of the client. These goals, of course, should
only be pursued with clients who wish to do so and should be tailored to best
meet the unique needs and preferences of individual clients.
1. Help clients experience and affirm their eternal spiritual iden-
tity and live in harmony with their understanding of God's
will.
2. Help clients examine and better understand what impact their
religious and spiritual beliefs may be having on their present-
ing problems and their lives in general.
3. Help clients identify and use the religious or spiritual resources
in their lives to assist them in their efforts to cope, heal, and
change.
4. Help clients examine and resolve religious and spiritual con-
cerns that are pertinent to their disorders and make choices
about what role religion and spirituality will play in their lives.
5. Help clients examine how they feel about their spiritual well-
being and, if they desire, help them determine how they can
continue their quest for spiritual growth.
Therapists need not necessarily be religious or spiritually oriented them-
selves to pursue these goals. Therapists who have expanded their multicultural
competency into the spiritual domain can often assist clients with these im-

24 RICHARDS AND BERGIN

portant goals. We recognize that some therapists may feel uncomfortable
working on spiritual issues with clients because of lack of training or their
personal views about religion and spirituality. In such circumstances, it would
be appropriate and ethical for them to refer clients who wish to work on
spiritual issues during treatment.

Appropriately Implement Spiritual Interventions

In our view, spiritual interventions should not be used exclusively but
combined with mainstream psychological and medical approaches in a mul-
tidimensional, integrative treatment strategy. In addition, spiritual interven-
tions should not be used rigidly or uniformly with all clients but in a flexible,
treatment'tailoring manner.
At the beginning of treatment, we recommend that therapists tell cli-
ents that they approach therapy with a spiritual perspective and, when ap-
propriate, use spiritual interventions along with standard psychological ones.
Therapists should not implement spiritual interventions in treatment until
they have assessed their clients' psychological functioning, spiritual back-
ground and beliefs, and attitude about exploring spiritual issues during treat-
ment. If therapists perceive that spiritual interventions are indicated for a
given client, we suggest that they clearly describe the spiritual interventions
they wish to use and make sure clients feel comfortable with them. Thera-
pists should work within the value frameworks of clients, making sure that
the interventions used are in harmony with their religious beliefs. Finally,
therapists should use spiritual interventions in a respectful manner, remem-
bering that many religious believers regard these interventions as sacred reli-
gious practices.
We encourage therapists to keep in mind that there are many variables
that could influence whether spiritual interventions will be appropriate and
effective. We think there are at least five situations in which spiritual inter-
ventions are nearly always contraindicated: (a) when clients have made it
clear they do not wish to participate in such interventions; (b) when clients
are delusional or psychotic; (c) when spiritual issues are clearly not relevant
to clients' presenting problems; (d) when clients are minors and their par-
ents have not given the therapist permission to use spiritual interventions;
and (e) when therapy takes place in a public, tax-supported setting that re-
quires exclusion of religious concerns.
There may also be other situations in which spiritual interventions are
not clearly contraindicated but in which they may be ineffective or perceived
unfavorably by clients. For example, spiritual interventions are probably more
risky and less likely to be effective when clients are young (children and
adolescents), severely psychologically disturbed, antireligious or nonreligious,
spiritually immature, view their spirituality as irrelevant to their presenting
problems, or perceive God as distant and condemning. Spiritual interven-
tions are also probably more risky in public and state settings than in private

A THE/STIC SPIRITUAL STRATEGY 25

and religious settings. Furthermore, spiritual interventions are less likely to
be effective if there is low therapist-client religious value similarity. We en-
courage therapists to keep these possibilities in mind as they consider whether
it would be appropriate to use spiritual interventions with their clients.

PLAN OF THE BOOK

We have assembled an impressive group of contributors and a fascinat-

ing variety of cases for this book. The authors are mental health practitioners
whose therapeutic approaches have been influenced by various theistic reli-
gious traditions including Islam (Sufism), Orthodox and Reform Judaism,
and a variety of Christian denominations (Roman Catholic, African Meth-
odist Episcopal, Quaker, Presbyterian, Evangelical Protestant, Seventh-day
Adventist, Latter-day Saint, etc.).
Although the religious backgrounds and theoretical orientations of the
contributors are relatively diverse, as are the clients described in the case
studies, the contributors hold in common the view that responding sensi-
tively to their clients' religious and spiritual issues is essential for effective
treatment. The variety of ways that this can be done will become apparent as
you read the case studies.
We would have liked to include an even greater diversity of theistic
viewpoints in the book. Given the fact that there are more than 160 Chris-
tian denominations and numerous non-Christian theistic traditions and groups
in North America (Melton, 1996), it was impossible to represent all of them.
Despite space limitations, and the pragmatic difficulty of locating authors
from some traditions to write chapters, we hope we have at least provided a
sample of theistic therapeutic perspectives that will be useful to clinicians.
We asked each of the contributors to do their best to explicitly describe
how they and their clients' theistic beliefs influenced the processes and out-
comes of treatment. We also asked the contributors to provide a description
of all essential aspects of their case, including client demographics, present-
ing problems and concerns, client history, diagnosis and assessment, treat-
ment setting, treatment process and outcomes, and therapist commentary.
We hope that this information will give you considerable insight into the
dynamics, processes, and outcomes of each case.
We have grouped the case reports into three categories: (a) Program-
matic, Group, and Marital Therapies, (b) Individual Denominational Thera-
pies (Within Faiths), and (c) Individual Ecumenical Therapies (Across Faiths).
This organizational scheme was a pragmatic decision to simplify and highlight
some important features of the cases (i.e., what treatment modality was used
and whether the spiritual approaches were applied widiin faiths or across faiths).
Within Part II of the book, Programmatic, Group, and Marital Thera-
pies, cases are presented that illustrate a theistic treatment community pro-

26 RICHARDS AND BERGIN

gram for a conduct-disordered adolescent girl (chap. 2, by Slife, Mitchell, &
Whoolery), a theistic inpatient treatment program for a Latter-day Saint
woman with an eating disorder (chap. 3, by Hardman, Berrett, & Richards),
a group, interpersonal-theistic approach for adolescent, depressed Christian
mothers (chap. 4, by Miller), and a theistic-marital-therapy approach for a
Lutheran and Roman Catholic couple experiencing religious discord and
marital conflict (chap. 5, by Krejci).
Within Part III, Individual Denominational Therapies, cases are presented
that illustrate a psychodynamic-cognitive-theistic approach for a Protestant
woman with alcohol problems (chap. 6, by Dobbins), a psychodynamic-cog-
nitive-theistic approach as applied with several different Orthodox Jewish
clients (chap. 7, by Rabinowitz), a biopsychosocial-theistic approach with a
Roman Catholic woman who was struggling with perfectionistic and obses-
sive-compulsive tendencies (chap. 8, by Sperry), and a psychodynamic-the-
istic approach with a Roman Catholic woman suffering from stress and mi-
graine headaches (chap. 9, by Shafranske).
Within Part IV, Individual Ecumenical Therapies, cases are presented that
illustrate a person-centered, multicultural-theistic approach with a Baptist
woman who was struggling with career-related stress, burnout, and identity
issues (chap. 10, by Cook), apsychodynamic-cognitive-theistic approach with
a Southern Baptist man who had a sexual addiction and problems relating
with women (chap. 11, by Rayburn), a cognitive-psychodynamic-theistic
approach with a Muslim (Sufi) convert who was experiencing conflict with
his work supervisor and identity issues (chap. 12, by West), a Rational Emo-
tive Behavior Therapy (REBT) theistic approach with a Muslim woman who
was experiencing discrimination and unresolved issues from being raped (chap.
13, by Nielsen), a psychodynamic-theistic approach with a woman who was
not affiliated with a religious tradition but who believed in God—and who
was suffering from posttraumatic stress disorder due to catastrophic medical
complications associated with a pregnancy (chap. 14, by Hedayat-Diba), a
REBT-theistic approach with a Protestant adolescent boy struggling with
depression about homosexual concerns (chap. 15, by Johnson), a psychody-
namic-theistic approach with a Protestant man experiencing marital dissat-
isfaction and another psychodynamic-theistic approach with two children
who were experiencing learning, impulsivity, and identity problems (chap.
16, by Lovinger & Lovinger).
As you read the case reports, we encourage you to keep in mind and
reflect on the following questions:

1. How did the therapist's spiritual beliefs influence the processes

and outcomes of treatment?
2. How did the client's spiritual beliefs influence the way he or
she presented problems as well as the processes and outcomes
of treatment?

A THEfSTIC SPIRITUAL STRATEGY 27

 3. How might have the processes and outcomes of this case been
different if the therapeutic work had not been informed and
influenced by theistic spiritual perspectives?
4- How might you have approached this case given your per-
sonal spiritual beliefs and theoretical orientation?
As you reflect on these questions and others that may be important to
you personally, we anticipate that you will gain greater insight and apprecia-
tion into the variety of ways that theistic perspectives can influence psycho-
therapy. Of course, we do not expect you to agree with all of the ways in
which theistic perspectives and interventions were applied in treatment. We
did not agree with every approach that was used or therapeutic decision that
is described in this book. However, if we had wanted every case report to
reflect our own theistic approach, this book would have contained only our
cases. That was not our desire.
We are grateful for all that we have learned through the religious and
therapeutic diversity that is represented in the case reports. We hope that
this will also be your experience. We feel optimistic that the cases will give
you much insight into how you can more fully and effectively incorporate
theistic perspectives into your own practice.

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32 RICHARDS AND BERGIN

 2
A THEISTIC APPROACH TO
THERAPEUTIC COMMUNITY:
NON-NATURALISM AND THE
ALLDREDGE ACADEMY
BRENT D. SLIFE, L. JAY MITCHELL, AND MATTHEW WHOOLERY

Although the short tradition of theistic therapy has emphasized the

individual client, the long tradition of theism itself has often emphasized the
community. The Hebrew tradition of theism, for instance, emphasizes com-
munity almost exclusively (Boman, 1960; Dueck, 1995; Lohfink, 1984). It
includes not only community'based "interventions"—divine and mortal—
but also community discernment of the Spirit and even community salva-
tion. Consequently, the formulation of a theistic approach to therapeutic
communities, as described herein, is an obvious and a necessary extension of
this long theistic tradition (a tradition that says God is actively involved in
the events of the world).
The problem is that most therapeutic communities have been founded
on the secular philosophy of naturalism. The popularity of this philosophy is
understandable. Many psychotherapists view it as an advance over the mys-
tical and magical paradigms of the premodern era, and many view it as a
relatively nonpartisan and objective philosophy regarding religion. Although

35
we agree, in some sense, with the first view, we cannot agree with the second.
Indeed, we agree with Richards and Bergin (1997) that the philosophy of
naturalism is incompatible with theism. If this is true, then a theistic ap-
proach to therapeutic communities cannot be naturalistic.
The purpose of this chapter is to describe a particular client's therapeu-
tic path through a non-naturalistic therapeutic community. We begin by
outlining briefly the problematic nature of naturalism for theistic therapy.
We next compare and contrast five of the major assumptions of naturalism
to a non-naturalistic philosophy—one that we believe clears a conceptual
space for a true theism to be practiced. As an illustration of this non-natural-
istic philosophy, we then describe a particular theistic therapeutic commu-
nity—the Alldredge Academy—and report one client's therapeutic journey
through the Academy.

NATURALISM AND THERAPEUTIC COMMUNITY

Several scholars and therapists have recently noted how problematic

the philosophy of reductive naturalism (hereafter, naturalism) is for psychol-
ogy, especially as the field attempts to incorporate theistic interventions
(Collins, 1977; Gunton, 1993; Leahey, 1991; Richards & Bergin, 1997; Slife,
2003; Slife, Hope, & Nebeker, 1999; Smith, 2001). However, this philoso-
phy is increasingly fueled by the perceived need to make the field more sci-
entific and biological. As Leahey (1991) notes, naturalism is "science's cen-
tral dogma" (p. 379). Consequently, as psychotherapy has moved increasingly
toward natural sciences such as medicine, this "central dogma" has become
increasingly influential. Indeed, this dogma has, like many other dogmas,
foreclosed many conceptual and clinical options that were once open to ex-
ploration (Slife, 2003), including theistic options. What is this foreclosing
philosophical "dogma?"
The philosophy of naturalism essentially postulates that laws or prin-
ciples ultimately govern the events of nature, including human nature (cf.
Griffin, 2000; Honer & Hunt, 1987; Leahey, 1991; Richards & Bergin, 1997;
Slife, 2003; Smith, 2001; Viney & King, 2003). From laws of gravity to prin-
ciples of pleasure (psychoanalysis), reinforcement (behaviorism), and organ-
ismic enhancement (humanism), these types of natural laws and principles
supposedly govern all aspects of human beings, including our bodies, minds,
and even spirits. Unfortunately for theism, this secular philosophy implies
that other entities, such as God, do not govern these aspects of humanity.
Natural laws and theoretical principles essentially fill up the conceptual space
where God might be, explaining human behavior and cognition without re-
quiring a God of any kind (Whoolery, Slife, & Mitchell, 2002). Because
theism does require a God, by definition, naturalism and theism are often
viewed as incompatible philosophies in principle (cf. Griffin, 2000).

36 SLIFE, MITCHELL, AND WHOOLERY

 Naturalism is so prevalent, however, that many theists attempt to make
naturalism compatible with theism. The most popular attempt at compat-
ibility is deism—the claim that God created the natural laws. However, natu-
ralism assumes that the operation of these laws is independent of any deity or
Supreme Being. Although a deity may have originally created the laws, the
laws now operate on their own. Moreover, the laws and principles must be
universal and unchangeable in order to be lawful. If a deity is assumed to
exist at all, then it cannot disrupt or suspend these laws on any particular or
regular basis, or the laws would no longer be lawful (Griffin, 2000). Most
theisms are thus impossible in this naturalistic account. A deity may exist, to
be sure, but it is rendered passive and effectively nonexistent because natu-
ralism does not permit it to actively change or disrupt the regular, autono-
mous operation of these laws. The universe is assumed to work as it always
has, whether or not this god exists.

COMPARING NATURALISTIC AND NON-

NATURALISTIC ASSUMPTIONS
We believe that the best way to make these issues clear, particularly for
therapeutic communities, is to explicate the assumptions involved. Assump-
tions are taken-for-granted beliefs about the world. All therapists make as-
sumptions because they postulate a world in which their techniques are ef-
fective. Slife (2003) has described the role of five of naturalism's major
assumptions in individual psychotherapy (as well as each assumption's prob-
lems and alternatives): objectivism, materialism, hedonism, atomism, and
universalism. Although the labels have sometimes differed, other scholars
have concurred with these five assumptions and noted others: determinism
(Baldwin & Slife, 2003; Richards & Bergin, 1997), rational order (Rychlak,
1988; Slife, 2001), reductionism (Griffin, 2000; Slife & Williams, 1995),
and empiricism (Collins, 1977; Viney & King, 2003).
Unfortunately, the implicit status of these assumptions means that few
therapists explicitly claim or acknowledge them in their practices. Many thera-
pists are unfamiliar with the subtle nature of assumptions and often do not
recognize their own assumptions or the assumptions of therapeutic practices
across the field. These therapists will undoubtedly need more explanation
(and space) than is permitted in this chapter (cf. Valentine, 1992). We ask
the reader's indulgence here and refer them to the references provided as
well as the introductory chapter of this volume. Our purpose here is to briefly
compare and contrast five naturalistic and five non-naturalistic assumptions
that specifically pertain to therapeutic community (see Table 2.1). As we
shall show, these assumptions are pivotal to the formulation and practice of
therapeutic community.
We anticipate that many mental health professionals will resist the
implied "versus" (either—or) of the items in Table 2.1, which is rendered

NON-NATURALISM AND THE ALLDREDGE ACADEMY 37

 TABLE 2.1
Comparison of Assumptions in the Therapeutic Community
Naturalistic assumptions Non-naturalistic assumptions

Objective: To obtain a true understanding of Value-laden: To obtain a true understanding

natural objects, including humans, of humans, therapeutic and scientific
therapeutic and scientific methods should methods should embrace the
strive for and can be value-free. inescapability of values.
Hedonic: The chief good and ultimate Altruistic: The chief good and ultimate
constant motivation of all natural beings, motivation of all humans can and should
including humans, is self-benefit. be the benefit of others.
Determined: Natural laws and/or principles Agentic: Natural laws and/or principles do
govern the actions of humans, preventing not govern human action, allowing them
them from acting otherwise. to act otherwise than they did.
Rational: The order of natural events and Dialectic: The order of human events and
human understanding is rational and thus understanding is not solely rational but
evidences logical consistency. also inconsistent and even paradoxical.
Atomistic: The qualities of all natural Holistic: The qualities of humans are not
objects, including humans, are self- self-contained, but instead stem from their
contained within the objects themselves. relationships to other humans.

more explicit in our narrative description of the comparison that follows.

However, assumptions are peculiar beasts. They are not factors that can be
combined, nor are they variables that interact; they are foundational philo-
sophical conceptions that rule out, in principle, other foundational philo-
sophical conceptions. This is not to say that some assumptions are not com-
patible with other assumptions. It is only to say that all assumptions rule out,
and are incompatible with, some other assumptions. In the case of the natural-
istic assumptions of Table 2.1, the ideas of their non-naturalistic counterparts
(and not the labels per se) are disjunctive—incompatible by definition (Slife,
2003; Slife & Williams, 1995). Consequently, we compare each pair of as-
sumptions, in turn, and then describe a therapy case in which the non-natural-
istic assumptions were applied successfully at the Alldredge Academy.

Objective Versus Value-Laden

Objectivism is the naturalistic notion that all worthy methods, including

therapeutic techniques and scientific methods, should strive to be objective
and value-free (Bernstein, 1983; Richardson, Powers, &Guignon, 1999; Slife,
2003). Although professionals are themselves biased by their values, the logic
of objectivism is that removing biases as much as possible removes distortions
of our knowledge of the natural world, including the natural world of therapy.
As applied to therapeutic communities, therapeutic techniques should be de-
rived from value-free scientific methods as much as possible. Also, such tech-

38 SLIFE, MITCHELL, AND WHOOLERY

niques should not themselves have implicit values that bias them against cli-
ent value systems (e.g., religions, traditions, ethnicity, and gender).
The position of the Alldredge Academy, by contrast, is that values are
not only inescapable but also necessary for understanding. All therapeutic
communities (including the naturalistic) accept and reject, and promote and
discourage particular values, whether or not they acknowledge it (Slife, Smith,
& Burchfield, 2003). This position implies that the therapists of such com-
munities should identify and prominently present their values (and assump-
tions) for the purposes of informed consent—especially regarding their meth-
ods and strategies (Slife & Richards, 2001). Another crucial task (value) of
any such community is helping clients to discern the values that are best
suited for them and their circumstances. Therapists will purvey values, and
clients will adopt them, regardless of the therapeutic system, so this process
of purveying and adopting should occur deliberately rather than by default.

Hedonic Versus Altruistic

Hedonism is the notion that the chief good and ultimate motivation of
all natural beings is self-preservation and self-benefit (Webster's New Colle-
giate Dictionary, 1981; Slife, 2000, 2003). If a species consistently seeks pain
instead of pleasure, then this pain seeking invites evolutionary extinction.
As applied to a therapeutic community, this assumption implies that the
chief good and most important motivator for therapeutic communities is cli-
ent benefits (in exchange for therapist benefits; Fisher-Smith, 2000). Client
self-benefit is the primary goal (even if helping others is the means) and self-
benefit is the primary client motivator (e.g., self-actualization) for achieving
this goal.
The altruistic position of the Alldredge Academy, however, assumes
that all people can be ultimately motivated by and for others (e.g., other-
actualization). The "can" here is important because this particular altruistic
position focuses on capability. It does not obviate the possibility of self as a
motivator; it merely claims that self-benefit is not the most natural (funda-
mental) or only motivator. As applied to therapeutic communities, the end
of any action (by therapist or client) should not be the self, with the means
being other people (as with hedonism). The end must be others, with the
means being the self. Benefits can ensue from the caring of others, but true
self-benefit cannot be pursued (Slife, 1999; Yalom, 1980).

Determined Versus Agentic

Because naturalism assumes that physical laws and principles govern

the real world—including the human world—human behavior and cogni-
tion are determined (Richards & Bergin, 1997). We may not yet know the
principles that are responsible for determining behavior (e.g., biological or

NON-NATURALISM AND THE ALLDREDGE ACADEMY 39

social principles), but they determine it nevertheless. Determinism is not
about limits here but about what is responsible for things and events. As ap-
plied to therapeutic communities, physical and social laws are responsible for
human behavior. Therefore, the psychotherapist's job is to discern those laws
(or postulate them through theory), as much as possible, and manipulate
them in instrumental ways that benefit the client (determinism plus hedo-
nism; Richardson & Bishop, 2002).
The Alldredge Academy assumes that the clients themselves contrib-
ute intentionally to their own behavior (agency) (Howard, 1994; Rychlak,
1988). This assumption does not exclude the contextual importance of the
environment and biology, but it does reorient the notion of ultimate respon-
sibility and thus modifies conceptions of causality and intervention (Slife,
2002; Slife & Fisher, 2000). As applied to therapeutic community, it means
that clients can and should be held responsible for their own actions, and
interventions can only facilitate healing experiences (an introspective per-
spective) and not cause behavior change (an extraspective perspective)
(Rychlak, 1981).

Rational Versus Dialectical

The lawfulness of natural laws is thought to imply their rational consis-

tency (Gunton, 1993; Rychlak, 1988; Smith, 2001). The laws and principles
of a therapeutic community must also occur in an orderly and even logical
fashion. They are not disorderly or irrational, implying that the most effec-
tive therapeutic interventions are themselves logical and consistent. For ex-
ample, interventions should be consistent, rather than inconsistent, with
the stated goals of therapy. Because clients are typically encouraged to frame
their goals hedonistically (e.g., self-benefit), the assumption of rational con-
sistency is often combined with hedonism to mean "consistent with self-
benefit" (Shaver, 1999).
At the Alldredge Academy, however, rational consistency, in this sense,
is intentionally violated to enhance dialectical relations (and altruistic rela-
tions). Instead of assuming that the primary relations among therapeutic
events are (or should be) relations of rational consistency (Rychlak, 1988),
this position implies that "inconsistency" and paradox are just as important
as consistency and rationality, particularly in a therapeutic community. For
example, particular learning opportunities are facilitated through paradoxi-
cal interventions in which clients are jolted from their typical ways of think-
ing and reasoning.

Atomistic Versus Holistic

The philosophy of naturalism assumes that the qualities of all objects

(e.g., the atom) are inherent in the objects themselves. That is, if we want to

40 SLIFE, MITCHELL, AND WHOOLERY

understand a particular object, we must study the object itself and not the
objects that surround it (atomism). In the behavioral sciences, atomism has
implied that the basic unit of study is the self-contained individual, not the
group or culture (Richardson et al., 1999). If a therapeutic group or commu-
nity is studied at all, it is often viewed as a collection of individuals, each
with his or her own self-contained qualities (e.g., reinforcement history, cog-
nitive schema, or intrapsychic structure).
The Alldredge Academy, conversely, believes the focus should be the
relationships among the individuals of a therapeutic community (i.e., the
community itself). This focus was, in fact, the original impetus for healing
theistic communities. Just as any part of a whole gets many of its qualities
from its relation to other parts, so too individuals of a community get many
of their qualities from their relationships to other individuals (Slife et al.,
1999). As applied to a theistic therapeutic community, the group or team is
as important as the individual, and meaningful relationships are more impor-
tant than individual self-benefits.

TREATMENT PROCESS AND OUTCOME

Therapeutic Setting

The Alldredge Academy is a rare example of an authentically non-

naturalistic treatment philosophy that is compatible with theism. As dis-
cussed previously, naturalistic assumptions do not require divine beings. These
assumptions are themselves naturalistic principles (e.g., hedonism) that op-
erate much like natural laws—autonomously and automatically (mechanis-
tically). The Alldredge Academy, by contrast, assumes that none of the as-
sumptions of non-naturalism are possible or helpful without the Source—the
Academy's term for God or Spirit. True altruism, for example, is not attain-
able without the inspiration of this divine entity. Although this philosophy-
theology is obviously compatible with theism, the Academy is not typically
viewed as a religiously based community per se. It is, instead, more ecumeni-
cal, accommodating several widely varying theistic traditions and worldviews,
from Christian to Jew to Muslim.
The Alldredge Academy is located in the mountains of West Virginia,
where rugged terrain and beautiful vistas are commonplace. Alldredge is an
accredited school with more than 500 graduates to date, typically of the one-
semester (3-month) program. At full capacity, the academy can accommo-
date 72 students along with 71 staff members. All counselors receive an ini-
tial 4 week, 10 hour per day course of training in the non-naturalistic Alldredge
model. In addition to regular weekly supervision, they receive a 4-hour train-
ing session every second week, with another 4-week training stint every year.
The owner/director of the Alldredge Academy (L. J. Mitchell) developed

NON-NATURALISM AND THE ALLDREDGE ACADEMY 41

the SUWS Adolescent Program and has 20 years of experience in educa-
tional programs.

Client Background

To bring the academy alive, we follow the experiences of a recent resi-

dent and "student," Laura (a pseudonym). We reconstruct salient aspects of
her therapeutic journey through Alldredge with the help of an extensive
collection of treatment notes and a three-inch pile of Laura's own journal
entries. Laura is a 16-year-old Caucasian girl with no particular denomina-
tional affiliation and custodial grandparents. Both her birth mother and fa-
ther were addicted to drugs, and neither parent was currently active in Laura's
life. Prior to attending Alldredge, Laura was admitted to an inpatient psychi-
atric ward for a series of incidents, including running away, heavy drug use,
and misdemeanor convictions for shoplifting and truancy. She was diagnosed
in this hospital as having attention-deficit/hyperactivity disorder (ADHD)
with secondary depression and placed on Prozac, but her problematic behav-
iors continued. Therefore, an educational consultant, with expertise in the
special needs of youth, referred her to the Alldredge Academy.
Laura arrived at the academy in May and joined a group of eight other
adolescent students for at least a 3-month (semester) experience, including
at least 1 month in "mountain search and rescue," 1 month in the "village,"
and 1 month in the "school." Her custodians asked that Alldredge help her
to stop the drug and antisocial behavior, develop new learning strategies,
and diminish her depression. The other adolescents of her group had similar
profiles, with the group moving together through the 3-month journey and
sharing experiences with similar size groups along the way.

Mountain Search and Rescue Phase

On arrival, members of the group were taken to the Canaan Valley,

which consists of high elevation mountainous terrain. They were outfitted
for continuous camping and told they would be trained as a search and rescue
team, with all the technical, emotional, and physical skills necessary to save
someone's life. Laura was "absolutely shocked," as she writes in her journal,
by the notion that she was not there primarily for herself. In fact, this was her
first exposure to the concept of true altruism, real teamwork, and a life based
on service (though initially the staff never mentioned these concepts). Even
at this early stage, the instructional staff was clearly led by two violations of
the philosophy of naturalism. First, students are not there for their own ben-
efit (hedonism); they are there for someone else's benefit entirely (altruism).
Second, as Laura will learn, she is not there to cultivate her individuality
(atomism); she is there to cultivate the team (holism).

42 SLIFE, MITCHELL, AND WHOOLERY

 These concepts are foreign to Laura, so she resists them. However, the
"instructors" do not attempt to convince or persuade her of anything (except
that she will successfully complete the program). Indeed, this is one of the
salient features of Alldredge. Although the instructors are committed to an
explicit set of broad values such as love, integrity, hope, and valor, there is no
preaching or proselytizing. Instead, the instructors model these values and
facilitate experiences that aid the students in coming to their own values by
and through the Source. In fact, there is considerable evidence that the
Mountain Search and Rescue phase facilitates the students' desire to explore
different values and seek inspiration to come to their own value systems.
How do the instructors facilitate such experiences? Two of the main
guiding principles are themselves violations of naturalism: agency and the
dialectic. In the case of agency, Laura is expected to be responsible for her-
self, because she is the agent of her own actions. She learns quickly that
important wilderness skills are required to care for others (as a member of the
rescue team) and herself. For the first time in many years, she seeks the ad-
vice of adults (because they volunteer very little)—and she listens. Hedo-
nists may assume that progress here is the result of natural reinforcement
contingencies, but the entire thrust of the group is precisely the opposite.
Although it is true that the staff is supportive of Laura taking responsibility
for her needs, her needs are only important insofar as she can be trusted as a
team member to save the life of another. In other words, even her responsi-
bility (and agency) is holistic and altruistic. She is not the individualistic
end; she is the relational means to serving others.
Of course, Laura has many old thought and behavioral patterns that
help her avoid personal responsibility and meaningful relationships. Again,
however, the instructors never cajole or preach. They instead help her to
generate her own lessons dialectically. That is, they act inconsistently with
Laura's "logic," even (seemingly) the logic of the program itself. At one point,
for example, Laura became frustrated with "doing all the stupid stuff every-
one else is doing," because she was "not like them." Rather than the instruc-
tors urging her to "stay with the program" or "take care of herself' (consistent
with the logic of their seeming purpose), they apologized for not recogniz-
ing her uniqueness, moved her bedroll away from the group, and had her
turn her sweater inside out to honor her uniqueness. After all, she could
not be part of a group to which she did not belong. After 3 days, Laura
tearfully requested that the group accept her back, but there were tense
moments as the group sincerely considered her request. Laura responded to
their eventual acceptance with cheerful enthusiasm for all her personal
and team duties.
Such dialectical interventions have sometimes been labeled "paradoxi-
cal" (e.g., Watzlawick, 1984). However, they are only paradoxical from a
deterministic, naturalistic perspective. When agency is truly incorporated
into the philosophy of treatment, dialectical interventions are a logical con-

NON-NATURALISM AND THE ALLDREDGE ACADEMY 43

sequence. In other words, the dialectic does not tell the instructors to be
inconsistent with their values; the dialectic merely recognizes that contrast-
ing meanings are intimately related to one another. When clients have agency,
especially adolescents, therapists will rarely persuade them with logic and
rationality, particularly if their patterns of decision making are ingrained and
longstanding. Therapists must therefore help clients to experience the con-
trast of their treatment goals so they can truly understand and desire the
goals for themselves.
Consider another of the many small and large dialectical interventions
with Laura. Although Laura worked more responsibly and cooperatively, she
resisted the search and rescue training in other ways. For instance, she con-
stantly interrupted instructors with wisecracks and invited other students to
join in. Instead of the instructors chastising or attempting to extinguish this
behavior, they "reinforced" it. They lauded Laura for her comedy and gave
her the team responsibility for being funny, an "important responsibility"
when the "going gets tough" (e.g., in a steady rain). This reframed her indi-
vidualistic (and thus atomistic) behavior as a service to the team (holism)
and their altruistic tasks, and Laura rapidly tired of her responsibility. Not
only did she find it hard to provide wisecracks during these tough times, she
also found very few people laughing with her. She solemnly asked the group
for a release from her responsibilities, abandoned her "clown" pattern, and
never interrupted anyone again.
Laura generally found herself "confused" by these experiences, as she
wrote in her journal. For some reason, her usual "games" were not getting
their usual result. In addition, she was experiencing other feelings that seemed
odd yet positive—feelings of belonging, camaraderie, caring, and a willing-
ness to be taught. As she reports, a particular incident helped these positive
feelings overcome her negative confusion. The local sheriff asked the team
to find a battered woman who had apparently taken refuge in the mountains
from her drunken husband. The woman's relatives were convinced that she
was lost and were afraid her husband would find her before anyone else and
abuse her again. Laura and her team worked like a well-oiled machine, not
only locating the woman and providing first aid but also shielding her at one
point from her threatening husband.
Laura recalls being completely unafraid for herself during this incident,
although she was voluntarily taking personal risks. She was so involved in
caring for and protecting the woman that she now believes she found herself
through this service. Not coincidentally, all five of the factors of non-natu-
ralism were included in this growth-producing incident. In other words, she
found herself in a moral (value-laden) situation that led her to choose
(agentically) to cooperate with the team (holistically) and give of herself
(altruistically) for the sake of another. The paradox (dialectic) of the situa-
tion is that Laura may have benefited most from an incident that was not,
ostensibly, for her sake at all.

44 SLIFE, MITCHELL, AND WHOOLERY

 There is, of course, much more to the wilderness experience. However,
the net effect for Laura, like so many other students, was that she now yearned
for something more substantive than her "silly games," as she came to call
them. After an emotional but productive visit with her family (during the
Alldredge parent—student program), her journal indicates that she wanted to
know how to be a good friend, how to best help others, how to be respectful,
and how to love (altruism).

The Village Phase

In the village phase of her journey, Laura often turned to her instruc-
tors for easy answers. However, the village is not set up to provide easy an-
swers; it is set up dialectically for Laura to experientially discover these an-
swers for herself. Although specific virtues such as love, hope, integrity, and
forgiveness are extolled and discussed in the village, these virtues are not
viewed as ends in themselves; they are viewed as the means for Laura to
arrive at her own answers and own moral system in relation to her commu-
nity (value ladenness). The hope is that students will find a more productive
and loving identity. The village is designed to help them choose to change
their irresponsible victim image by connecting to the Source, discovering a
sense of mission and life purpose, and living more virtuously.
The village is a group of primitive hutlike structures nestled between
two rivers. Yet, the village was "luxury" to Laura after her monthlong camp-
ing and hiking experiences (a dialectic appreciation for "what I usually take
for granted"). Village experiences are divided into four "Journeys," with each
journey essentially representing a different system of theistic values from a
particular primitive culture. The four Journeys together form a dialectic,
through contrasts and oppositions, bringing hidden life meanings to each
student's awareness.
As the students enter each Journey, they enter a culture—living like,
thinking like, and basically trying on the values and spirit of each culture.
For Laura (as she reports in her journal), this dialectic helped her to gain a
"perspective" on her teenage culture, beliefs, and spirit. Relationship issues
are a main focus (holism), with students counseling each other to trod the
"path of virtue" (value ladenness). Each night there is a truth circle where a
truth stick is passed to each student and feelings are expressed. As problems
are identified, students must take personal responsibility for solving their
problems rather than blaming others (agency).
The Journeys also provide students with value-clarifying experiences.
For example, part of the South Journey is the theme of the Shadow (a some-
what Jungian conception). Laura learned that her greatest fear and pain came
from her Shadow. On one occasion, she made a list of three people whom she
"most hated," listing two characteristics of each that were particularly dis-
gusting. As she described these characteristics and her loathing for them in

NON-NATURALISM AND THE ALLDREDGE ACADEMY 45

the group, her peers and instructors began to help her see her loathing for
these characteristics in herself. She began to see these characteristics as part
of herself, her Shadow, in relation to the community (holism). She learned
as she reclaimed, examined, and released them that she was less harsh with
herself and others.
The students spent the entire week of the South Journey noting how
each other's shadows waxed or waned. One of the wonders of the village is
one of the missing elements of our society—constant, loving, but brutally
honest, feedback to one another. Students and instructors can deliver this
type of feedback because the students themselves invite it. Indeed, they hun-
ger for it. As a culminating South Journey experience, Laura vividly reports
that she and her group entered a "deep and mysterious" cave called the "den
of the serpent." One by one, the members of her group shared their shadows,
discussed how they affected their friendships, and then "left" them in the
cave chamber. Laura was "deeply moved" by this experience and felt consid-
erable relief from "unloading my 'shadowy' burdens." More important, she
found herself "a better friend," a "better leader," and a "better listener"—
again, the Alldredge emphasis on altruistic relationships rather than self.
Uniting all the Journeys is the Source. Indeed, the Alldredge instruc-
tors see the Source as uniting all their therapeutic interventions, from the
Mountain Search and Rescue phase to the end of the program (holism).
However, the notion of a Source is made less explicit in the wilderness be-
cause the students are typically not ready (i.e., they may not initially desire
the guidance the Source can bring). Still, the instructors attempt to facili-
tate student experiences of the Source. They assume the Source is already
present; their only job is to facilitate "spiritual" experiences and loving rela-
tionships that help the students to sense and acknowledge the Source (how-
ever they might conceive of it).
Before leaving a campsite, for example, the instructors routinely as-
semble the group for a moment of silence—a silence that can only be appre-
ciated if one has been in the mountains of West Virginia. Students are also
asked to go "solo," camping (under the watchful eye of the instructor) alone.
The hunger here for any mind-occupying activity is deep, so students are
given short novels that bristle with "Source" themes. As Laura says in her
journal, "I was pulled into the book at the start—the love, the conflict, the
caring. I had forgotten the awesome feeling books had always given me."
Laura also discussed the "religious" experience of her "team" rescuing the
woman (both in group discussion and her journal)—how she felt empowered
by "something," how she felt prompted by "something," how "something"
helped her "to care more about her than me."
In the Village, the Source is discussed more explicitly and directly. If
students show an interest in the Source, they are directed to consider their
own experiences. Spiritual experiences are described and students are asked
if they have ever felt anything like these. Without exception (particularly

46 SLIFE, MITCHELL, AND WHOOLERY

when students have already shown an interest), they reply that they have
experienced similar "communications" with the Source. The students are
then asked if they would like to enhance and deepen these communications.
For example, the North Journey—the Finder of the Truth—is a series of
exercises/experiences to accomplish this enhancement, including (for Laura)
a realization of her history with the Source, an acknowledgment of the Source's
reliability, and some skills in distinguishing counterfeit sources. She eventu-
ally learned that deepening this communication meant letting go of the "im-
age management" and "personal agenda" that she believed originally led to
her addiction.
At one point, Laura asked her instructors for advice about "praying." In
keeping with the Alldredge lack of explicit direction, the instructors offered
several options (dialectic), with Laura choosing one (agency). As she put the
experience in her journal, "I asked Carrie [the instructor] to show me, Brad,
and Julie how to create Indian prayer ties. She gave each of us five squares of
fabric and a string. We picked a pinch of ashes out of a bowl, held it up,
silently thought our prayer, held it to our hearts, then wrapped it and tied it
to our strings. It was one of the coolest things I'd ever done. I told Julie I was
glad we shared this together and gave Brad and her hugs." Laura later con-
nects these good feelings to the wholeness and relationships she felt, which
"could only have come from the Source."
Well known to all present and former students of the Alldredge Acad-
emy is that no one, but no one, ever wants to leave the village. Its soil is
considered almost sacred and holy. It is viewed as a place of vital discoveries
as well as a location of deep security and incredible relatedness to the in-
structors, the other students, the land, and perhaps most of all, the Source
who unites them all. Laura reported the same feelings in her journal. How-
ever, she also admitted considerable fear and anxiety. How was she going to
leave this "womb?" How could she face "school" and all the "crap" that this
might bring with it? She felt she had "new wings," but now they would really
be tested. Could she fly?

The School Phase

The school phase is intentionally more "school" oriented to provide a

more realistic transition from the academy. After another 4-day round of
family therapy, more traditional coursework is studied and more conven-
tional schedules are kept. However, school counselors are plentiful, and con-
siderable time is allotted for "conversation" and the "future." Here, the goal
is to consolidate the often incredible emotional and relational gains made
and provide a means by which these gains can be translated into a life of
service "on the outside" (altruism). Although this transition is a familiar
problem to any counselor in a therapeutic community, the main academy

NON-NATURALISM AND THE ALLDREDGE ACADEMY 47

tool for solving this problem is perhaps less familiar, at least less profession-
ally familiar—the Source.
As an explicitly non-naturalistic, theistic model, the Alldredge Acad-
emy recognizes that the only part of the students' therapeutic context that
they will always be able to take with them is the Source (along with the sense
of life purpose and virtue that accompanies the Source). Few, if any, students
will end up in a place as beautiful as the mountains of West Virginia. Few, if
any, students will ever experience again the magic associated with saving a
life. Few, if any, students will experience another "village," with its loving
relationships, mysterious caves, and constant personal feedback. Still, from
the perspective of the Academy instructors, all these things were produced
by and are presently available in the Source (holism). Moreover, the Source
can never be stolen, mutilated, or deceived. It can only be rejected, in spite
of its imminent and universal accessibility.
Consequently, the mission of the "school" is to transfer and consolidate
the experiences and insights related to the Source. Instructors accomplish
this task by continuing the spiritual scaffolding and dialectic begun by the
Journeys (and their dialectical relations). What lessons did you learn? How
are you applying them in this new context? How are they fading, conflicting,
hurting you? How can they be enhanced? With Laura, the West Journey had
always been her Achilles heel. Reasoning dialectically, she also knew that
this was her greatest opportunity for relational growth. She also had the
fervent wish to serve the Source and somehow this challenge was her best
way to effect this service (altruism). Therefore, she and her counselor set
their sights on understanding and overcoming her struggles with the West
Journey.
Although the West Journey is adorned with important symbols of primi-
tive cultures such as the Invisible Warrior, its main theme (or virtue) is for-
giveness (value ladenness). Laura admitted to having many problems with
this virtue, problems in forgiving herself and problems in forgiving others.
She knew and endorsed the concept intellectually, but she also knew that
she did not "know it in my heart." She also knew that the Source would not
be wholly available to her when she left the Alldredge Academy if she did
not work through her struggles with this virtue. Rather than her usual "games"
with such struggles—isolating herself and avoiding the things that really
mattered—she turned to the members of her group (along with the school
counselors) and made a point of asking their help in investigating her prob-
lems with forgiveness (agency and holism).
Through an honest, forthright, and courageous give-and-take with her
peers and instructors, Laura realized that she had several preconceptions about
the notion of forgiveness from her journal:

1. Forgiveness means giving someone permission to continue

their wrong behavior.

48 SLIFE, MITCHELL, AND WHOOLERY

 2. Forgiveness is only a verbal statement, which cannot be
trusted.
3. Forgiveness can only come after forgetting.
4- Forgiveness can only be given when someone deserves to be
forgiven.
Of course, to recognize these preconceptions as faulty is to realize at
some level what is true (the dialectic). However, Laura knew that she was
still struggling with the heartfelt forgiveness of someone. Her instructors then
provided her with empathy exercises, allowing her to step into the identity,
beliefs, and history of another person. At the same time, she asked the Source
for the "spirit of forgiveness," and to her utter surprise, she realized her re-
quest had been granted. She learned that she had always had a gift for under-
standing what people were going through, though this gift had somehow been
blocked. As she developed this gift, however, she found compassion for oth-
ers and the desire to forgive even people who had wronged her, like her
parents (holism). By empathically understanding the vulnerability of another,
even when they seemed strong, she found she wanted to forgive, indeed for-
give herself.
She realized that the Source had provided; the Source had granted her
request. Indeed, her discovery of the forgiveness virtue and all that she gained
through more fulfilling relationships indicated to her that the Source would
always provide. Suddenly, her fears about leaving the village "womb" were
gone, and her hopes for the future "outside" brightened considerably. She
realized that she would have to give up much of what she once thought she
had, including her old "druggie" friends, her old images of her grandparents
(and parents), and her need for approval. However, she knew that with the
help of the Source she could belong somewhere else, minister to others some-
where else, and continue to grow somewhere else.
As of this writing—2 years after her Alldredge experience—Laura's
parents report that she is doing well in college, with no drug abuse or bouts of
serious depression. They also report that she is currently searching for a ma-
jor that will maximize her service to others.

Therapist-Author Commentary
How would a naturalistic, and thus nontheistic, treatment have led
Laura on a different therapeutic journey from the one above? How would the
five assumptions of naturalism have coalesced into a different experience for
Laura? In answering these questions, we would first contend that naturalistic
assumptions are not only used in many systems of treatment but also fre-
quently considered axiomatic across the field. Many familiar notions of men-
tal health care owe their existence and widespread endorsement to these
assumptions. We realize that some researchers would claim empirical sup-
port for many of these assumptions (e.g., Higgins, 1997), but the fact is that

NON-NATURALISM AND THE ALLDREDGE ACADEMY 49

their efficacy and effectiveness have rarely, if ever, been directly compared
to non-naturalistic assumptions. Consider the following common notions of
therapeutic community (with the main naturalistic assumption in italics)
along with their comparison to Laura's actual treatment:

1. The best or ultimate motivator of clients is their own self-benefit

(e.g., reinforcement, happiness, satisfaction, well-being). Because
the human nature of clients is ultimately hedonistic, all strate-
gies for motivating clients should take advantage of this na-
ture. Even the helping of other people should not be encour-
aged unless it results in client fulfillment and thus self-benefit.
However, this common understanding of motivation is be-
lied by perhaps the primary turning point in Laura's treat-
ment—her risking her life (and perhaps suffering) for the sake
of someone she barely knew. Laura believed that the altruism
of the Source, as learned through her interactions with the
team, led to her altruism with the rescued woman. This altru-
ism, in turn, resulted in her service orientation toward the
team and her counselors.
2. The core therapeutic principles of a mental health community should
be objective—as free from bias as humanly possible. This objectiv-
ity usually has two implications for therapeutic communities.
First, only therapy strategies that are supported by supposedly
bias-free research are permitted (e.g., empirically supported
treatments; Nathan & Gorman, 1998). Second, all residents—
regardless of their value systems—are thought to be treatable
by the objective techniques and strategies of the community.
With Laura, however, instructors at the Alldredge Academy
were up front and constant in their promotion of her virtue
and character. (The academy also holds that no research is
bias-free; see Slife & Williams, 1995.) Laura was encouraged
to arrive at her own values, through the value-laden experi-
ences of the three phases of the academy. However, not all
values are considered equal or correct, so she was gently guided
by her counselors to consult the Source as she did so.
3. Changes in environmental and/or biological factors are responsible
for changes in client behavioral patterns. In other words, the set-
ting, structure, and interventions of the therapeutic commu-
nity itself, along with medications, are responsible for client
changes. However, if these factors are responsible for these
changes—factors that are, for the most part, outside the per-
sonal control of clients—then the clients themselves are not
responsible for them; the intervention is deterministic. The
Alldredge Academy, by contrast, did not view Laura's biol-

50 SLIFE, MITCHELL, AND WHOOLERY

 ogy or her environment in this fashion. Although these fac-
tors undoubtedly play a role in Laura's behavior, she is also
the agent of her actions, permitting her to do otherwise than
her nature and nurture would dictate. In this sense, Laura was
helped to desire change. Although nothing can force her to
desire change, dialectical and relational experiences with the
Source can facilitate her evaluation of her current desires and
offer options she did not have before.
4. Therapeutic systems and interventions should be applied rationally
and consistently. Clients should be taught how each portion of
the healing process is consistent with the treatment goals of
long-term, hedonistic self-benefit. Laura, however, was not
motivated by her long-term self-benefit; she was motivated
by the benefit of others (e.g., her team and the woman she
rescued). Moreover, many interventions seemed quite para-
doxical to Laura, and thus inconsistent with her long-term
self-benefit. That is, her usual patterns or "games" were chal-
lenged in such a way that she sincerely began to give up the
selfish ends of her games (using others for pleasure or power).
She gave up these games because they were incompatible with
the relationship she discovered with the Source (and others).
5. The individual is the primary unit and concern of a therapeutic com-
munity. Because individuals supposedly carry around with them
their unique, self-contained qualities (e.g., intrapsychic con-
flicts, reinforcement histories, cognitive schemas), these atom-
istic qualities are the primary reason for client problems and the
primary focus of client treatment. This focus does not preclude
interactions with others, but it does fundamentally isolate the
individual. The therapeutic community becomes a collection
of autonomous individuals with their own self-contained prob-
lems. Therapeutic strategies are limited to the effect of outside
factors (e.g., people and environment) on the individual's self-
contained problem. By contrast, the primary unit and concern
of the Alldredge Academy is the relationship, including rela-
tionships between people, between people and nature, and most
important between people and the Source. Consequently, rela-
tionships, not individuals, are nurtured and guided. Treatment
goals are not so much about individual fulfillment as they are
about relational caring and true intimacy.

CONCLUSION
At this point, we should reunite important aspects of the case presented
here. Our case is, in some sense, the field of therapeutic communities, with

NON-NATURALISM AND THE ALLDREDGE ACADEMY 5]

its emphasis on a secular and naturalistic philosophy. Without some non-
naturalistic philosophy, we contend that it will be difficult to formalize the-
istic interventions. Our case is also a particular therapeutic community, the
Alldredge Academy. This unique institution has pioneered not only a rela-
tively unfamiliar philosophy (for therapy) but also many of the practices that
would seem to follow from it. We believe that secular psychotherapy—
restricted as it is by its naturalistic dogma—can learn a great deal from a
therapeutic community such as the Alldredge Academy. Finally, our case is
Laura, who was privileged not only to solve her problems and reconstitute
her relationships but also to discover the greatest gift of all—the fellowship
of the Source.

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54 SLIFE, MITCHELL, AND WHOOLERY

 3
A THEISTIC INPATIENT TREATMENT
APPROACH FOR EATING-DISORDER
PATIENTS: A CASE REPORT
RANDY K. HARDMAN, MICHAEL E. BERRETT, AND
P. SCOTT RICHARDS

Despite indications that religion and spirituality may be important in the

treatment of eating disorders (Hall & Cohn, 1992; Hsu, Crisp, & Callender,
1992; Mitchell, Erlander, Pyle, & Fletcher, 1990; Rorty, Yager, & Rossotto,
1993; Smith, Richards, Fischer, & Hardman, 2003), spiritual interventions are
rarely used in contemporary treatment programs. We have described elsewhere
why we believe that spiritual treatment approaches and interventions hold
promise for enhancing the effectiveness of eating disorder treatment programs
(Hardman, Berrett, & Richards, in press; Richards, Hardman, Frost, Berrett,
Clark-Sly, & Anderson, 1997). Briefly, we believe that some of the core issues
that eating-disorder patients struggle with are spiritual in nature (e.g., lack of
spiritual identity, negative images of God, feelings of spiritual unworthiness
and shame, etc.), and that the most powerful way to resolve these issues is
through spiritual interventions (Richards et at., 1997).
In this chapter, we describe an integrative, multidisciplinary inpatient
treatment program for women with eating disorders. Undergirding the Cen-
ter for Change (CFC) treatment philosophy and approach is the belief that

55
faith in God and spiritual self-understanding and growth can be crucial for
those recovering from eating disorders (Richards et al., 1997). To more clearly
illustrate the processes and potential outcomes of our nondenominational
theistic treatment approach, we share the treatment history of one patient,
Jan, whose faith in God and personal spirituality played a crucial role in her
healing and recovery.

DESCRIPTION OF THERAPISTS
Randy K. Hardman

I completed a PhD in counseling psychology in 1984 at Brigham Young

University (BYU). Since 1984,1 have worked as a program director and clini-
cal practitioner in university, hospital, specialized treatment center, and pri-
vate practice settings in Indiana, Colorado, and Utah. I served as an adjunct
faculty member at BYU in the Counseling Psychology program. I am cur-
rently an owner and codirector of Center for Change, an inpatient special-
ized eating disorder treatment center, in Orem, Utah.
I am a committed and active member of the Church of Jesus Christ of
Latter-day Saints (LDS). I grew up on a farm in rural Idaho, and my own
religious upbringing was without regular church attendance or participation
by either my parents or by our family. In a real sense, I was on my own a great
deal in both a literal and in a religious-spiritual way. I spent many hours
alone in farming responsibilities, and in the quietness and isolation of this
rural setting, I communed with God in personal prayer on a regular basis. I
was a believer in God, and as a boy felt a connection with God spiritually
before I became acquainted with and fully engaged in the religious teachings
and tenets of my church as an older teenager.
Over the years, in many thousands of hours of face-to-face interactions
with individuals, couples, and families, I have become more in tune with
how relationships with self, God, and others are interconnected and need to
be addressed and included together in successful therapeutic change. I be-
lieve that these relationship experiences, whether perceptual, emotional, or
spiritual, have the greatest long-term impact on healing, change, and recov-
ery. I listen closely to clients to understand where they are willing to go in
the spiritual-religious experiences of their relationships. I have become more
willing over the years to openly and directly discuss spiritual concerns and
needs because clients are so eager to explore them. I have found spiritual
recovery as the key for bringing hope, healing, and recovery for women with
eating disorders.
Michael E. Berrett
I completed my doctorate in counseling psychology at Brigham Young
University. I also completed a formal doctoral minor in marriage and family

56 HARDMAN, BERRETT, AND RICHARDS

therapy as well as a master's degree in school psychology. I began working in
the field as a school psychologist and then as a high school counselor. Fol-
lowing these positions, I worked as a primary therapist in adult and adoles-
cent acute inpatient treatment and in an inpatient specialty eating disorder
program. In the more recent years of my career, I have served as a business
consultant, taught college courses in clinical and counseling psychology, di-
rected a clinical wilderness treatment program for troubled adolescents, op-
erated a successful private practice, and cofounded and codirected an inten-
sive inpatient treatment program for anorexia, bulimia, and coexisting
emotional disorders.
Throughout my career, I have noticed that those with spiritual beliefs,
and especially those who live congruent with their spiritual beliefs, seemed
to make more dramatic gains in the recovery process and in maintenance of
treatment gains. I have repeatedly heard from patients that their own focus
on religious and/or spiritual issues in treatment, whether within the thera-
peutic relationship or "on their own," including their faith in their own spiri-
tual tenets and consequent life activities and choices, were some of the most
powerful catalysts for positive change.
As a result of this "personal learning" over time, which I consider a
blessing to me from the clients I have worked with, myself and several col-
leagues began conceptualizing those spiritual themes that were both recur-
rent and most powerful in our patients' lives. This led to designing a spiritu-
ality workbook, a spirituality group in treatment, spiritual interventions in
treatment, research on the efficacy of spiritual interventions in treatment
outcome, and several professional publications about spirituality and eating
disorders.
Although I believe that the spiritual approach is not the only worth-
while modality of treatment and indeed that the best treatment is multimodal
and multidisciplinary, I strongly believe that the spiritual is the most impor-
tant aspect of healing and recovery. I intend to continue to attend to this
understanding, and I hope that attending to it will help many individuals in
their road to recovery, healing, and peace.

TREATMENT SETTING AND PROGRAM

CFC is a private inpatient care facility for women with eating disorders.
Some staff members also provide outpatient psychotherapy services to women
and men with a wide variety of other psychological and relationship con-
cerns. The multidisciplinary inpatient treatment staff includes 2 medical
doctors, 2 psychiatrists, 5 PhD psychologists, 1 PhD marriage and family thera-
pist, 2 clinical social workers, 2 PhD psychology residents, 3 PhD psychology
interns, 1 director of nursing and health services, 9 registered nurses, 3 regis-
tered dieticians, 1 dietary technician, 1 PhD instructional psychologist/educa-

EAT1NG-DISORDER PATIENTS 57
tion director, 5 experiential therapists, 18 care technicians, and 2 chefs; 81%
of the treatment staff are women. Approximately 50% of the staff are members
of the LDS church and the remaining adhere to a variety of spiritual traditions,
including Protestant Christian, Jewish, and Muslim perspectives.
The CFC treatment program is grounded in current research findings
and accepted clinical guidelines for treating eating disorders (American Psy-
chiatric Association, 1993; Richards, Baldwin, Frost, Clark-Sly, Berrett, &
Hardman, 2000; Yager, 1989). Treatment is customized to meet each patient's
needs; thus, length of stay varies. However, as a general rule, patients and
their families commit to a minimum of 12 weeks of inpatient treatment for
anorexia and 8 weeks for bulimia. The treatment team continuously evalu-
ates ongoing needs and adjusts treatment length when needed.
Once admitted to CFC, each client receives a medical assessment. The
evaluation includes a complete medical history, physical assessment, neces-
sary medical procedures, and medications. Throughout the treatment pro-
gram, the physician oversees the physical aspects of recovery including the
medical progress of each client, her diet, and her weight gain. In addition, at
the time of admission, a psychiatrist, psychologist, or social worker gathers
an eating disorder history and assesses the patient's emotional condition.
Along the recovery path, patients work their way through a four-phase
treatment program. The four phases of recovery represent distinct stages of
growth and change. Each phase has clearly defined guidelines, assignments,
and therapy tasks, as well as increased privileges and responsibilities.
Phase one: The patient recognizes and acknowledges the presence, real-
ity, severity, and effect of her eating disorder and other emotional disor-
ders. She also begins to understand herself and the development of the
eating disorder.
Phase two: The patient takes responsibility and ownership for her eat-
ing disorder and other difficulties; learns to take responsibility for her
recovery; and regains a sense of choice, power, control, and hope.
Phase three: The patient increases in desire to let go of her eating
disorder, deals with her difficult feelings, and makes a personal commit-
ment to do the work necessary to overcome her eating disorder.
Phase four: The patient actively works to decrease her feelings of shame
and self-criticism, and to increase patterns of self-acceptance and self-
correction. She also begins to share with others some of what she has
gained in treatment.
Each patient advances individually through each phase as soon as she is ready,
and great care is taken to ensure that each patient progresses at her own
pace. Her privileges and responsibilities increase over time as she demon-
strates readiness to move ahead. This stepped-care approach to treatment
gently helps patients gain confidence as they advance through the phases of
change at their own pace.

58 HARDMAN, BERRETT, AND RICHARDS

 Patients participate in a variety of needed therapies to assure compre-
hensive treatment and progress toward recovery. These include (a) individual
psychotherapy sessions (4 times weekly); (b) group psychotherapy (7 times
weekly) and body image group (2 times weekly); (c) experiential and expres-
sive activities, including music, dance, movement and recreation therapies
(8 to!2 times weekly); (d) family counseling (frequency varies per patient
needs); (e) nutrition monitoring and counseling (3 times weekly); (f) medi-
cal evaluations and treatment (frequency varies per patient needs); (g) eat-
ing disorders education classes on a variety of topics, including diet and nu-
trition, self-esteem, healthy exercise, assertiveness, communication skills (3
times weekly); (h) individualized academic management and tutoring (as
needed depending on patient needs); and (i) spiritual exploration and growth
activities, including spirituality groups (3 times per week), spiritual readings,
and service activities.

SPIRITUAL COMPONENT OF THE TREATMENT PROGRAM

We believe that a spiritual component is an essential part of a multidi-

mensional, multidisciplinary treatment approach for women with eating dis-
orders. Our integrative, theistic approach to using spiritual interventions is
consistent with the recommendations of numerous professionals that spiri-
tual interventions should not be used alone, but integrated with standard
psychological and medical interventions (Richards & Bergin, 1997; Richards
& Potts, 1995; Shafranske, 1996).
We use a nondenominational spiritual emphasis that has proved help-
ful to patients from a wide variety of religious backgrounds. Two research
studies conducted at CFC have provided evidence that spiritual growth and
healing during treatment is positively associated with better patient outcomes
(Richards, Berrett, & Hardman, 2001; Smith et al., 2003).
During treatment, patients are encouraged to explore their own spiri-
tual beliefs and to draw on their faith to assist in their recovery. We believe
that as patients align their behavior with their own spiritual beliefs, they will
benefit from improved confidence, self-respect, and peace of mind. Patients
are invited to explore spiritual issues related to their recovery if they desire
during their individual psychotherapy sessions.
To further facilitate spiritual exploration and healing, patients attend a
weekly 60-minute spiritual exploration and growth group, and read a self-
help workbook (Richards, Hardman, & Berrett, 2000), which includes scrip-
tural and other spiritual readings and educational materials about topics such
as faith in God, spiritual identity, grace, forgiveness, repentance, faith, prayer,
and meditation. Each patient utilizes the structure of the workbook and sup-
port of the group to help them come to an understanding of their own spiri-

EATING-DKORDER PATIENTS 59
tual beliefs and convictions, and to include those understandings in their
recovery program.
Patients also participate in a biweekly, 12-step group, adapted for women
with eating disorders. Patients are also given opportunities during the treat-
ment program to attend religious services of their choice and to engage in
altruistic acts of service within the Center and community.

CLIENT DEMOGRAPHIC CHARACTERISTICS

Jan was a 19-year-old, Caucasian woman from the western United States.
Before her admission to CFC, she resided with her parents and a younger
sister. Jan was the second of three children. Her parents were in their first
marriage. Their socioeconomic status was upper-middle class. Jan's older
brother was 22 years old and her younger sister was 8 years old.
A high school graduate, Jan had enrolled as a freshman at a university
in a western state, but she was unable to successfully continue in the educa-
tional program because of the severity of her anorexia. Jan and her family of
origin were members of The Church of Jesus Christ of Latter-day Saints (LDS
church; Ulrich, Richards & Bergin, 2000). Jan considered herself an "active"
(orthodox) member of the church.
Dr. Randy K. Hardman was assigned to be Jan's individual psychothera-
pist during her inpatient stay at CFC. Jan met with Dr. Hardman four times
per week. As the president and director of Clinical Services at CFC, Dr.
Michael E. Berrett oversaw Jan's treatment during her inpatient stay. He also
served as the group leader for Jan's weekly spiritual exploration and growth
group.

PRESENTING PROBLEM AND CONCERNS

Jan had suffered with anorexia since the eighth grade and it had be-
come extremely severe in the year prior to her admission. She had also had a
long-standing, depressive disorder, with a general state of guilt and unhappi-
ness. She had tried some outpatient therapy but had not persisted with it.
She came to CFC following an assessment and referral by an outpatient thera-
pist in her community. This was the first intensive therapeutic treatment
that she had received.
In her first individual therapy session with Dr. Hardman, Jan said,
I'm at a stand still. I have no social life. I don't see any way for a future
family or career because of my eating disorder. My eating disorder con-
trols everything. Health is a big concern. I'm very worried about it. I'm
scared of a heart attack. I feel sick inside, tired. I'm aged. I've aged myself
fifty years. I'm not okay.

60 HARDMAN, BERRETT, AND RICHARDS

 CLIENT HISTORY

Significant Childhood and Family History

Jan grew up in a Latter-day Saint home, but her father was not active in
the Church. Her mother was always very involved in the church. Jan de-
scribed her parents' marriage as "stable." She said that her parents have never
been abusive to her or her siblings.
When she was a small child (6 or 7 years), Jan was placed in the care of
a babysitter, and in that placement, the father of her babysitter sexually abused
her. She also witnessed the father sexually abusing his daughters, and found
pornographic pictures of the father's children.
As she grew up, Jan felt like she could never please or satisfy the expec-
tations of her mother in regards to cleanliness and behavior. She also felt
that her parents were emotionally distant and rarely praised her or validated
her worth and goodness.
Jan described her parents as strict and structured, but indicated that her
younger sister got away with a lot of things that she and her older brother did
not. Jan said that she felt like she "always had to be a good child. I was a
pleaser." Jan said that this pattern has not changed in her life.
Jan said that her mother viewed her as a very emotional child. Her
older brother was more oppositional than she was and tended to break the
rules. Jan did not feel that she got rewarded for being the compliant and
obedient child.
Jan said that her father drank every day at home and got intoxicated on
a somewhat regular basis. He ran a family business and her father's relatives
all consumed alcohol. As Jan got older, she had a lot of negative feelings
about her father's use of alcohol and his lack of religious participation. Jan
said that her father made an effort to be close to her when he became aware
of the eating disorder, but she emotionally pulled away from him.
Jan described her mother as a sensitive person, but said, "She's not very
sensitive to me." Jan felt an emotional disconnection from her mother most
of her adolescent life. Jan explained, "I am very sensitive when I'm talking to
her. Instead of responding to me and what I'm saying, she will talk about
something that she is worried about." Jan described her mother as a poor
listener. Jan said her mother was always worried and preoccupied with other
things. Jan described herself as being "wanted, but not needed."
During the year prior to Jan's admission to CFC, Jan felt like her par-
ents' focus was on her older brother, who was preparing for his church mis-
sion. Jan said that at one point she was afraid her parents might forget her
high school graduation.
Jan said that she and her brother are close, but she believes her parents
favored him. Jan admitted, "I feel selfish for saying things about that because
I feel like I'm the expensive child. I go through money, braces, dance, and

EATING-DISORDER PATIENTS 61
now I'm here with therapy." Jan said that her little sister is a worry for her,
but that their relationship is good.
Jan had a good high school experience, except for her junior year when
her eating disorder became extremely severe. She said that she was some-
what popular during high school. She had close friends and dated periodi-
cally, although she had no serious boyfriends. Jan was a very good student in
high school, had a 4-0 grade point average, and received a scholarship to
attend university.

Eating Disorder History

Jan said that she started her eating disorder when she was in eighth
grade by restricting and going on a very rigid diet. When she started to lose
weight, she increasingly restricted her eating. Jan would divide the food on
her plate in half and eat only half of her food. She gradually eliminated all
sugars, butter, peanut butter, and all fat foods from her diet. By the spring of
1996, she was eating only fruits and vegetables. Even then, she felt much
guilt and self-incrimination about her eating. Jan also often fasted when she
knew that she could not get out of eating a meal. She felt like she had to
restrict and fast in order to feel deserving to eat. She would not eat to com-
pensate for the times she did eat. Jan also participated in many dietary trends.
When Jan became a junior in high school, her eating disorder wors-
ened. Jan said that school became much more difficult because her grand-
mother worked at the high school and she would "send her attack dogs—
other teachers and administrators—out on me to make sure I'd eat. Everybody
focused on my eating and my eating disorder." Jan said it was very difficult
and embarrassing to have her grandmother watching over her in that way.
Jan's eating disorder continued through her senior year, although she
viewed it as less severe than it was during her junior year. In her senior year, Jan
was extremely unhappy, felt like her pants were too tight, and she stated that
"everybody else thought I was doing great, but on the inside I was miserable. I
was never happy. I felt dull inside. Because of that, I made a suicide attempt."
Jan said that as her eating disorder continued to worsen she would not
eat breakfast, yet eat a small lunch and a small dinner with the family. She
indicated that the amount of food she would eat continued to decrease. She
hated to eat in front of other people. When she was on dates, she would only
eat a salad. She stopped going to social events because she could not stand to
eat in front of other people and she could not have complete control over her
food.
Jan said that she became consumed by her eating disorder. Every thought
was about food. She began to hide things, lie a lot, keep secrets, deny things,
and tell people she was eating when she was not. She stated, "I hate lying,
but I got good at it. I'd fake that I had eaten meals, but I hated the fact that I
lied all the time." Jan said they she did not ever engage in laxative or diet pill

62 HARDMAN, BERRETT, AND RICHARDS

abuse. She did, however, overexercise somewhat during the 2 years prior to
her admission at CFC.
Jan attended university for one semester, but she had a very difficult
time with the eating disorder even though she did all right with her grades.
While at college, Jan said she restricted every meal: "My roommates never
saw me eat. My main meal in college was a Diet Coke." Jan said that some-
times she would drink water and other times she would go days without drink-
ing it because she hated the "full" feeling that drinking would give her. Jan
dropped out of university because the eating disorder had escalated to the
point where she could not function.
In spite of all of her weight loss efforts, Jan admitted on her admission
to CFC that she constantly felt fat. Her hair was falling out. Her skin was
pallid and white. She looked like she did not feel well physically. She lost her
menses prior to her admission to CFC. She had also lost her menses for a year
during high school. Jan admitted that for several months prior to her admis-
sion she was purging up to three times a day, and she continued to both
restrict and purge up until the time of her admission.

ASSESSMENT AND DIAGNOSIS

When Jan was admitted to CFC, she underwent a physical and nutri-
tional exam, and Dr. Hardman conducted a psychiatric evaluation and a
mental status exam. Jan also completed a comprehensive battery of psycho-
logical tests, including the Minnesota Multiphasic Personality Inventory—2
(MMPI-2; Butcher, 1990), Eating Attitudes Test (EAT; Garner & Garfinkel,
1979), Body Shape Questionnaire (BSQ; Cooper, Taylor, Cooper, & Fairbum,
1987), Outcome Questionnaire (OQ 45.2; Lambert & Burlingame, 1996),
Multidimensional Self-Esteem Inventory (MSEI; O'Brien & Epstein, 1988),
Spiritual Weil-Being Scale (SWBS; Paloutzian (Si Ellison, 1991), Religious
Orientation Scale (ROS; Allport & Ross, 1967), and Spiritual Outcome Scale
(SOS; Richards & Smith, 2000). She completed all of these measures again
except the MMPI—2 and ROS when she was discharged from CFC. Jan's
admission and discharge scores on the EAT, BSQ, OQ 45.2, MSEI, SWBS,
ROS, and SOS are presented in Table 3.1.
Jan's physical exam at admission revealed that she was 5' 6" tall and
weighed 94.5 Ibs. Jan's physical, cardiac, and neurologic exams were unre-
markable, although her heart rate was only 55. The physician also noted that
Jan was "thin and somewhat cachectic appearing, occasionally gets some sharp
chest pains and some constipation," and her last menstrual period was in
September of 1999.
The nutritionist estimated Jan's Body Mass Index at 15.5. She also con-.
eluded that Jan's body weight and somatic protein stores were below normal
limits. She noted that Jan had "poor hair growth and falling out," "skin bruises

EATING-DISORDER PATIENTS 63
 TABLE 3.1
Jan's Scores on the Battery of Psychological Tests Completed on
Admission and Discharge From Center for Change

Psychological test Admission score Discharge score Normal range

EAT 80 7 <30
BSQ 162 57 < 110
OQ 45.2
Total score 78 26 <63
Symptom distress 45 12 <39
Relationship distress 15 10 <15
Social role conflict 17 4 <13
MSEI (Global self-esteem) 33.6 46.3 40-59
ROS
Intrinsic 41 N/A N/A
Extrinsic 28 N/A N/A
SWBS
Religious well-being 60 60 >47
Existential well-being 53 57 >43
Spiritual Outcome Scale
Total 46 61 >54
Love of God 17 22 >19
Love of others 20 23 >19
Love of self 9 16 >15
Note. For the Eating Attitudes Test (EAT), Body Shape Questionnaire (BSQ), Outcome Questionnaire
(OQ 45.2), Spiritual Well-Being Scale (SWBS), and Spiritual Outcome Scale, the estimates that are
considered in the normal range are based on normative data. The Multidimensional Selt-Esteem Scale
(MSEI) subscale scores are all f scores, and so the normal range is between 40 and 59. ROS = Religious
Orientation Scale.

easily," "increased sensitivity in teeth and gums bleeding," "stomach pain,

bloating, and gas," and "cold body temperature." She concluded that Jan is
"at risk for malnutrition."
During her psychiatric interview with Dr. Hardman, Jan described her
eating disorder symptoms, as well as symptoms of major depression that had
been present for several years. There were no indications of psychotic fea-
tures or thought disorders. Jan's DSM-IV Axis I diagnosis was Anorexia
Nervosa (Purging Type, Severe) and Major Depression (Single Episode,
Moderate). Jan's Axis II diagnosis was deferred.
Jan's MMPI-2 profile confirmed that she was suffering from clinically
significant levels of a variety of psychiatric symptoms such as depression,
anxiety, fearfulness, obsessive thoughts, guilt, low self-esteem, self-blame,
and feelings of worthlessness. Jan also suffered from multiple somatic symp-
toms, including poor appetite, fatigue, insomnia, and cardiac pain. Jan's
MMPI-2 configural code type was a 72. Her Pt scale was 94, D scale was 90,
and her Hs scale was 86. Her F scale was also elevated at 82, although her L
scale was 62 and her K scale was 46. We concluded that Jan's profile was
valid, but that she had exaggerated her symptoms somewhat in a cry for help.
Jan's EAT score revealed that Jan was experiencing a clinically signifi-
cant level of eating disorder symptomology, including restricting, hinging,

64 HARDMAN, BERRETT, AND RICHARDS

purging, anxiety about eating, and preoccupation with food. Jan's scores on
the BSQ revealed that she was also experiencing a clinically significant level
of distress about her body shape (e.g., feeling too fat, wanting to be thinner,
and feeling ashamed of her body). Jan's scores on the OQ 45.2 revealed that
she was experiencing clinically significant levels of distress and symptoms in
her (a) intrapsychic functioning (depression and anxiety), (b) interpersonal
relationships, and (c) social role performance (e.g., as a daughter, student,
and sister). Jan's score on the MSEI global self-esteem scale revealed that Jan
did not view herself in a favorable manner. More specifically, she was self-
critical and self-doubting. She also viewed herself as being incompetent, un-
likable, unassertive, and physically unattractive.
Jan's scores on the ROS revealed that she was intrinsically religious,
which suggests that she believed in her religion and was attempting to live it
in her daily life. Jan's scores on the SWBS revealed that she believed that
God loved her and was concerned about the problems she was experiencing,
and that she felt a sense of purpose in her life. Thus, based on the ROS and
SWBS, Jan's religious faith and involvement appeared to be a potential
strength and resource in her life. However, Jan's scores on the SOS subscales
indicated that her feelings of love for God, others, and herself were below the
normal range.

TREATMENT PROCESS AND OUTCOMES

Medical Issues and Outcomes

Jan participated in all of the aspects and components of the inpatient

program at CFC. She received a medical consultation evaluation and a psy-
chiatric evaluation. The Center's physician placed Jan on 40 mg of Prozac
for her depression and also prescribed Adivan (0.5 mg) for Jan to use as needed
for her anxiety.
Jan ate three meals and three snacks a day throughout her stay. Toward
the end of her stay, she ate in "family style," which meant she was allowed to
choose the type and portions of the food she wished to eat. Jan began men-
struation in CFC and had two menses during her treatment stay. At the time
of admission, she weighed 94 pounds, and at the time of discharge she weighed
117 pounds. At the time of discharge, Jan was no longer restricting her eat-
ing or hinging and purging. She also reported that she rarely had thoughts
about engaging in eating disorder behaviors.

Psychosocial Issues and Outcomes

Jan received individual therapy from Dr. Hardman 4 times a week, daily
group therapy, and regular nutritional and dietary consultations. She took

EATING-DISORDER PATIENTS 65
part in nutritional classes, educational classes, art therapy, dance and move-
ment therapy, music therapy, and recreational therapy. She participated in
all four phases of the treatment program and successfully completed each
phase.
Jan was extremely motivated and committed to the recovery process.
She worked hard and faced her fears. She challenged herself to face her is-
sues. Jan experienced much fear, guilt, and emotional conflict at times dur-
ing treatment due to the emotional and traumatic issues of her past. But she
was able to talk about and emotionally work through her issues in an appro-
priate fashion.
Jan worked on understanding and exploring the underlying causes of
her anorexia and the contributing factors of the depression. She came to
realize that the sexually abusive experiences she had gone through when
being babysat had been traumatic and negatively affected her. She was able
to address and resolve much of the affect of these negative sexual molesta-
tion and observation experiences.
Jan participated in family therapy on two extended weekend visits with
her parents and younger sister. She was able to address issues and patterns
from her own family of origin that had influenced her throughout her life,
including her feeling that she was never "good enough" for her mother. For-
tunately, Jan's mother and father were responsive to treatment and made
positive efforts and changes in their support of Jan's recovery.
Jan also addressed her intense feelings of self-rejection and self-
criticism and the underlying theme that she felt like she was always in trouble
and had done something wrong. Jan also addressed her constant feeling of
low self-esteem, not being good enough, and feeling weak. She was able to
become more self-accepting and self-forgiving.
Jan was able to take risks and face fears related to her eating disorder
and her social life throughout the course of treatment. Jan also addressed
some sexual fears and concerns during treatment, including dating and social
involvements. During her stay at CFC, Jan went on several dates and en-
gaged in a variety of social activities while she was on therapeutic passes.
Jan also addressed future plans and living arrangement during her treat-
ment stay. At the time of discharge, Jan was committed to continue her
recovery on an outpatient basis. She had made arrangements to live with her
cousin, someone who Jan viewed as a positive, noneating-disorder support
person. Jan also made plans to have periodic visits with her parents and sister
to continue to receive and develop positive support from them. Jan also made
plans to return to her university studies several months after her discharge.

The Role of Faith and Spirituality

Jan's faith in God and personal spirituality were frequently discussed

during her individual psychotherapy sessions and spirituality group meetings

66 HARDMAN, BERRETT, AND RICHARDS

and played a central role in her healing and recovery. Although Jan was
active in her church and publicly expressed her belief in God, it became
apparent during her individual psychotherapy that she privately harbored
intense feelings of shame, irrational guilt, and unworthiness. Jan superficially
or "theoretically" believed that God loved her and was concerned about her
problems, but in her heart she felt that God viewed her in a disapproving,
condemning manner.
During her individual psychotherapy sessions it became clear that the
sexual abuse she had suffered at the hands of her neighbor was the origin and
root cause of her feelings of shame and unworthiness in her relationship with
God, her parents, and others. The experience of being abused had left her
feeling like she had done something terribly wrong, and ever since that expe-
rience she had lived with the feeling that she was bad and unworthy. Her
parents had further reinforced these feelings through their emotional dis-
tance and failure to praise and validate Jan's goodness and competence.
As these core spiritual identity issues surfaced during treatment, Dr.
Hardman and Dr. Berrett implemented several spiritual interventions that
they believed might help Jan address them. First, Dr. Hardman and Dr. Berrett
acknowledged the spiritual nature of Jan's concerns and communicated their
willingness to discuss religious and spiritual concerns with her. Once Jan
understood that it was acceptable and safe to discuss her personal faith and
spirituality during individual therapy and during her spiritual growth group,
she frequently initiated discussions about these topics.
Second, Dr. Hardman suggested that Jan read some scriptural writings
from the Bible and Book of Mormon (The Church of Jesus Christ of Latter-
day Saints, 1981) about God's view of children, including God's affirmations
about their innocence and His love for them. These scriptural readings proved
effective in helping Jan begin to reexamine her assumptions that God held
her responsible for the abuse she had experienced as a child or that God
viewed her in a condemning, judgmental way.
Third, Dr. Hardman and Dr. Berrett encouraged Jan to use the private
time that is provided for patients in the CFC's daily treatment schedule to
engage in contemplation, prayer, and journaling about her feelings and spiri-
tual impressions. Jan's "spiritual solo time" played a powerful role in her healing
and recovery. On several occasions as she contemplated and prayed, Jan re-
ceived personal spiritual witnesses that God loved her and that it was okay
for her to speak the truth about the sexual abuse she had experienced, even if
people chose not to believe her.
During these sacred spiritual experiences Jan felt deep reassurances of
God's love come into her heart and mind. Jan said that during these times
she felt comforted, uplifted and sustained, and loved and nurtured. Her feel-
ings of hope and faith that she could face and overcome her problems were
also strengthened. As Jan shared these experiences during therapy and group
sessions, Dr. Hardman and Dr. Berrett communicated their belief in the value

EATING-DISORDER PATIENTS 67
and reality of Jan's experiences, and they affirmed the validity of the personal
insights about her identity, worth, and sense of life meaning and direction
that came to her during these times. Over the course of her stay, Jan wrote
down in her own words the spiritual impressions and feelings that came to
her and these writings became a personal code of living that she used every
day to comfort and encourage herself in the recovery process.
Once Jan felt safer in her relationship with God and knew in her heart
that God was with her in her recovery, she became very willing to take sig'
nificant risks in treatment to face her fears and to resolve issues with her
family. The permission she had felt from God during her spiritual solo times
to tell the truth about the sexual abuse gave her the courage to disclose what
had happened to her parents. The security that Jan felt because of her grow-
ing faith that God loved her as a child and now as an adult helped her be
honest and face her fears and pain. The growing sense of security about her
personal spiritual identity and worth provided an anchor or foundation that
enabled Jan to move forward with courage and confidence as she actively
engaged in all aspects of the CFC treatment program. Jan described her spiri-
tual healing as "bigger than her own thoughts and feelings." She came to
trust in a power beyond herself to help her change and overcome the prob-
lems in her life.

Psychological and Spiritual Outcome Measures

Jan's scores at the time of discharge on the EAT, BSQ, OQ 45.2, MSEI,
SWBS, and SOS confirmed our clinical judgment that Jan had improved a
great deal during her stay at CFC. As can be seen in Table 3.1, Jan's scores on
the EAT dropped from being in the high clinical (abnormal) range (80) into
the normal range for women (7). This indicates that Jan no longer suffered
from eating disorder symptoms, such as restricting, hinging, purging, anxiety
about eating, preoccupation with food, and so on. Jan's scores on the BSQ
also dropped from the high clinical range (162) into the normal range for
women (57). This indicates that Jan was no longer experiencing clinically
significant levels of concern, worry, and distress about her body shape.
Jan's scores on the OQ 45.2 also dropped from being in the clinical
range into normal ranges. This indicates that Jan no longer suffered from
clinically significant levels of distress and symptoms in her (a) intrapsychic
functioning (depression and anxiety), (b) interpersonal relationships, or
(c) social role performance (e.g., as a daughter, student, sister). Jan's score on
the MSEI global self-esteem scale also fell into the normal range at the con-
clusion of treatment, indicating that during treatment Jan became more self-
accepting and self-confident. She also came to view herself as being more
competent, likable, powerful, and physically attractive.
Jan's scores on the religious well-being scale of the SWBS did not change
during treatment, perhaps because her admission score of 60 is the highest

68 HARDMAN, BERRETT, AND RICHARDS

possible score on the SWBS. Jan's scores on the existential well-being scale
of the SWBS increased from 53 to 57, staying in the high normal range. This
indicates that Jan continued to believe that her life had purpose and mean-
ing, but again because of the ceiling effect of this measure her scores may not
accurately reflect how much progress she experienced in this dimension of
her life. Others have raised concerns about the ceiling effect problem of the
SWBS and its lack of sensitivity to change among highly religious people
(Hall, Tisdale, & Brokaw, 1994). With Jan, the SWBS provided a good mea-
sure of her cognitive, doctrinal beliefs about God, but it failed to sensitively
measure the changes in the inner dimension of her spirituality.
Conversely, Jan's scores on the love of God, love of others, and love of
self SOS subscales all increased and fell in healthy, normal ranges at the time
of discharge. Thus, it appears that the SOS was a more sensitive measure of
the changes in the inner dimension of Jan's spirituality—that is, her love of
God and others, as well as her growing felt conviction based on personal
spiritual experiences that she is a lovable and worthy person.

Jan's Postdischarge Functioning

Follow-up phone interviews with Jan by Dr. Hardman and the CFC
research staff and aftercare coordinator on periodic occasions since she was
discharged 2 years ago have confirmed that Jan has continued to progress in
her journey of healing and recovery. Jan did return to university several months
after she was discharged from CFC and enjoyed success in her studies. During
a one-year follow-up standardized phone interview conducted by a CFC re-
search staff member, Jan indicated that she viewed herself as "mostly recov-
ered." Jan also indicated that during the previous month she had not hinged
or purged. She said that she had only restricted her eating by skipping meals
about once a week during this time.
Life for Jan since her discharge has not been without challenges. Jan
experienced two temporary relapses into her eating disorder behaviors (some
restricting, hinging, and purging) after her discharge. One of her relapses
occurred 8 months after discharge when she returned home to live with her
parents for a summer break from school. In this situation where so many of
the "old triggers" were present, Jan went back into her feelings of shame and
badness and her eating disorder coping mechanisms. This relapse lasted for
about 3 months. After returning to university, Jan stopped engaging in her
eating disorder behaviors and enjoyed positive psychosocial functioning for
about 6 months.
Jan's second relapse lasted longer—almost 6 months—and the "trig-
ger" for this setback was an emotionally intimate relationship with a man.
This relationship stirred up Jan's fears about men and sexuality, which con-
tributed to her relapse into her old ways of thinking, feeling, and viewing
herself.

EATING-DISORDER PATIENTS 69
 During both of her relapses, Jan was ultimately able to pull out of her
shame and cease her eating disorder behaviors by reaffirming her faith that
God loves her, she is not alone, her life has purpose and meaning, and God will
support her. Thus, by going back to the "spiritual anchors" she discovered dur-
ing her treatment at CFC, Jan has been able to overcome her challenges and
relapses and move forward on her journey of healing and recovery.
Jan's level of psychosocial functioning since her discharge has remained
consistently higher than it was previous to her treatment, even during her
relapses. Jan has enjoyed and functioned more effectively in her family and
social relationships. She has dated more than she ever did before treatment,
and has experienced two close dating relationships with men. Overall, Jan
has reported that she is much happier and satisfied with herself and her life
since her treatment. Currently, 2 years after her discharge, Jan is free of her
eating disorder behaviors and is functioning well psychologically, socially,
and spiritually.

THERAPIST AND AUTHOR COMMENTARY

Although we use many standard medical and psychological interven-

tions at CFC, at the core of our nondenominational theistic treatment phi-
losophy and approach is our conviction that God exists. Our approach is also
grounded in other theistic assumptions about human nature and therapeutic
change, including (a) God has the power and desire to help people cope,
heal, and grow, and (b) people who have faith in God's healing power and
draw on the spiritual resources in their lives during psychological treatment
will have added strength and power to cope, heal, and grow (Richards &
Bergin, 1997, p. 100).
As described in this case report, Jan's personal faith and the spiritual
experiences she had during her stay at CFC played a crucial role in her heal-
ing and in the process of treatment and recovery. The spiritual assurances
Jan received of her spiritual identity, worth, and goodness, along with the
affirmations of her worth and goodness that she received from Dr. Hardman
and other members of the treatment staff, helped heal her shame, guilt, and
distorted sense of identity. Jan's faith in God's love and support gave her
added courage to face the pain of the sexual abuse she had experienced, as
well as the pain she felt over her parents' emotional neglect. It also helped
her recommit to recovery and health on those occasions after her discharge
when she relapsed into her old behaviors and ways of thinking.
We doubt that a secular treatment approach that did not value or honor
Jan's faith in God and personal spirituality would have been as effective in
helping Jan heal and recover. If Jan's individual psychotherapist had not en-
couraged her to engage in times of spiritual contemplation and prayer, it is

70 HARDMAN, BERRETT, AND RICHARDS

unlikely that Jan would have engaged in such practices on her own. By the
time Jan entered treatment, the progression of her eating disorder and self-
contempt had so undermined her feelings of worthiness and acceptability to
God that she would most likely not have felt deserving of seeking God's
assistance in her treatment and recovery. As a result, she may not have opened
her heart and mind to the spiritual experiences she had during treatment
that so powerfully assured her of God's love and of her goodness. Without
these powerful and emotionally healing experiences to serve as her anchor
and strengthen her faith and confidence, we doubt that Jan would have en-
gaged so courageously in the treatment process and in facing her pain and
fears.
For Jan, God was the first to validate her worth and goodness in a way
that made her feel and know deeply in her heart that she was lovable and
good. Receiving a spiritual assurance of God's love, and of her lovability and
goodness, changed the way Jan thought and felt about herself. She began to
heal from the inside out. Once Jan had felt God's loving and healing valida-
tion, it became much easier for her to feel and accept Dr. Hardman's love
and validation, as well as love from other treatment staff members. From our
theistic perspective, God is the ultimate healing power in patients' lives.
When patients open their hearts to God's love and healing presence, then
psychotherapists simply become facilitators and witnesses to a healing pro-
cess that transcends ordinary psychological change processes.

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The Church of Jesus Christ of Latter-Day Saints. (1981). The Book of Mormon: An-
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477-482.

EATING-DISORDER PATIENTS 73
 A SPIRITUAL FORMULATION OF
4
INTERPERSONAL PSYCHOTHERAPY
FOR DEPRESSION IN PREGNANT GIRLS
LISA MILLER

DESCRIPTION OF THERAPIST

Lisa Miller is a 35-year-old, Caucasian Jewish woman who is currently

an assistant professor of psychology and education in the Clinical Psychol-
ogy Program at Teachers College, Columbia University. Dr. Miller has a
PhD in clinical psychology from University of Pennsylvania where she stud-
ied positive psychology under Martin Seligman, a bachelor's in psychology
from Yale University and has practiced in various settings since 1994 with a
spiritually informed eclectic orientation.

THEORETICAL ORIENTATION

My theoretical orientation might be described as a form of Interper-

sonal Psychotherapy with a spiritual foundation. Interpersonal Psychotherapy
(Klerman, Weissman, Rounsaville, & Chevron, 1984) holds that irrespec-
tive of its etiology, depression is ameliorated through renegotiating our in-

75
terpersonal relationships. To this formulation I add that interpersonal rene-
gotiation teaches us a more spiritually enlightened form of interaction, such
that interpersonal growth culminates in spiritual growth. Suffering, includ-
ing nonbiologically based depression, may happen when we break absolute
spiritual laws of living, just as we skin a knee when we ignore gravity. Many
cultures and religions endorse a set of ultimate laws, which share a great deal
in common (most obviously not to kill, steal, or commit sexual transgres-
sions). Richards and Bergin (1997) have posited the notion of the Spirit of
Truth, which I understand to be a body of pandenominational, universal
laws for living which sustain us, and if violated, can destroy us. For example,
commitment to family and keeping our word promotes a fruitful life, and
violating these absolute laws creates turmoil. Therapy is most successful—
interpersonally, emotionally, and spiritually—when as the outcome the Spirit
of Truth is upheld.
Central to my theoretical orientation is that the life transitions that
clients experience are not random, but rather they are universal opportuni-
ties for profound spiritual evolution. A parent's death, one's marriage, or
one's becoming a parent inherently transforms individuals emotionally and
spiritually. When one embraces and attends to these transitions, one can
grow interpersonally and spiritually. If ignored or left willy-nilly, however,
these opportunities for spiritual growth can devolve into depression or de-
structive inclinations. Of course this is old knowledge, as ancient societies
and many current-day religious practices honor these transitions throughout
the life span. In our American society, which is relatively scarce on cer-
emony, one needs to be mindful, perhaps even vigilant, of the power and
ultimate spiritual significance of life transitions if one wishes for the powers
to take hold in an evolutionary way.
The current case study concerns one of life's most significant transi-
tions—the emergence of motherhood. Many religious traditions celebrate
the profound spiritual experience around conception, gestation, childbirth,
and new motherhood. In the cases presented here I attempt to show the
effect of this enormous transforming spiritual power of motherhood on young
poor mothers in Harlem, New York.

SETTING AND DEMOGRAPHICS

Seven poor pregnant girls with depression nominated themselves to

join a group Interpersonal Psychotherapy which had been explained to them
as a treatment likely to ameliorate depression and support the transition into
motherhood. At the completion of the group, the treatment was repeated
with 7 new girls in the second semester of the school year. The adolescent
girls met in a room of a public high school exclusively for pregnant and
parenting girls located in Harlem. Inclusion in the psychotherapy group hinged

76 USA MILLER
on a pregnancy beyond the third month, at least moderate symptoms of de-
pression, no indication of functional impairment, and no history of suicidal
attempts (which would suggest the necessity of individual treatment rather
than group). The group met for 1 hour and 15 minutes weekly for 12 sessions.
Initially the group had been constructed as a classic interpersonal treat-
ment. It was my first time conducting a psychotherapy group for pregnant
girls, although treatment of depressed poor women has been central to my
clinical research and practice for nearly 10 years. I have found that treating
depression in women almost always leads to discussion of spiritual life, and
that central to healing is a renewed spiritual perspective. On the basis of this
previous experience, I suspected that in the course of treatment the girls
might show a significant spiritual underpinning to their current situation.

CLIENT DEMOGRAPHICS

The girls in the psychotherapy group ranged from 14 to 18 years of age,

were African American or of Latin descent, and all lived in economic condi-
tions below the poverty line. Of the 14 girls in the two groups, none lived
with two stable parent figures (neither a mother and father nor mother and
grandparent). Seven girls lived with their mothers, of whom 4 girls were
primary caretakers of younger siblings and emotional supports to mothers
who could not fully function. Seven girls did not live with any parent or any
biological relative; 5 of these girls lived with a boyfriend, 1 girl lived in foster
care, and 1 girl lived with a friend. Several of the girls had witnessed the
dissolution of their biological family through intervention from child ser-
vices, had been homeless, sold drugs and prostituted to pay for food, or had
escaped the perceived perils of living in a government-sponsored group home.
In childhood, most of the girls had been raised within some form of Christian
denomination, often taught by a member of the extended family such as a
grandmother. When asked about current religious beliefs, most girls responded
that they were spiritual but not currently involved in either a religious com-
munity or a religious denomination. The girls spoke in group about meaning-
ful synchronicity, instructive dreams, and signs from the Creator. Perhaps
most profound, the girls spoke of their gestating children as ultimate gifts
from the Creator. Love of their child was a spiritual love.

CLIENT HISTORY

The immediate commonality between the girls was the decision to carry
the fetus to term. All 14 girls had been strongly urged to have an abortion by
older adults such as a mother, social worker, or school counselor. Some of the

DEPRESSION IN PREGNANT GIRLS 77

girls had insisted on keeping the child at enormous personal cost: being thrown
out of their mother's home, public shaming, or dismissal from their previous
high school.
Contrary to prevalent assumptions in our society surrounding pregnant
girls, the decision to carry the pregnancy for most girls was not based on
unrealistic assumptions about children or greed. None had illusions of mar-
riage from the baby's father or aspirations of receiving money either from
him or through public assistance. The girls raised younger siblings or shared
quarters with babies and young children in foster care. On one occasion I
brought my own child (about 18 months old) to the group, and felt particu-
larly taken by the girls' level of comfort and adoration for him. The girls had
few prominent illusions about motherhood. Motivating the decision to keep
the child was a genuine love of children and a vital sense of the sacredness of
life.
Two broad paths emerged among the girls in the group—which might
be called (1) the way of the young survivors—who had no immediate family
and often had been homeless; and (2) the way of the childhood mother—who
throughout her own childhood had been a primary caretaker for younger
siblings and steadfast support for her mother.
Among the young survivors, several girls had left home to escape sexual
abuse from a maternal boyfriend or to flee the emotional assaults of maternal
substance abuse or mental illness. Other young survivors had faced parental
death or parental abandonment, in the latter case often in response to news
of the pregnancy. One mother had learned of her daughter's pregnancy and
then left without notice or contact information on a one-way bus to Vir-
ginia. Another mother had thrown her daughter out of the house when the
girl refused to have an abortion. To find money to eat, some young survivors
begged, sold drugs, prostituted, or stripped. Some girls found this solution
preferable to foster care or group homes. Ultimately most young survivors
moved in with a boyfriend primarily for shelter. Their choices were not with-
out moral struggle and shame.
The childhood mothers stood by their own mothers and younger siblings
at all costs. One girl's biological father had abandoned the family and offered
no financial support or relationship. Another childhood mother guided her
own mother and younger siblings through a maze of homeless shelters so that
they might remain anonymous from a physically abusive maternal boyfriend.
Still another childhood mother fiercely guarded her two younger brothers in
a particularly dangerous segment of public housing and within her home from
her alcoholic mother. Childhood mothers felt highly responsible and carried
an extreme sense of duty for their younger siblings, determined to shelter
their siblings from parental abandonment, parental violence, and societal
abuse or neglect.
The path of both the young survivor and the childhood mother, respec-
tively, are illustrated through the personal stories of Renee and liana.

78 LISA MILLER
 CASE OF RENEE: A YOUNG SURVIVOR

Presenting Problems and Concerns

Renee's mother had died within the past year, leaving Renee without a
family or home. Although Renee knew her biological father, he would not
allow her to live with him and his new wife, and currently refused to speak
with Renee on account of her pregnancy. He was a harsh disciplinarian but
unhelpful in offering support.
Renee's boyfriend also had turned against her on account of the preg-
nancy. On learning that Renee was pregnant, her boyfriend had insisted that
she have an abortion. When Renee indicated her desire to keep the baby, her
boyfriend proposed a Faustian deal: If she kept the baby the relationship would
end, if she aborted the baby he would eventually offer marriage. Renee re-
fused the boyfriend's deal, and in the third month of pregnancy the boyfriend's
mother moved him to Mississippi so that he would no longer see Renee and
thus disown his child.
With no family, Renee entered foster care. She petitioned the foster
care system to allow her to live with her best friend's mother. Soon after
Renee moved in with her best friend, the friend threatened to kick Renee in
the stomach to deliberately kill her gestating baby. Renee called the police
to protect the gestating child, which eventuated in the Child Welfare Agency
removing the friend from the girl's own home. The girl's mother, Renee's
foster mother, became furious with Renee, henceforth disallowing Renee to
use the family telephone or eat food from the refrigerator. The harsh neglect
from her foster care mother particularly hurt Renee as she continued to hold
out hope that she might be a loving surrogate mother.

Assessment and Diagnosis

Using a structured clinical interview, Renee met Diagnostic and Statisti-

cal Manual of Mental Disorders (4th ed., rev.; DSM-IV-R, American Psychi-
atric Association, 2000) diagnosis for Major Depressive Disorder. Her score
on the Hamilton Rating Scale for Depression (Hamilton, 1960) was a 16,
indicating a moderate to severe level of depressive symptoms. From an inter-
personal perspective, Renee's depression stemmed from grief: a harsh spate of
abandonment and loss including her mother's death, rejection from her fos-
ter mother, and denial of love from her boyfriend who refused to acknowl-
edge his child.

Treatment Process and Outcomes

A very pretty and vibrant African American young woman of 16 years,

Renee was 5 months pregnant at the start of group. Renee would talk to her

DEPRESSION IN PREGNANT GIRLS 79

baby in utero, and felt a strong relationship with him. She shared with the
group that she noticed the baby kicking when she confronts people who are
destructive or threatening, indicating a companionship with her baby in a
world where Renee was otherwise painfully alone. Renee felt that her baby
boy would have good judgment and a strong will.
Renee first presented in group with a slick and sometimes jocular tone
around the events surrounding her pregnancy. In the initial two sessions she
was very guarded with personal material, talking tough and retributive around
her losses.
After the first few sessions, however, Renee ceased resisting the oppor-
tunity to do psychotherapy. She worked from a place of genuine emotion and
became a leading contributor to the group. Renee repeatedly and emphati-
cally reviewed the episode with her boyfriend in which he had pressured her
to have an abortion under penalty of abandonment. She loved her boyfriend
still, and suffered enormously for his loss. Were he to return to New York, she
admitted that she would quickly take him back. Amidst this heartbreak, Renee
kept reiterating her decision. She asserted, "I told him that I am not going to
kill my baby. No way. This is my child."
It was at this juncture that my spiritual perspective as the therapist may
have informed Renee's process and the group process. I supported Renee's
decision on spiritual grounds. I supported her view that preservation of the
child's life was a legitimate decision, and this conveyed that she had been
clear and brave in protecting her child under unsupportive conditions. I ac-
knowledged that indeed she must love her child very much. Because I be-
lieved that Renee genuinely loved her child (that this was not an immature
illusion), Renee may have felt the first signs of support from an adult for her
decision to become a mother. The group supported Renee for sticking with
her conviction to carry the child and to love the child, over the great pain of
romantic loss. The group process may have been validating to Renee, or sup-
portive of her healing process, in that she shared in a subsequent group, "What
kind of father says that! You know, I knew that he would leave me anyway. It
hurts me he does not own his child. But this is my child and I love my child.
It's me and my child in this world."
Renee also shared with the group feelings surrounding her mother's
death. On one occasion Renee recounted a vicious argument from the past
week in which a boy in her foster care home had touched a pillow left to her
from her mother. It was her only material remain of her mother. Renee was
blinded with rage, threatened the other foster care child, and throughout
group could not stop venting her anger. "I told him whatever you do, don't
touch my mother's pillow or I'll whip you down." It was in this episode of
rage around the loss of her mother that Renee's sole support behind her preg-
nancy became clear. "I am having this baby for me and my mother. I know
that she is looking out after me, and that she will help me." She then elabo-
rated. "You see me and my mother, we were real close. She knew what I was

80 LISA MILLER
thinking, and would say things before I ever said a word." Renee's mother
had been a bright source of love in her difficult world, now a world plagued
with abandonment. The knowledge that her deceased mother watched over
her as she was becoming a mother served as the sole source of solidarity,
familial commitment, and guidance in her life.
Again, at this juncture in the therapeutic process, I think that my spiri-
tual orientation as the therapist may have informed the group process. I readily
supported Renee's belief that her mother walked with her and attempted to
guide her as a single young mother. My endorsement of this belief may have
helped Renee separate her mother's spiritual companionship from the com-
plicated grief surrounding her ardent wish for a physical mother. Renee's
complicated grief was fostering a destructive attachment to her foster mother
who continued to painfully reject and degrade Renee. After several ses-
sions, Renee shared with the group her realization, "You know she don't
love. She treats me like a second class citizen." Strikingly the tone of this
realization was one of clarity and relief from the confusion of a complicated
bereavement.
Renee started to realistically appraise the suitability of her current liv-
ing situation to motherhood. The lack of sustenance and emotional support
coming from the foster mother, the lingering physical threat to the fetus by
the imminently returning friend, and the lack of opportunity for child care
emerged at the forefront of her concerns. The world that she had hoped was
full actually, on realistic appraisal, looked empty. In group and outside of
group, Renee began to investigate how she might build her world out of her
desire to be a mother; to better care for her well-being and that of the soon-
to-be newborn.
Throughout the emerging realism in the intermediate phase of treat-
ment, Renee continued to speak of the unborn child from a stance of great
love and intimacy, again indicating to me that her attitude toward her child
was authentic and independent of the confusion surrounding her losses. Renee
started speaking about what kind of role model she hoped to set for her child.
She emphatically confronted a fellow group member who was struggling to
step back from fistfights saying "you cannot go around getting into fights in
front of your baby, what kind of mother is that?" Renee knew that mother-
hood was a profound transition, one that carried absolute moral standards of
conduct. Once a mother, you are accountable to your child and simply ac-
countable in an absolute sense. I supported her (as well as fellow group moth-
ers) in the belief that motherhood is a spiritual imperative, unaltered by youth,
poverty, and confusion.
In the final phase of treatment Renee announced to the group that she
had successfully secured a new living situation through seeking assistance
from the school social worker (whom most girls in the high school avoided
for fear of losing autonomy). Renee located a government-sponsored pro-
gram that would provide her with an apartment and child care while she

DEPRESSION IN PREGNANT GIRLS 81

completed her final year of high school as well as 4 years of college. Renee
explained her desire for independence as the opportunity to build a world for
herself and her child far away from her old neighborhood and the people who
might harm her or her child. Renee had journeyed through the distortion
and pain of abandonment. She had achieved clarity about the reality of her
world. Now she was setting about building a new world in which her youth
and poverty did not attenuate her effectiveness and love as a mother.
At termination Renee no longer met criteria for a DSM-IV-R diag-
nosis of Major Depressive Disorder and her score on the Hamilton Rating
Scale for Depression had fallen from a 16 to a 4, well below the cutoff for
depression.

CASE OF ILANA: CHILDHOOD MOTHER

Whereas a young survivor builds a new world motivated by mother-

hood, a childhood mother attempts to heal her surroundings through chang-
ing the people in her family. A childhood mother has been handed a broken
world by her own mother, and now seeks to better this collective home.

Presenting Problems and Concerns

At age 14, liana entered treatment as one of the youngest girls in the
school. Dressed in an oversized pink sweat suit, wearing a Minnie Mouse
watch, and with a childlike face, liana appeared young. Her living situation,
however, belied any trace of blithe childishness. liana, her mother, and two
younger brothers lived in a series of homeless shelters. The family constantly
relocated from one shelter to another to hide from an abusive maternal boy-
friend, liana had been the effective leader of the family since her father had
left the family 3 years ago (out of humiliation for not providing sufficient
financial support); her mother was severely depressed and abused alcohol.
Despite the ongoing strains of poverty, maternal dysfunction, and danger
associated with living in a homeless shelter, the chief concerns for liana were
her boyfriend's lifestyle now that he was becoming a father, specifically his
use of drugs and involvement in a gang, and her mother's harsh disapproval
of the pregnancy.
In contrast to several of the girls in the group, liana had been truly
surprised by the pregnancy and was ambivalent about becoming a mother.
She stated "I would not kill my baby, but I did this so I have to live with it."
liana described the great shock and fear she felt upon learning that she was
pregnant. She described her mother's fury over the pregnancy as not stem-
ming from anticipation of another child in the very poor family, but rather
out of dismay that liana had been sexually active. In contrast to most girls in
the group, liana's mother, a Catholic, agreed with her daughter that the fetus

82 LISA MILLER
was a life and that the baby must be carried to term. To the extent that she
could draw a distinction between her mother's feeling and her own, liana did
not personally feel dismayed that she had sinned, but rather simply could not
stand the enduring looks of her mother's anger and disapproval.
Because of liana's unstable living situation, she and her boyfriend had
decided that the baby primarily would live with her boyfriend and his mother.
Hence it was particularly upsetting to liana that her boyfriend continued to
use drugs and belong to a gang despite her urging to change his lifestyle. She
felt that his drug use drew him away from her, and she feared that drugs
would impair his capacity to parent and expose the baby to violence. liana
also feared that the baby would grow up surrounded by fellow gang members
offering only the role models of gang membership.

Assessment and Diagnosis

liana showed the highest level of depressive symptoms of any girl in the
treatment group. In a structured clinical interview, the Schedule for Affec-
tive Disorders and Schizophrenia for Children (K-SADS), liana met DSM—
IV-R diagnosis for Recurrent Major Depressive Disorder and scored 24 on
the Hamilton Rating Scale for Depression, indicating severe depression.

Treatment Process and Outcomes

In the initial session, liana shared with the group her upset over her
mother's current rejection, and her mother's disappointment in her for being
sexually active. To a large extent her mother's shame colored her own senti-
ment surrounding the pregnancy.
liana spoke extensively about her rage over her boyfriend's ongoing use
of drugs and affiliation with a gang. Although her boyfriend had long used
drugs and been a gang member, she had repeatedly asked him to stop these
activities since learning of the pregnancy. Her greatest upset came when he
had expressed his hope that the baby could be "blessed" as a gang member
soon after birth, as was the custom in his gang, for lifelong membership.
Despite the unstable life her own mother had offered, liana wanted to be-
lieve that she could make a better life for her child. That her boyfriend un-
dercut her efforts produced profound defeat and depression.
From the therapist's perspective, it seemed that liana was unaware of
her extraordinary resilience and strength that allowed her to protect and
guide her family through their uncertain lifestyle. Her strong desire to make
a better world for her baby indicated to me that despite her ambivalence
around pregnancy, her emerging motives as mother were healthy and whole.
As in the case of Renee, the treatment process surrounding liana was
buttressed by my belief, and the belief among group members, that carrying
the child to term was a valid spiritual choice, and that motherhood as an

DEPRESSION IN PREGNANT GIRLS 83

absolute spiritual calling which inherently transforms women is not less ac-
cessible to young and poor girls. The urgent treatment goal was to empower
liana to use the emerging powers of motherhood to make a safe world for the
baby. On many subsequent occasions liana had exercised strength and deter-
mination as a childhood mother to protect her family. She now needed to be
conscious of her great maternal strength and apply it toward her own child.
As a second treatment goal, liana's shame and negativity surrounding her
pregnancy, despite her genuine concern for the child, suggested that liana
needed to distinguish her own spiritual convictions about carrying the child
from the stigma applied to her pregnancy for signaling sexual activity, ironi-
cally amidst a community in which most girls are sexually active.
As liana's pregnancy advanced, her mother focused away from the issue
of sexual activity and became excited about the birth of a grandchild. Her
mother even purchased presents for the baby out of the limited family funds.
Because of her mother's emerging enthusiasm, and potentially because of the
group support as well, liana recognized in group that most women in her
community had birthed children in adolescence, and that it was relatively
normative for grandmothers to help raise babies. She noticed a prevalent
disparity between the structure of motherhood in her community and the
duplicitous talk given to chastity. Few people in her childhood community
sexually abstained in adolescence, including her own mother who had given
birth to liana when she was 16 years old. This paradox surrounding her preg-
nancy then seemed to prompt spiritual individuation in which liana clarified
her own spiritual views from those of her mother or her community. Amidst
poverty, suffering, and maternal dysfunction appeared a classic adolescent
spiritual individuation process. Supporting this therapeutic process may have
been my belief in the spiritual validity of keeping her child and an awareness
of a universal process of adolescent spiritual individuation.
For having worked on spiritual individuation, liana's shame over her
mother's initial reaction and community stigma lifted. liana now claimed
that although she had initially been surprised by the pregnancy, she was now
eager to be a mother. She loved children. She had taken care of children all
her life, and now she was eager to have her own child. liana recognized her
sense of responsibility, preservation, and efficacy in raising her two younger
brothers; these were maternal strengths. Her maternal powers would rise to
new heights as she carried her own child. "It's always been that when I walk
down the street guys give me a hard time. But now someone will cut him off
and say 'hey, don't talk that way to her, she's going to be a mother.' Being a
mother is a better thing and they know it."
Embracing her emergent motherhood gave liana a sense of moral au-
thority as a mother. She now had the confidence to confront her boyfriend's
drug use and his intention to swear their newborn baby into his gang. The
group helped liana consider ways to effectively approach him. In exploring
their pattern of conflict, it became clear that liana's urging had been ineffec-

84 LISA MILLER
tive because she was perceived by her boyfriend as nagging, in part because
she actually had felt powerless to change the situation for her child. The
group suggested to liana that she might explain from a position of love that
his drug use made her feel, as a mother, that he did not care about her or their
baby. When liana framed her concerns in the context of her hope that he
might love and protect the baby, the boyfriend was far more able to listen.
He claimed that he would try to cut back the drug use.
The group also supported liana in her emerging belief that she could
offer her baby a life better than that she had inherited. The newborn child
need not join a gang, at least not at her bequest. liana worked through her
latent ambivalence: on the one hand the gang would have given the baby
clothes and presents—her only hope for a baby shower; on the other hand
she did not know if she could face her child the day he understood that she
was responsible for his "blessing" by a gang. At this point the group regarded
the power and authority a mother has in the eyes of her child, and that mother
is often the sole source of moral and spiritual standards. liana clarified her
feelings by saying, "If the child someday decides to join a gang, then it is his
choice. A mother does not tell her child to join a gang." She was now moth-
ering her own child.
liana was the most improved of any girl in the group. At 12-week ter-
mination she no longer met DMS-IV-R diagnosis for Major Depressive Dis-
order, and her score on the Hamilton Depression Scale had dropped to 5,
below the range of even mild depression. liana's boyfriend stopped using drugs
(at least for the time being) and respected liana's conviction that the baby
not be "blessed" by the gang on the grounds that it was her wish as the mother.
Even though the baby was to live with the boyfriend and his mother, liana's
role as the mother was more clear to all involved. I believe that liana's ex-
treme improvement was due to her recognition of her spiritually endowed
power through which to enact motherhood.

THERAPIST COMMENTARY

None of the pregnant girls were depressed because they were poor or
homeless, lacked access to opportunity, or because they did not have an easy
or protected adolescence. These girls were depressed over seemingly insur-
mountable challenges to their emerging motherhood, a calling which they
embraced with a profound respect. Depression, from a spiritual perspective,
served as the valuable guide, granting focus on the necessary changes to pre-
pare for the arrival of the baby.
Motherhood might be understood as a spiritual developmental process
that starts with conception. Against all recommendations from family and
counselors, and in some cases against coercion, these girls initiated mother-
ing by insisting on carrying the child. The inherent grace and power in moth-

DEPRESS/ON IN PREGNANT GIRLS 85

erhood emerged as profoundly transforming against each girl's material and
interpersonal challenges. To the extent that each girl's world budged, it is
now more supportive of her motherhood. To the extent that each girl tried
but the world did not budge, the girl still is now that much more a mother. It
is worth considering that ultimately motherhood protected not only the new
babies but also the adolescent girls. Several girls feared that had they not
become mothers, they might have been destroyed by the abuse, drugs, and
relational neglects that they now sought to transform.

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders (4th ed., rev.). Washington, DC: Author.
Hamilton, M. A. (1960). A rating scale for depression, journal of Neurology, Neuro-
surgery and Psychiatry, 23, 56-62.
Herman, G. L, Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Inter-
personal psychotherapy of depression. New York: Basic Books.
Richards, P. S., & Bergin, A. E. (1997). A spiritual strategy for counseling and psycho-
therapy. Washington, DC: American Psychological Association.

86 LISA MILLER
 FORGIVENESS IN
5
MARITAL THERAPY
MARKJ.KREJCI

DESCRIPTION OF THERAPIST

Mark Krejci is a professor and chair of the Psychology Department at

Concordia College in Moorhead, Minnesota, where his primary teaching
responsibilities fall in the area of mental illness and psychotherapy. Dr. Krejci
received his PhD in counseling psychology from the University of Notre Dame
and completed a clinical psychology internship at the Norfolk Regional Center
in Norfolk, Nebraska. For the past 14 years he has been seeing clients through
a part-time private practice at a local Roman Catholic church. Dr. Krejci is a
practicing Roman Catholic whose therapeutic orientation is influenced by
both humanistic and cognitive-behavioral approaches to psychotherapy. He
became interested in the use of religious coping in the lives of his clients
beginning in graduate school. His research, investigating the acceptance of
nontraditional (female) God images, developed as he worked with clients
whose use of male God imagery reinforced traditional female/male stereo-
types. Dr. Krejci recently served as editor of the Psychology of Religion News-
letter, a publication of Division 36 (Psychology of Religion) of the American
Psychological Association.

87
 SETTING
The clients were seen through the author's part-time (5 hours per week)
private practice located at a Roman Catholic church in a moderate-size ur-
ban area in the upper Midwest. Parish staff members refer clients to the prac-
tice with self-referrals also accepted from within the parish. In addition, some
clients are referred from the local Catholic diocese and other area priests.
Clients are not charged for therapy. Individual, marital, and family therapy
are provided for a range of issues although referrals with severe, acute mental
illness are at times referred to other agencies that are able to provide more
comprehensive care. The majority of cases deal with marital therapy or de-
velopmental and life adjustment issues.

CLIENT DEMOGRAPHIC CHARACTERISTICS

Mary and John were both 34 years old and married for just more than 10
years when they came in for marriage therapy. At the time of their first session,
their two children were ages 8 (daughter) and 3 (son). Mary was raised Roman
Catholic (RC), whereas John was raised in the Lutheran Church-Missouri
Synod (LCMS) by orthodox parents. Her family of origin were devout and
liberal Catholics, and Mary was always a very active church member. John,
after moving to college, dropped out of active participation in the LCMS much
to the consternation of his parents who feared he would not remain a Chris-
tian. At the time of their wedding, John professed a belief in God but was
indifferent to active participation in a denomination although he did attend
Catholic services with Mary during their courtship. Their wedding was in a
Catholic church, which was fine with John, Mary, and her family, but dis-
tressed his parents. They stated a fear that this was another sign that their son
was rejecting his faith, a concern that John and Mary dismissed.
Mary and John received college degrees and he worked in a professional
position that required travel and long hours. Mary worked a part-time (less
than 10 hours per week) retail job while the children were in school and
preschool. They lived an upper-middle-class lifestyle but acknowledged that
they did not have enough income to meet their perceived needs. They were
devoted parents and recognized this in each other. He stopped attending RC
services after approximately 2 years of marriage to take care of the baby while
Mary attended services. Approximately 1 year before first contact, John started
to develop a renewed interest in participating in the LCMS. John had for-
mally joined an LCMS congregation 10 months before their first session, a
move that Mary supported.

PRESENTING PROBLEMS AND CONCERNS

The couple came in for marriage therapy because of the excessive anger
they felt toward each other that manifested itself in daily verbal fighting over

88 MARKJ. KREJCl
whatever topic came up that day. The fighting included calling each other
names, raising their voices to the point that the children could hear their
shouting, and arguing with each other. They acknowledged that they did not
listen to each other, but they justified this by their belief that the other per-
son was wrong.
When asked what were some specific things over which they fought,
they each had a very different list of topics. She said that he was condescend-
ing toward her for many reasons. According to Mary, John thought that she
was not as intelligent, that she did not contribute enough to financial secu-
rity by not making enough money at her part-time job and by spending too
much money, and that she demanded too much from him. She further com-
plained that he was emotionally isolated and that he put her down for having
emotions. Mary felt very alone in the marriage because of her emotional
isolation, and she wanted a spouse who would be able to cue in to her emo-
tions and meet her emotional needs.
John said that he and Mary fought when she was "needling" him about
what was going on in his life. He saw Mary as always checking up on him,
wanting to know what he was doing every minute of his day. He used the
phrase "I want a wife, not a mother" to describe how he perceived Mary as
being too controlling. He also complained that she became emotional "about
everything" and that she "refused" to step back and look at issues from a more
logical perspective. John claimed that he was open to her emotions but that
it was too draining to have her become emotional about everything in their
marriage.
During the initial session when John and Mary presented their con-
cerns, while one person was talking the other person wanted to interrupt to
give the "correct" view. For example, Mary said that she was not "needling"
John but only wanted to know about his life and be involved with him. John
said that he never complained about Mary not making enough money but
did acknowledge that he questioned her spending habits.
The couple detailed a series of past hurts that continued to be a source
of anger in their lives. They listed several behaviors, perceived thoughts, and
behavioral omissions that they observed in the other person that stretched
over the entire marriage. For example, both individuals were able to talk
about a specific incident in the first year of their marriage that continued to
anger them. The anger was apparent while they recounted the incidents.
The couple even attempted to argue about the details of these events that
had occurred more than 10 years ago.
Thus, anger was the obvious presenting issue and the couple readily
acknowledged that they did not deal well with anger or disagreements in
their relationship. They did not possess good listening skills and reported
that they viewed conversation with apprehension because of their common
fear that any verbal exchanges would deteriorate into an argument. Because
they each tended to believe that they were "correct" while their spouse was

FORGIVENESS IN MARfTAL THERAPY 89

"wrong," they had very little empathy for the other's beliefs and subsequent
emotional experience.
The lone area in which they could and did communicate in a positive
manner was about the children. In fact, the marriage had reached a point at
which the only tender exchanges between John and Mary were in relation to
the children, and they stated that one motivation for keeping the marriage
going was for the sake of the children. Although they acknowledged that this
was not the best motivation for keeping a marriage together, they admitted
that this was probably the most effective motive at that point in time. They
also expressed remorse for having their children observe their arguments.
During the first session, the couple also presented that religion was be-
coming an increasingly contentious issue in the relationship. He stated a
long-standing resentment to Mary's suggestions that he convert to RC. Mary
acknowledged that early in the marriage she hoped that his nonparticipation
in the LCMS and his attendance at RC services would result in him joining
the RC church. She began to explicitly ask him if he wanted to join the
RCIA (the Catholic church's Rite of Christian Initiation for Adults) process
after the birth of their first child. His initial response was that he would
"think about it" yet he admitted that he said this to give her an answer that
would make her happy. He felt he could not convert because it would upset
his parents and because he did not agree with some Catholic doctrine. He
began to resent what he perceived as Mary's regular overtures toward him on
the topic. For example, when Mary came home from mass and talked about
the sermon or music at the service, John interpreted this as her attempts to
make him feel guilty for not attending services and as an attempt to get him
to join RCIA. Mary commented that she was only trying to share her faith
experience with her husband. This behavior pattern culminated in a Sunday
afternoon argument about the topic, which concluded by John stating his
interest in going back to the LCMS. Mary saw this statement as an attempt
to emotionally hurt her in the situation and accused John of just this, which
he denied. The next day, John sought out an LCMS congregation and pastor.
He joined the congregation and religious doctrine became a new source of
argument for the couple. When John perceived Mary as suggesting he join
the RC church, he now presented the idea that she, and the children, should
join the LCMS. This type of argument had just emerged before their initial
therapeutic contact and during the initial contact they acknowledged that
each should be able to pursue their own denominational identity and that
the children would remain RC.

CLIENT HISTORY

Mary and John were raised by married parents who stressed the virtue
of a religious life. The couple had similar families of origin in that both fa-

90 MARK;. KREJCJ
thers worked outside of the home, both mothers stayed at home and took
care of all of the domestic responsibilities short of yard work, and both had a
similar number of brothers and sisters. Neither John nor Mary could remem-
ber their parents fighting. John reported that when his mother and father
disagreed, she would state her opinion and then become silent with his father's
opinion prevailing. Mary did not have any insight into parental disagree-
ments and believed that her parents just agreed on everything. The only
instance when she saw anything to the contrary was when Mary and her
sisters started to date. Mary's father would at times pronounce a strict rule for
the evening date (e.g., to be in by 9:00 p.m.), Mary's mother would gently
tease the father about his strictness, and then Mary's father would change his
mind and allow more leniency. Mary and John's parents had a family struc-
ture in which the father had a greater amount of actual power in the marital
relationship and the mother exerted a more subtle power.
Both John's and Mary's families of origin stressed the importance of
family activities and centered many of their activities on church. The fathers
were involved in leadership positions in their church yet the mothers were
the ones identified by John and Mary as being more religious. One notice-
able difference had to do with their ability to express religious doubt with
their parents. Whereas Mary's parents accepted religious doubts and en-
gaged her in conversation about her doubts, John's parents punished reli-
gious doubt by engaging him in what he described as "indoctrination" ses-
sions. In the end, neither John nor Mary were rebellious about religious
beliefs and participated in their respective denominations throughout their
time at home.
Mary and John met in college during their senior year and saw each
other daily after their first few dates. They reported that they were physically
attracted to one another on first sight and that their first months of courtship
were filled with only happy times, no fighting, and a general feeling of eu-
phoria. They talked about religion early in their relationship because they
believed they wanted to only get serious with a Christian who strongly be-
lieved in their faith. It was at this time that John began to go on "church
dates" with Mary, going with her to Sunday mass nearly every week. As the
end of their senior year approached, they talked about marriage and used
school breaks to introduce each other to their families of origin. On gradua-
tion, they found jobs in their professions at companies located in major cities
that were within 50 miles of each other. At first, they believed it would be
easy to maintain a relationship by meeting every weekend and talking on the
phone during the week. Within a year, this proved to be unsatisfactory for
the couple and they decided to live in the same city. At this time, they also
became formally engaged. While they looked for different employment, Mary
finally moved and was employed in a lower paying job. She moved into an
apartment in the same building as John to keep an illusion of separate resi-
dences for the sake of the parents, but in actuality Mary lived with John. The

FORGIVENESS IN MARITAL THERAPY 91

couple reported avoiding arguments during this period because they wanted
their time together to be pleasant.
Planning for the wedding was difficult given that they were to be mar-
ried in Mary's hometown but they were living in a distant city. Thus, Mary's
mother made many of the arrangements, carefully checking with the couple
on any needed decisions. The couple stated that this was a stress-free ar-
rangement because all they needed to do was arrive in Mary's hometown one
week before the ceremony and everything was prepared. However, the couple
reported that their first argument developed over wedding plans. John's mother
expressed to him that she felt left out of the preparations. John related this
concern to Mary but did not suggest any resolution. Mary saw this as criti-
cism of her and her mother and became upset that John "would think that I
was trying to hurt your mother." John felt that the accusation was unjustified
but did not share this view with Mary. Rather, they gave each other the
"silent treatment" but ended this the next day. They never did go back and
discuss the issue that created the original rift until it was brought up during
therapy.
After their wedding, Mary and John continued to pursue careers until
Mary became pregnant with their first child. They believed that the mother
should stay at home with the children and so Mary was not employed outside
of the home until 4 months prior to their first session when their son had
started preschool.

ASSESSMENT AND DIAGNOSIS

The initial therapy sessions involved time devoted to assessment of the

marital condition and taking a complete history of the individuals and the
marriage. As part of these initial assessment interviews, couples are routinely
asked about their religious beliefs and if they think that their religious beliefs
could assist them as they work on their marriage. Given that both believed
this to be the case, Mary and John were asked several questions about their
religious beliefs, how religion influences their lives, and how they think their
faith helped them deal with their marriage. The religious issues presented in
this chapter were highlighted as a result of these questions. Given their de-
nominational differences and the stress associated with their religious views,
the couple completed the Christian Orthodoxy Scale (Fullerton &
Hunsberger, 1982). This scale measures acceptance of core beliefs found across
Christianity. Mary and Jack had very similar scores that reflected a moderate
to strong agreement with the tenets of Christianity measured by the scale. As
a general evaluation of the degree of conflict in the marriage, the couple also
completed the Marital Satisfaction Inventory (Snyder, 1979). This assess-
ment revealed elevations on the subscales of Affective Communication, Prob-
lem-Solving Communication, and Disagreement About Finances.

92 MARK;. KREJCI
 Mary and John's marriage was dysfunctional in many ways. The most
obvious difficulty was the extreme and constant anger that set a negative
emotional and relational tone in the marriage. The anger developed from
sources of frustration that appeared early in the relationship but were never
resolved through honest problem-solving communication. Rather, the couple
established a pattern in which they ignored differences to avoid the ill will that
developed in the short term as they coped with the issues. By ignoring the
issues, the frustration grew to anger and the couple would then deal with their
differences when motivated by their anger. The anger was compounded over
many years given that they did not forget about their spouse's past offenses.
The marital relationship was also hurt by the lack of commonality be-
tween Mary and John. The couple did not continue to develop their rela-
tionship after their marriage. The couple fell out of the practice of talking
with each other about positive topics, of developing activities that they could
share, and in spending time with each other. As a result, John and Mary
found themselves sharing very little with each other except for anger.
Given that the couple's agenda for therapy was to talk only about the
anger, it was important for them to also spend time in sessions talking about
something positive that could assist the growth of the marriage. There were
two areas of agreement that existed when they first came in for therapy. One
had to do with their views of the children. They agreed that the other was a
good parent and that they shared love for the children. However, the chil-
dren were not a good choice for building marital cohesion because they could
become entangled in an emotional triangle with their parents. Also, the fo-
cus of therapy would then be on their roles as parents and not on their roles
as marital partners.
The other area in which they shared some commonality was their faith
in God. Given what has been discussed to this point, this may seem contra-
dictory because John and Mary seemingly had much disagreement regarding
this topic. Although it was true that they identified with different religious
denominations and manifested their religious life differently, they shared a
deep and genuine belief in God. They believed that their Christian beliefs
were central to their lives and recognized the same in the life of their spouse.
Both wanted to share their faith in their marriage but did not know how to
do this. Religion had become something that they pursued individually, not
something that was part of the marriage, and not something to be shared
within the context of the relationship.
Marital therapy with John and Mary became primarily focused on two
issues. One was the need to resolve the anger and change the basic dynamic
governing interaction in the relationship. This meant developing appropri-
ate communication, which included empathic listening, and developing prob-
lem-solving abilities. Ultimately, to resolve the lingering anger, John and
Mary needed to engage in a process of forgiveness to end the sustained state
of anger.

FORGIVENESS IN MARITAL THERAPY 93

 The second issue was to develop a greater sense of commonality in the
relationship. This was accomplished by having the couple focus on sharing
their spiritual life with each other rather than having it be a source of divi-
sion. It was hoped that the couple would use the sharing of their faith life as
a base from which they would begin to develop other things that they could
share. Also, by focusing on their spiritual life in therapy, the couple would be
examining an emotional issue in their life and sharing a positive emotion in
their relationship. Finally, the two goals were connected because the couple's
working image of forgiveness came from their belief in God's unconditional
forgiveness.
Tan (1996) described a model in which therapists need to consider
whether spiritual issues will be integrated into therapy at either an implicit
or explicit level. In implicit integration, religion is not discussed as a topic
during sessions but the therapist remains mindful of the clients' religious
views and beliefs. In contrast, explicit integration is when the therapist and
clients openly talk about religious issues from the perspective of the clients'
spiritual life. Given that this couple welcomed an explicit integration, reli-
gious issues became a focus in the therapeutic process as a way for the couple
to work toward improving the state of their marriage. For those couples who
have an active faith life, the development of a shared spiritual life serves as a
means of bringing in a positive force to their relationship. Couples can search
for their roles in their marital vocation by incorporating their sense of Chris-
tian vocation into the relationship. As a Christian is called to love others, by
pursuing their marital vocation within the context of their Christian voca-
tion, the couple can share deeper love, can sacrifice with love, and can learn
to forgive. When this type of love is mutual, the couple develops a deeper
and more satisfying relationship.
In sum, John and Mary strongly identified with the principles of Chris-
tianity but failed to manifest these principles in their marriage. Therapy served
the purpose of helping them to reflect on how to share their spiritual lives
with each other and to facilitate the development of behaviors and thoughts
that allow them to live Christian values with each other. This approach fa-
cilitated the work needed in forgiveness and allowed them to share a positive
force in their lives.

TREATMENT PROCESS AND OUTCOME

The initial sessions involved assessment, taking complete histories, and

developing goals for therapy. During these sessions, the couple repeatedly
expressed anger toward their spouse every session and attempted to re-argue
disagreements with the hope that the therapist would agree with their side.
Not allowing this to happen, but wanting to gauge the depth of the anger, I
interviewed Mary and John separately on the topic. This allowed them to be

94 MARK/. KREJC/
less defensive and more open about their emotions related to the marriage as
well as more reflective on their own role in the marital discord. The couple
kept an interaction log for 3 weeks, noting the nature of their exchanges at
home. This revealed that the couple had an argument at least one time per
day and that harsh words were exchanged, on average, three times per day.
This number could have been higher but their overall number of interac-
tions averaged only five per day. The only positive exchanges concerned the
children.
The assessment phase revealed their strong personal commitment to
their Christian faith and their desire for sharing spirituality in the mar-
riage. Although they had areas of disagreement and argued about religious
issues, the orthodoxy scale showed the couple that they shared the same
basic beliefs. Their areas of religious disagreement, related primarily to de-
nominational identity, were discussed. As mentioned previously, John had
concerns that Mary wanted him to become RC and, though she initially
denied this, she did admit that for several years after the birth of their first
child she wanted him to convert. Mary consciously supported John's mem-
bership in his LCMS church, but he needed to reflect on schemas she de-
veloped while attending Catholic school that suggested that the RC Church
was the "one true church" and that other Christian denominations were
not. Mary modified these schemas after consulting with a priest about the
teachings of the RC Church and by coming to the realization that her emo-
tional allegiance to the RC Church interfered with a true acceptance of
the LCMS.
John reflected on the timing of his return to the LCMS. He developed
the insight that he initially returned to the LCMS as a way to punish Mary
and prove to her that she was not "better" than him. He thought Mary flaunted
her church participation to make John believe he was not as good as her.
When John returned to the LCMS, he attended to church dogma that al-
lowed him to use the LCMS's teachings to support him in his arguments with
Mary. He told Mary that the LCMS held that men should be the authority in
the family as they were in the LCMS and that this was official church teach-
ing. The fallacy of his beliefs was dealt with in a visit with an LCMS pastor
who told John that Christ teaches all Christian men to love their wives and
treat them with dignity and respect. John developed an awareness that while
he initially used his reconnection with the LCMS in an attempt to hurt
Mary, the time back in the church awakened a new interest in congrega-
tional religious life and that he wanted to continue to participate in the
LCMS for the sake of his own faith journey.
Because mutual respect of each other's denominations was established,
spirituality could be used as a means for unifying the couple. The couple
agreed to common goals for marriage related to their religious life. They would
work toward ending their anger by attempting to forgive each other, a for-
giveness motivated by the image of Jesus Christ forgiving sins. They would

FORGIVENESS /N MARITAL THERAPY 95

also work toward developing a shared spiritual, but not denominational, life
as a means toward building a more positive relationship. The goals were dealt
with in parallel during the course of therapy but for the sake of this chapter
the topic of forgiveness in their relationship will first be addressed followed
by how the couple built commonality by sharing their spiritual lives.
After completing an assessment phase and agreeing on common goals
for therapy, Mary and John began to consider what they needed to do to
forgive each other. They believed that, as Christians, they were expected to
forgive each other and initially they thought they had forgiven the other.
Yet, their forgiveness was short lived and was entirely a cognitive process.
They described numerous instances when they were offended by the actions
of the other, had made a conscious decision to "forgive and forget," yet when
the next transgression occurred the memory and emotions of the previous
events came flooding back with accompanying anger.
I presented a model of forgiveness informed by the work of Worthington
(McCullough, Worthington, & Rachal, 1997; Worthington, 1998) and
Enright (Enright, Freedman, & Rique, 1998) to the couple. Forgiveness was
described as a process that was initiated when a decision was made to stop
resenting the other person for what they had done, moving toward a process
of understanding the other person with greater empathy, and finally being
able to treat the offending person with a spirit of altruism. This phase of
therapy focused on the couple gaining greater insight into their motivation
to forgive and in stating an apology to each other.
John and Mary worked toward apologizing to their spouse by writing a
letter to their spouse asking for forgiveness. These letters described what John
and Mary believed they needed to be forgiven for and were worked on during
individual sessions with the spouses. The apologies initially reflected senti-
ments that tended to communicate "I am sorry for hurting you but I would
not have done these things if you were not the person who you are." In effect,
they were claiming that the actions of the other were the sole motivation for
their inappropriate behavior. The couple eventually developed an apology
reflective of their sorrow for hurting the other person and taking responsibil-
ity for their hurtful actions. The apologies were formally exchanged and their
reactions to these were processed during sessions.
After the apologies and request for forgiveness were exchanged, they
struggled with the concept of making a decision to give up their resentment
toward the other person. Mary and John felt justified in harboring resent-
ment toward the other and the resentment was a major block to forgiveness.
As part of the attempt to address their resentment, the couple was given an
assignment to find religious stories and images that showed someone who
forgave in spite of grievous circumstances. Such images as Christ forgiving
while on the cross and God forgiving the people of Israel were used as ex-
amples of God's ability to forgive all. These images were helpful models to
John and Mary as they worked toward ending their resentment.

96 MARK]. KREJC1
 This approach resulted in the couple reflecting on their human inabil-
ity to give up their resentment as God does for us, an inability that they saw
as indicating sinfulness. John and Mary developed a common insight that
the way they treated each other when angry represented sin in their lives. I
was nondirective during this time to allow the couple to develop their own
insights into the lingering anger. Mary thought that one way she could cope
with her continuing resentment was to participate in the RC sacrament of
Reconciliation, or more commonly called confession. John became upset with
this because he thought that Mary did not need to see a priest to realize she
harbored resentment toward him just as he did not need a priest to recognize
the same about her. John held a common misconception about Reconcilia-
tion—that Catholics can only ask for God's forgiveness within the sacra-
ment of Reconciliation. He learned that this was not true and that Mary
wanted to experience a ritualized forgiveness, a process that he entered via
prayer. Although Mary eventually went to Reconciliation, John accompa-
nied her and prayed in the church for his own forgiveness.
The important thing at this stage of therapy was to keep the couple
focused on the amount of work they needed to do within themselves and the
relationship and that the Reconciliation ceremony or focused prayer was not
going to be sufficient in ending all of the anger in the relationship. By turn-
ing to their religious beliefs in an attempt to end resentment, neither could
expect a miraculous cure. Mary and John continued to struggle with the issue
of lingering resentment as they worked toward developing empathy for their
spouse.
As this topic emerged in therapy, the couple was asked to reflect on the
emotions, thoughts, and motivations of their spouse. The couple started
therapy with very little empathic understanding of their spouse's experience
of the marriage and so they needed to hear this from each other. This also
afforded the couple an opportunity to work on their active listening, which
would improve marital communication. Initially, as they listened to their
spouse, they would think through counterarguments. Thus, while Mary was
talking about how John had hurt her when he talked to her in a condescend-
ing way, John was thinking, "What I said wasn't condescending, she is just
being overly emotional." Likewise, while John was describing his view that
Mary was overly emotional, Mary was thinking "he thinks he has it bad,
while I could be much more emotional but I have to hold my full emotions
back from him." As this tendency to cognitively counterargue was recog-
nized, the couple was asked to identify an empathic response to their spouse's
comments. Both needed to develop more of the idea that the first goal of
conversation was listening versus simply talking. They also used this phase of
therapy to work on their own ability to clearly communicate their thoughts
and not expect the other to infer them.
Mary and John developed an ability to recognize their spouse's view of
their marriage and in that process also see their own view. To deepen the

FORGIVENESS IN MARITAL THERAPY 97

understanding of the other, they worked on refraining their reactions to their
spouse's statements into a more empathic reaction. They learned to listen to
and accept the emotion in each other. For example, John worked toward
accepting that Mary's emotions could be a rich source of energy in the rela-
tionship and Mary grew to see John's emotional indifference as reflecting an
inability to understand his own emotional life.
By this point in therapy, the couple reported a decrease in the amount
of fighting at home and more "civil" conversations with some positive emo-
tional exchanges taking place. As they grew to better empathize with each
other, they developed a more compassionate reaction to each other. To de-
velop the compassion, the couple worked toward giving altruistic gifts to
each other. The gifts were to be given in such a way that the spouse did not
know it had happened. The issue of trust came up at this time as John and
Mary were willing to give to the other but wanted to make sure the other was
giving back. It was acknowledged that if only one approached the other in an
altruistic spirit, the forgiving would not continue and the work they had
done up to this point would slowly regress back to more arguing.
Some of the altruistic gifts were acts such as doing the other's chores,
spontaneously saying words of affection, and taking care of the children to
allow the other person some time alone. Another altruistic gift that the couple
introduced was the idea of praying to God for blessings for their spouse. Mary
and John became very interested in the idea of praying for their spouse. It
was agreed that they would not be praying about the faults found in their
spouse (e.g., "Oh God, make my spouse less of a complainer") because this
type of prayer was ultimately seen as benefiting themselves. Rather, they
prayed to God to grant positive emotional states ("Dear Jesus, bless my spouse
with joy"), in thanksgiving for their spouse ("God, thank you for bringing
Mary/John into my life"), or in personal petitions ("Holy Spirit, guide me so
that I can be a better spouse for John/Mary"). These prayers were written
together by Mary and John outside of therapy sessions and were privately
prayed as part of their daily prayer life.
Even though Mary and John developed a deepening sense of forgive-
ness over the later sessions, the process of forgiveness was not linear as they
needed to rework several issues. They recognized that forgiveness falls along
a continuum and is not a yes or no issue as it is for their God. They also saw
God's forgiveness as spiritual but worked toward recognizing that their own
forgiveness had to also be cognitive and emotional. Mary and John, through
all of the ups and downs of their marital forgiveness journey, were sustained
by the image of God's forgiveness. The image of Jesus forgiving those who
crucified him while still hanging on the cross became a very powerful moti-
vator for the couple.
Gradually, forgiveness became a regular occurrence in the relationship.
When new offenses emerged, forgiveness was revisited and, though the couple
initially had difficulty accepting the idea that forgiveness had to be ongoing,

98 MARfCJ. KREJC1
they grew to appreciate that they were committed to seeking as well as grant-
ing forgiveness into the future. They began to say they were sorry for losing
their temper in the middle of an argument. They recognized when an unre-
solved issue was still bothering them and sought out the other to discuss it so
that anger would not develop. This resulted in a spirit of reconciliation in
the relationship manifested by a decrease in arguments (averaging one argu-
ment per week at the end of therapy) and the near elimination of the ex-
change of harsh words. At the end of the therapeutic contact, the couple had
learned to forgive each other of the past offenses, which allowed them to
develop a stronger relationship focused on the positive dynamic of forgive-
ness and reconciliation rather than anger.
While dealing with issues related to forgiveness, the couple also began
to consider how they could share their spiritual life with each other. In addi-
tion to the spiritual focus of their forgiveness work, other means to share
their spiritual lives were introduced given that the couple identified this as a
means to increase positive interaction in their marriage.
Initially, this was manifested by the couple praying with each other on
a daily basis. This prayer was begun before the previously mentioned altruis-
tic prayer created in response to the development of forgiveness. For prayers
used early in therapy, it was suggested that they find a brief prayer that they
would together offer to God for blessings on their marriage. Mary and John
debated whether to construct their own prayer or use one that they knew.
The couple agreed to pray the Lord's Prayer with each other just before bed.
As they discussed this issue in therapy, the couple worked on developing
listening skills and reflected on how they reacted to their spouse's statements.
At the beginning of the next session, anger between the two was evi-
dent when the couple reported getting into a major argument before the first
time they prayed. Given his LCMS background, he wanted to include the
doxology (For Thine is the kingdom, and the power, and the glory, forever
and ever, Amen) as part of the Lord's Prayer. Except as used in the mass,
Catholics do not commonly pray the doxology. The argument became heated
and resulted in the couple not praying together that evening, not talking
about the argument the next day nor praying on subsequent days, and bring-
ing up the topic early in their next session. The couple, when reflecting on
the idea that they had actually argued about how to pray the Lord's Prayer,
gained greater insight into how much they were locked into an argument
mode for most of their interactions. Eventually, they agreed to and did write
their own prayer that they prayed on a daily basis.
As therapy continued, the couple worked toward actively sharing their
religious lives in other ways. They participated in a nondenominational bible
study for couples. They began to attend services in both the LCMS and RC
churches together and with the children. Mary and John also reported more
conversations focused on sharing their spiritual journeys with the other. The
resulting positive exchanges became a means for the couple to improve their

FORGIVENESS IN MARITAL THERAPY 99

communication skills and increase the overall number of positive conversa-
tions that were now happening in their relationship.
The forgiveness and the mutual exchange of their spiritual lives re-
sulted in the couple developing a stronger marriage. They were able to gener-
alize the positive emotions developed from forgiveness and spiritual exchanges
to other areas of their relationship. For example, going to the bible studies
resulted in them realizing that they needed to spend time with just each
other. That led to Mary and John occasionally going out together as a couple
for meals or entertainment. Also, when disagreements now arose, they ap-
proached each other with what they described as "Christian love," which
meant that they were not interested in fighting about the issue but compro-
mising toward a solution. In general, a more positive relationship was built
on the foundation of their Christian beliefs.

THERAPIST COMMENTARY

This couple's spiritual life affected therapy more than any other couple
with whom I have worked. They came to therapy wanting me to settle their
arguments and not thinking about their difficulties within the context of
their Christian beliefs. Their anger toward each other was so strong that I
found myself looking for common areas in their lives on which positive in-
teractions could be built. It has been my experience that refighting previous
arguments is not therapeutic and that anger-filled couples need to build some-
thing positive into their marriages. John and Mary expressed that they each
had a spiritual life and that they wanted to share this with each other. It
seemed important that the couple quickly start to have some positive inter-
actions so that they would continue to be motivated to remain in what had
become an entirely negative relationship. Thus, sharing their spiritual lives
became a major theme in therapy.
I have worked with many couples on forgiveness issues. Although most
of my clients express a belief in Christianity, all do not see marital forgive-
ness as an issue related to their spiritual lives. Mary and John did and I think
this gave them additional resources on which to draw for the forgiveness
they needed to give and receive. They drew hope and energy by approaching
their forgiveness from a spiritual perspective because they had numerous
models of forgiveness reflected in Christianity. This allowed them to move
beyond a mere cognitive forgiveness to a spiritual and emotional forgiveness.
An issue that needs to be addressed with some couples is the idea that they
do not have to forgive. Some Christians believe that because God forgives,
they do not have to. Invariably, these people turn the forgiveness over to
God but keep harboring their own resentment. This couple not only realized
that God would forgive their inappropriate marital behavior, but that their
spouse would forgive as well.

100 MARK;. KREICI

 Sharing their spiritual lives became a very effective means for this couple
to develop positive emotional exchanges. If a couple tells me that they have
any kind of spiritual beliefs, I will ask them to pray together for the sake of their
marriage. Many couples report that they do not know how to do this and some,
like John and Mary, have difficulty in agreeing how to pray. Yet, when couples
work on this and develop their ability to pray, it has commonly been cited by
the couple as something very unifying and positive during their therapy.
It is important that religion is not used as some type of marital panacea
by the therapist and by the couple. I have worked with people in abusive
relationships that believe God calls them to forgive their abuser, which they
interpret to mean as needing to put up with the abuse. These individuals
need to recognize the dynamics of the abusive relationship and protect them-
selves from further abuse. John and Mary, just like all couples who develop
their spirituality within the context of marriage therapy, still needed to gain
insight into their relationship that extended beyond a religious understand-
ing. Their work went beyond developing their spiritual lives. However, using
a theistic perspective allowed for therapeutic issues to be addressed and av-
enues to be explored that might otherwise have been overlooked. A thera-
pist working with this couple without this perspective may not have recog-
nized that their religious beliefs could serve as a potential source of unity in a
relationship dominated by discord. Further, the forgiveness issues they ad-
dressed may not have been raised in the context of their religious faith. This
religious context proved to be a motivating factor as the couple sought rec-
onciliation in their relationship. Further, prayer would likely not have been
approached as a means of increasing positive communication in the relation-
ship. Considering therapy from a theistic perspective allowed for these issues
to be raised in therapy and actively used by Mary and John as they worked to
better their relationship.
As a final point of reflection, I needed to be aware of my own spiritual-
ity as I worked with this couple. First, given that I am RC, I needed to be
checking my own reaction to John's and Mary's view of Catholicism. They
had views different from my own and I needed to keep this in mind so as not
to unconsciously attempt to shape their views toward my own. For that mat-
ter, because I pray and work toward forgiving others, both issues central to
my identity, I was more nondirective during my sessions with John and Mary
when the topic of religion arose. This was to ensure that they developed a
shared spirituality that reflected their individual religious lives and not influ-
enced by my own. For example, when they regularly referred to the forgive-
ness image of Christ on the cross, they were, in effect, using the cross as a
metaphor for their marriage. My own spiritual journey would not lead me to
this image, but it was very effective for John and Mary as they worked toward
understanding how to forgive in their marriage.
Clients' faith beliefs can be a tremendously powerful tool for coping
with issues addressed in therapy. Christian beliefs are, at their core, positive

FORGIVENESS IN MARITAL THERAPY 101

and affirming in a person's life. Even though religion, as it was initially in
this case, can have a potentially negative effect, it has ultimately proven to
be a positive force when individuals search for the core beliefs and values of
their spiritual traditions. Although most of my clients have been Christian, I
found this to also be the case with Hindu, Buddhist, and Native American
clients with whom I have worked.

REFERENCES

Enright, R. D., Freedman, S., & Rique, J. (1998). The psychology of interpersonal
forgiveness. In R. D. Enright & J. North (Eds.), Exploring forgiveness (pp. 46—
62). Madison: University of Wisconsin Press.
Fullerton, J. T., &. Hunsberger, B. (1982). A unidimensional measure of Christian
orthodoxy. Journal for the Scientific Study of Religion, 21, 317-326.
McCullough, M. E., Worthington, E. L, & Rachal, K. C. (1997). Interpersonal
forgiving in close relationships. Journal of Personality and Social Psychology, 73,
321-336.
Snyder, D. K. (1979). Marital Satisfaction Inventory. Los Angeles: Western Psycho-
logical Services.
Tan, S. Y. (1996). Religion in clinical practice: Implicit and explicit integration. In
E. P. Shafranske (Ed.), Religion and the clinical practice of psychology (pp. 365-
387). Washington, DC: American Psychological Association.
Worthington, E. (1998). An empathy-humility-commitment model of forgiveness
applied within family dyads, journal of Family Therapy, 20, 59-76.

102 MARKJ.KREJCl
 SPIRITUAL INTERVENTIONS IN
6
THE TREATMENT OF DYSTHYMIA
AND ALCOHOLISM
RICHARD DOBBINS

DESCRIPTION OF THERAPIST

Richard Dobbins is a 75-year-old White man who is a traditional Pen-

tecostal. Dr. Dobbins holds a doctorate with dual credentials as a psycholo-
gist and ordained minister with the General Council of the Assemblies of
God. He has been in practice as a therapist for 37 years. His theoretical ori-
entation is eclectic, with a heavy emphasis on dynamic and cognitive ap-
proaches to therapy. He founded EMERGE Ministries, an Evangelical Chris-
tian Mental Health center in 1974 and has remained there as director and
chairman of the board. He also is a professor in a graduate program of coun-
seling in which EMERGE Ministries partners with Ashland Theological Semi-
nary, a Brethren seminary located in Ashland, Ohio, approximately 40 miles
from EMERGE. This 2-year cohort program is now in its 27th year and satis-
fies the legal academic requirements for preparing students to take the li-
censing exam for counseling in Ohio.

105
 TREATMENT SETTING

Kathy was seen at EMERGE Ministries where 1 psychiatrist, 4 other

psychologists, and 14 master's level therapists see between 300 and 400 people
per week. The clients seen at the center range from preschool children to
senior citizens and present a full array of mental health problems: childhood
physical and sexual abuse, learning disabilities, addictive disorders, individual
adjustment problems, conjoint marital, divorce, and so forth.

CLIENT DEMOGRAPHIC CHARACTERISTICS

Kathy, a 51-year-old female Caucasian homemaker, was seen at

EMERGE, an evangelical Christian mental health center in Akron, Ohio.
After graduating from college Kathy met and married her husband Bert while
he was still in medical school. When she came for therapy he was a 59-year-
old medical doctor. They had been married 29 years and had two sons:
Raymond, age 27, and Robert, age 24. Bert and Kathy were active members
of a traditional Pentecostal church (Assemblies of God) when they initially
presented for marriage counseling.

PRESENTING PROBLEMS AND CONCERNS

Bert and Kathy had grown apart through the years and expressed a de-
sire for conjoint marital counseling to revitalize their relationship. However,
during the intake process Kathy acknowledged she had struggled with de-
pression for more than 20 years. Her attempts to find relief in alcohol finally
resulted in her becoming addicted. Her alcohol addiction was very disruptive
to her family so they focused on dealing with that while her depression had
been left undiagnosed and untreated for years.
Kathy had found periodic help for her alcoholism through Alcoholics
Anonymous (AA). However, because the traumas underlying her depression
were never dealt with she would inevitably turn again to alcohol for relief.
So, she wondered whether it would be better for her if she were to be seen in
individual therapy before any attempt at marriage counseling was made. The
therapist agreed that this would be a wiser procedure.

CLIENT HISTORY

Kathy's depression was rooted in a very sad and tragic family history.
She was the youngest of four siblings: two brothers and a sister. All of them
were deceased at the time she entered treatment.

106 RICHARD DOBBINS

 Kathy recalled no display of affection or other evidence of an emo-
tional bond between her parents during the years she was in the home. She
recalled no evidence of an emotional bond between her mother and any of
her siblings, including herself.
During her childhood Kathy was closer to her father than her mother,
but she seemed to be the child both parents chose as a confidant. She had to
listen to both of them express dissatisfaction with their troubled marriage.
This role became deeply traumatic for Kathy when, at age 6, her father told
her about his girlfriend. Of course she was expected to keep this information
from her mother.
From the time she was age 10, her father used Kathy as a courier to send
his lover money for her house payment. Kathy's mother knew about the af-
fair, but she did not know about the money Kathy's father was giving to his
lover. Keeping this secret from her mother was a major source of guilt for
Kathy. It was the root of much of her hatred of her father.
The woman in her father's life was very affectionate with Kathy. So
Kathy reached out to her to compensate for the absence of affection in her
relationship with her mother. Often, her father would use Kathy as a liaison
between him and his girlfriend. She would carry notes from one of them to
the other. As a child, Kathy was torn between her need for the affection she
received from her father and his girlfriend and her guilt over betraying her
mother in protecting their secret.
One day, while Kathy's mother was lamenting about the affair her fa-
ther was having, Kathy learned that earlier her father had infected her mother
with a sexually transmitted disease he acquired from other promiscuous rela-
tionships. That disease resulted in the loss of vision in her mother's right eye.
Kathy knew her mother could not see out of her right eye, but until then
never knew why.
This incident intensified the ambivalence Kathy felt toward both her
mother and her father. She despised her father for doing something so despi-
cable and lost respect for her mother because she tolerated it and stayed in
the marriage.

ASSESSMENT AND DIAGNOSIS

Kathy was administered the Minnesota Multiphasic Personality Inven-

tory (MMPI) and the Sentence Completion Blank (SCB). The validity scales
on the MMPI were within normal range. There were significant elevations
on the 2, 4, 6, and 7 scales. Several responses to the SCB reflected the "help-
less-hopeless" syndrome often seen in depressed and addicted clients.
Testing and evaluation resulted in the following Diagnostic and Statisti-
cal Manuai of Mental Disorders (4th ed., DSM-IV; American Psychiatric As-
sociation, 1994) diagnosis:

DYSTHYMIA AND ALCOHOLISM J 07

 Axis I: 300.40 Dysthymic Disorder
305.00 Alcohol Abuse
Axis II: V 71.09
Axis III: V 71.09
Axis IV: Marital Stress
Axis V: GAP 55

TREATMENT PROCESS AND OUTCOME

After her initial session Kathy was referred to her medical doctor for
antidepressant medication. She adjusted well to it and this enhanced her
ability to participate in the therapeutic process.

Beginning Phase of Therapy

Kathy's alcoholism precipitated the crisis that brought her to counsel-

ing. Therefore our first goal was keeping the addiction under control so Kathy
could effectively engage in therapy.
I took a complete history of Kathy's addictive behavior. Succumbing to
peer pressure, Kathy began to drink as a sophomore in high school. By the
time she and Bert got married she had learned to disguise her drinking so well
he was not aware of it. During her pregnancies Kathy managed to stay sober
but not long enough to nurse her babies. After I took the history of her addic-
tion, I showed her a four-stage cognitive-behavioral model for "putting off
the old self... putting on the new self," based on the Apostle Paul's admoni-
tion to Ephesian Christians (see Figure 6.1).' Then I explained the four stages
somewhat as follows:

As you can see, the horizontal plane represents the time when you are
free from temptation. This is why it is called the Plane of Rest. The ver-
tical plane represents the rising intensity of your need to drink. So it is
referred to as the Plane of Intensity. As you move up the Plane of Inten-
sity you reach a point beyond your control. The only successful way you
have learned to relieve this intensity is to drink alcohol. So you "act
out." This does succeed in relieving the intense turmoil you are experi-
encing, but at the expense of deepening your addiction and lowering
your self-esteem. Inevitably, once the effects of the alcohol diminish you
evaluate yourself and feel defeated by the addiction. Notice the calibra-
tions on the vertical plane of intensity. Try to define the urgency of your
temptation to drink by identifying it with a number on this vertical plane.

'Ephesians 4:20-24

108 RICHARD DOBBINS

 Now look at the window of escape introduced in Stage 2. It represents
a period of time you have to engage in some other kind of behavior ap-
proved by your conscience that also will break the intensity of your crav-
ing for alcohol and turn it back toward the plane of rest, enabling you to
avoid reaching the point of inevitable acting out. The discovery that this
plane of intensity can be broken by some behavior other than drinking
results in tremendous relief and a positive self-evaluation.
At this point, it is important that you mentally compare the way you
remember feeling about yourself when you resorted to alcohol to break
this tension with how you feel about yourself when you use some other
behavior, consistent with your conscience, to break it. However, it is
important for you to understand that once the intensity builds beyond
the upper limits of this window of escape, you will lose control and pro-
ceed toward the point of inevitable acting out. This is when your addic-
tion takes control of you and acting out becomes inevitable.
Then, I explained the two things that must happen if successful treat-
ment is to occur. Kathy would have to define the following:
1. The triggering mechanisms that compelled her to alcohol.
Was it loneliness, depression, stress and conflict, things not
going well in the marriage, and so forth? She would need to
identify as many of these triggering mechanisms as possible.
2. Substitute behaviors consistent with her value system that
would help her turn the rising intensity of temptation back
toward the plane of rest.
Kathy was told to notice the time intervals on the plane of rest and
estimate the time it took her to process her temptation through the window
of escape and return to the plane of rest. I explained that she should be able
to trace her recovery by noticing the number of times she was able to antici-
pate the triggering mechanisms and to implement her substitute behaviors. I
reviewed with her a printed copy of the typical homework assignments for
Stage 1, which are as follows:
1. Bring to the next session a list of triggering mechanisms.
2. See how early you can detect the rising level of intensity.
3. Discover some substitute behaviors that work for you.
4. Hold yourself responsible for being honest and accountable
to your counselor and at least one other person in reporting
temptations, failures, and successes.
5. Memorize at least one verse of Scripture from the recom-
mended list each day.
6. Carry your accountability card with you all the time and read
it during your devotions each day.
7- Daily rate your feelings about yourself on a 10-point scale rang-
ing from 1 (worst) to 10 (best).

DYSTHYMIA AND ALCOHOLISM 109

 Putting Off the Old Self/Putting On The New Self
Ephesians 4:22-24
POINT OF INEVITABLE
ACTING OUTOLD BEHAVIOR

10 20 30 40 SO
Plane of Rest

B
Putting Off the Old Self/Putting On The New Self
Ephesians 4:22-24
POINTOF INEVITABLE
ACTING OUTOLD BEHAVIOR

. SUBSTITUTE *
NEW
BEHAVIOR
1COR. 10:13

10 20 30 40 50 60
Plane of Rest

Figure 6.1. Four-stage cognitive model for putting off the old self and putting on the
new self (Ephesians 4:22-24).

continues

110 RICHARD DOBBINS

 "You were taught, with regard to you r former way of life, to put off your old
self, which is being corrupted by its deceitful desires; to be made new in the
attitude of your minds; and to put on the new self, created to be like God in true
righteousness and holiness." (Ephesians 4:22-24,NIV)
POINTOF INEVITABLE
ACTING OUTOLD BEHAVIOR
10.

» EVALUATION

» 30 40 SO 6'0
Plane of Rest

Putting Off the Old Self/Putting On The New Self

Ephesians 4:22-24

30 40 so
Plane of Rest

Figure 6.1. Continued.

DYSTHYMIA AND ALCOHOLISM

 I explained that the solid line in Stage 2 indicates that acting out would
still be the most frequent way of dealing with the buildup of stress. However,
there would be times when substitute behaviors would work to bring the
plane of intensity back to the plane of rest. Kathy was encouraged to com-
pare the way she felt about herself when she acted out with the way she felt
about herself when she took the way to escape temptation.
By contrasting these feelings, Kathy would learn the relationship be-
tween the new spiritual disciplines she was learning and her ability to choose
the way to escape rather than acting out as a means for relieving the stress
of temptation. The following is a set of typical homework assignments for
Stage 2:

1. Review triggering mechanisms and add any new ones you have
discovered.
2. Report any improvement in becoming aware of the rising level
of intensity earlier in the process.
3. Report which substitute behaviors are most helpful and indi-
cate any new ones you may have discovered.
4. Continue to hold yourself responsible for being honest and
accountable to your counselor and at least one other person
in reporting temptations, failures, and successes.

I called attention to the progress that would be indicated in recovery by

showing Kathy that in Stage 3 the solid line of "acting out" is now a broken
line and the line of the "way to escape" is now solid (see Figure 6.1, Panel C).
This indicates that, most of the time, at this stage in her recovery she would
be able to identify the triggering mechanisms and put the substitute behav-
iors into place so that she would find the way to escape and avoid the need to
act out. Instead of feeling defeated, she would feel victorious over a bondage
that had left her feeling defeated for years.
I then called her attention to the final stage of treatment. Here the old
behavior has been replaced by the new behavior. The "old self has been put
off. The "new self has been put on. I urged her to have patience with herself
in the process of recovery, reminding her that this usually involves a period
of 6 to 18 months.
Putting off the old person and putting on the new person was a Bible
teaching that Kathy had been familiar with for years. She knew she ought to
be able to do this, but she did not know how to do it. I reminded her that
Christ was living in her mental process and as she demonstrated a willing-
ness to break free from her addiction, she could count on Him to strengthen
her will. She welcomed this practical application of her faith and found that
when joined with weekly group meetings at AA it was very affective in help-
ing her successfully battle her addiction. Eventually Kathy became an AA
sponsor.

112 RICHARD DOBBINS

Intermediate Phase of Therapy

Within 4 months Kathy had made sufficient progress in overcoming

her problem with alcohol to begin working on refraining some of the major
traumas in her history. This was signaled by her announcing at the beginning
of one session, "I was able to drive myself here today. Up until now, I have
had to depend on someone else to bring me. This is the first time in months
I have had the courage to drive on the interstate."
The intake interview had surfaced several major goals for Kathy's
therapy: her self-image (which greatly improved as she recovered from alco-
holism), her relationship with her father, and her relationship with her mother.
So, Kathy chose to focus first on her relationship with her father.
I have found "praying through" to be an effective way of helping believ-
ers cognitively restructure or reframe traumas in their history. 1 explained to
Kathy that none of us lives with the facts of our history. We live with the
feelings generated by the way we interpret the facts of our history. These
interpretations become stories we use to explain our life to ourselves and
others. The facts of our history cannot be changed, but these facts are subject
to a variety of interpretations ranging from very destructive ones suggested
by Satan to very creative ones suggested by the Lord.
Kathy was very familiar with the term spiritual warfare. Hence, I shared
my belief with her that spiritual warfare is the ongoing battle between the
urges, fantasies, and ideas stimulated in her mind by the Lord and those stimu-
lated by Satan. This battle is fought for control of how the believer explains
life to herself.
Although we cannot change the facts of our history, the stories we tell
ourselves about the facts of our history can be edited. When we learn to talk
to ourselves differently about the traumas in our history we learn to feel dif-
ferently about them. I explained to Kathy that mental processes are not sim-
ply driven by neurohormones or neurotransmitters, but spiritual intrusions
influence the interpretations we impose on events in our history. Invisible
spiritual powers are at least as active in shaping our interpretations of the
events of our world as invisible, natural forces are in shaping the physical
world. Christ wants to use His healing influence to suggest more redemptive
ways of interpreting our painful experiences while Satan wants to maximize
their crippling impact upon us.2
I shared with Kathy that the most effective way I have found for facili-
tating this editing process is by "praying through." Of course, she wondered
what was involved in "praying through." I explained this circular four-step
process to her, adding that in some ways "praying through" is like peeling an
onion. The pain of the past is dealt with one layer at a time . .. and you may
cry a lot.

2
]ohn 10:10

DYSTHYMIA AND ALCOHOLISM 1 13

Step 1: Talk to God Honestly About What Hurts You
The painful parts of Kathy's history with her father were stored in her
memory when she was very young. There are ideational and emotional com-
ponents to these memories. Often, the ideational dimension fades over time,
but the painful emotional residual continues to intrude on and color our
current view of life. The Apostle Paul seems to refer to this as "dark glass," or
the distorted lens through which each of us views life.3
If we can identify these painful feelings and talk about them, we can
modify them. But if we cannot identify them and articulate them we may not
be able to modify them. "Praying through" is designed to help a person get in
touch with painful feelings from their past by recalling the underlying his-
toric events and any relationships involved with them.
A therapeutic letter is often useful in bringing the ideational and emo-
tional components of our history together. I asked Kathy to begin writing her
father a letter that she never intended to mail. I suggested that she probably
would not be able to get everything she wanted to say written in the first
installment, but this would give her something she could read to God in
prayer as this first step.
By way of helping her talk to God honestly I asked her to read several of
David's imprecatory Psalms (e.g., Psalms 35; 54-59) in which he tells God just
how he feels toward his enemies.4 Sometimes, a person finds this difficult espe-
cially if he or she is uncertain about how God feels toward him or her, but
Kathy seemed to welcome the opportunity. Reading such a letter to God en-
courages the person to familiarize himself or herself in prayer with God. Ex-
pressing himself or herself to Him in prayer becomes an important part of the
therapeutic process.

Step 2: Emotionally Respond to the Contents of Your Letter

In this second step in "praying through," Kathy was encouraged to al-
low the feelings originally generated by this hurtful history to surface and be
expressed to God in a cathartic prayer. She was to plan her time for "praying
through" when she would be alone. Such intense prayer and emotion can be
upsetting for children or confusing to adults who might not understand.
Because Kathy's ego defenses were strong enough to support such a ca-
tharsis, I encouraged her to weep and pray intensely so that the underlying
emotions could be discharged and not interfere with her entertaining less pain-
ful ways of interpreting the events and relationships referred to in the letter.
Kathy was instructed to remain in prayer until she received recogniz-
able emotional relief. . . until the emotional burden lifted. At this point she
was encouraged to take the next step in this process.

'I Corinthians 13:12

1
Psalms 35; 54-59

U4 RICHARD DOBBINS
Step 3: Meditate and Wait far God to Give You a New and Less Painful
Interpretation of This Damaging Chapter in Your Life
I drew a continuum representing the many ways her history could be
interpreted ranging from very destructive to very creative. I assured Kathy
that as she waited on the Lord she could trust the Holy Spirit to help her
formulate increasingly more redemptive and healing understandings of her
painful history with her father, moving her more and more from the destruc-
tive side of the continuum toward the creative side.
The more often she would expose this painful part of her history to her
loving Heavenly Father the more redemptive ways He would give her for
interpreting it. I assured her that God loved her and wanted to heal her mind
of this crippling pain.

Step 4: Thank God for Helping You Store in Your Memory This New Way of
Looking at Your Old Hurt
Kathy was to thank and praise God for new interpretations of the old
experiences received in Step 3. It is important to spend time mentally re-
hearsing the new interpretations so they are seated in memory in such a way
as to override the old way of looking at it. Kathy was to write this new view of
her old hurt down in her Bible and date the time when she received it.
She was instructed to repeat this four-step process until she could recall
nothing else to write. When she was no longer troubled by her memories of
her relationship with her father, I asked her to design a symbolic way of
destroying what she had written in the presence of her pastor or someone she
trusted, thus bringing closure to this process.
Over the next 6 months Kathy worked hard in therapy dealing with the
destructive history of her relationship with her father. Her self-esteem began
to recover as she dealt honestly with these feelings from her past. The higher
her self-esteem rose the more effectively she worked at "praying through."
Finally, this circular process brought her to the place where she was
able to forgive her father. She arranged a meeting with him to share her
disappointment in him and to express her forgiveness to him. Then she was
ready to destroy her therapeutic letter.
The way she chose to do that was very interesting. She asked me if I
would observe her tearing the letter up in tiny pieces and flushing it down
the commode, "as so much waste in my life." It was gratifying to experience
the elation of that moment with her.
Over the next 3 months we targeted her history with her mother for
"praying through." As Kathy got in touch with the contempt she felt toward
her mother for being so dependent as to stay in such a destructive relation-
ship, she began to get insight into why vulnerability was so frightening for
her. She also began to understand why she detested any hint of weakness in
herself.

DYSTHYM!A AND ALCOHOLISM 1 15

 She experienced more ambivalence in dealing with her relationship
with her mother than she did in dealing with her father. There were no
redeeming virtues to temper her rage toward her father. However, the thought
that her mother might have stayed in the relationship to keep the home
together for the children was very disturbing for her.
Finally, she was able to vent her anger toward her mother for the pain
she experienced from feeling no maternal love. She forgave her. Even though
her mother had died several years before Kathy came into therapy, the use of
a therapeutic letter and the process of "praying through" proved to be an
effective way of helping her put closure on this painful part of her past. She
chose to destroy this letter by burning it in a metal container symbolically
offering it to God as a burnt sacrifice.

Final Phase of Treatment

The last few months of therapy focused on Kathy's self-esteem. Effec-

tively dealing with the traumatic history of her childhood had relieved much
of her depression. Her medical doctor was able to reduce her antidepressant
medication.
Successfully sponsoring another member of AA added to her growing
sense of self-worth. However, there were two junctures in her history that
were still very painful for her. One had to do with allowing herself to receive
affection from her father's lover. This became especially painful when, at
about 12 years of age she learned the cause of her mother's blindness in her
right eye. Then, guilt for betraying her mother by keeping her father's secret
began to haunt her. She hated herself for allowing herself to receive affection
from "that woman."
The other trauma she had to deal with occurred when she fell in love
for the first time with a man who betrayed and rejected her. As a devout
person, Kathy construed this to mean that God was visiting some kind of
divine retribution on her for betraying her mother.
Obviously, the condemnation she felt was self-imposed. I asked her if
she had ever asked God to forgive her for hating her father and betraying her
mother. She assured me she had. So, I asked if she believed God had forgiven
her. She said, "Oh, yes. I believe God forgave me the first time I asked Him,
but how can 1 ever forgive myself."
I then asked her on what basis she believed God was able to forgive her.
She replied, "Jesus died for my sins. So, God can forgive me." Then I asked,
"If God can forgive you because Jesus died for your sins, shouldn't Jesus's
death for your sins allow you to forgive yourself?"
This insight proved to be liberating for Kathy. We revisited this ex-
change several times during the termination phase. Her new attitude toward
herself is reflected in this excerpt from a letter I received from her a year after
termination.

116 RICHARD DOBBINS

 Three and a half years ago I could not write a thank you note much less
a letter. There is so much I have thought of saying to you, but words just
fail me. I think of myself when I came to your office as merely being like
a picture frame with so many pieces of the picture outside the frame. I
guess a jigsaw puzzle with nothing much put together would be more like
it, just a fragmented personality. Time has dulled the memory of that
devastating emotional pain and I continue on the road to being a whole
person. This is a far cry from the person who felt unworthy to even go to
church. This letter is just trying to thank you for directing me on the
road to mental health.

THERAPIST COMMENTARY

Sharing a common faith with Kathy created a trust that enabled her to
build a therapeutic relationship quickly with me. By using spiritual interven-
tions such as "Putting off the Old Person and Putting on the New Person"
and "Praying Through," Kathy found help and healing through concepts that
were familiar to her. These were critical in helping Kathy deal with the com-
plexities of dysthymia and alcohol addiction. The therapeutic use of Scrip-
ture and prayer proved to be important parts of each session I had with Kathy.
When the therapist shares common spiritual resources of faith with the
client they can become powerful tools in the therapeutic process. They assist
in building rapport and facilitate the treatment process necessary for helping
believing clients experience healing from life's hurts and deliverance from
crippling addictions.

REFERENCE

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental

disorders (4th ed.). Washington, DC: Author.

DYSTHYMIA AND ALCOHOLISM 117

 7
JUDAIC THERAPEUTIC SPIRITUAL
COUNSELING: GUIDINGPRINCIPLES
AND CASE HISTORIES
AARON RABINOW1TZ

This chapter describes the attempts of one psychologist, myself, in alle-

viating psychological distress and emotional pain. The uniqueness of this
chapter, as of the other chapters in this book, is that the focus is on the
religious and spiritual dimensions of the problems and the therapy. Psycho-
logical pain may be rooted in (a) the client's dissatisfaction with his or her
fulfillment of religious obligations, and (b) in situations in which the pre-
senting problem does not have discernible religious characteristics, but, nev-
ertheless, hints at spiritual aspects that bear examining. Another feature of
this chapter is the presentation of spiritual and theistic material that can be
used in the therapeutic encounter with almost all patients.
The theoretical basis and the techniques used in therapy that includes
spiritual counseling are no different than the principles that guide me and
the methods I use in my usual practice of psychotherapy. There are, however,
problems and patients for which the inclusion of spiritual goals and the dis-
cussion of religious material contribute greatly to successful therapy. In this
respect, my approach is similar to that advocated by Richards and Bergin
(1997, p. 116). Inclusion of spirituality is naturally appropriate for religious

119
or spiritually inclined patients. There are also instances in which this novel
therapeutic approach is suited for nonreligious clients as well. Furthermore, I
believe that some of the material is useful for non-Jewish clients, emphasiz-
ing as it does, universally accepted ethical and moral values. Source materi-
als are the Bible, Talmud, Midrash, and the teachings of Jewish sages from
the distant past to the present generation. This integrative, multifaceted
therapy strives to present the spiritual viewpoint and values so that they are
perceived as an integral part of the therapy. This requires attuning the reli-
gious teachings with my understanding of personality. I feel most comfort-
able with the dynamic approach assigning a prominent place to unconscious
motivational forces. I do not, however, accept instinct theory as the prime
mover of behavior. I am convinced that the two, the concept of the uncon-
scious and instinct theory, are not inseparably linked. Interpersonal relations
theory, object relations theory, seem to me as more accurately portraying the
human condition. In addition, the concept of the self-image, both as an en-
ergizer and as a barometer of one's functioning, seems to me an important
component both of personality and of the therapeutic process. Combining
psychotherapy with spiritual counseling also implies, in my view, a fusion of
methodologies. Cognitive therapy seems appropriate for spiritual counseling
that sometimes deals with analysis of theistic doctrines and their relevance
to the patient, joining cognitive and dynamic therapy to form what is per-
haps a new entity—therapeutic spiritual counseling. This unique combina-
tion ensures that the spiritual facets touch on people's deepest emotions and
burrow deep into their hidden recesses.
Introspection regarding the steps taken in my development as a clini-
cian leads me to conclude that my orthodox Jewish beliefs directed me to
view the unconscious as a vital cog in the structure of personality. This pro-
cess seems to have operated as well for other principles to which I subscribe.
In this respect, my religious beliefs, psychological orientation beliefs, and
personality are congruent. It is generally accepted that all clinicians choose a
therapeutic approach in accordance with their philosophy and personality.
My studies seem to confirm what others have said as well, that Jewish thought
accepts and anticipates the impact of the unconscious on behavior and per-
sonality, but it does not view instinct theory as the basis of personality
(Rabinowitz, 1999, pp. 41-95).
My clinical work is in addition to my teaching load at Bar-Han Univer-
sity from which I recently retired. The majority of my clients are Israeli, but
I have also treated Americans and others who have come to Israel for either
an extended or limited period of time. Sessions are held in my office at home.
I was born in 1931 in the United States where I attended yeshivot (rabbini-
cal academies) and City College in New York (where I earned a bachelor's
and a master's degree). My doctorate is from Bar-Han University. I am an
orthodox Jew and follow Halacha (Jewish law). It affords me great pleasure
that I lecture daily in Talmud at the local synagogue.

120 AARON RABINOWITZ

 The following points need to be addressed before proceeding. Advo-
cates of a rapprochement between religion and psychiatry-psychology are
increasingly discontented with mere accommodation between the two and
instead promote dialogue which, hopefully, will lead to integration (Blazer,
1998, chap. 2; Richards & Bergin, 1997, Part II). There are many issues per-
tinent to the dialogue. I want to note two points that should be discussed to
avoid misleading therapists who use theistic-spiritual material. Blazer (1998),
in a critique of popular books on Christian counseling, appreciated their strong
points but criticized what he considered weak points. An example is his cri-
tique of proposed facile formulas to deal with depression. He writes,
Though he (the author) quotes Scripture frequently, he usually extracts
passages to support his formula, as opposed to searching the Scriptures
themselves for a deeper understanding of the pain of depression. The
ancient biblical writings are filled with wisdom relevant to the depressed
in the 20th century. The ancient writers both expressed and empathized
with persons suffering emotional pain. No formulas were provided to
guarantee freedom from depression, (p. 119)

I fully concur with his statements (Rabinowitz, 2001).

This leads to the second point. Blazer is disturbed that psychiatry and
religion have not grappled with the angst that pervades Western society.
The following is his analysis of why this is so:
We live in a disturbingly narcissistic society, a society that demands in-
stant gratification, including the right to emotional well-being Anti-
intellectualism also pervades psychiatry and Christianity. . . . Christian-
ity is not about instant relief, immediate gratification and the power of
positive thinking The Christian life is a goal-directed life given mean-
ing by the fullness of the Judeo-Christian heritage, a life that struggles
every step of the way, a life that often suffers emotionally, (p. 97)

This perception of religion has been articulated by Rabbi Dr.

Soloveitchik (1983): "The popular ideology contends that the religious ex-
perience is tranquil and neatly ordered, tender and delicate.... If you wish to
acquire tranquility without paying the price of spiritual agonies, turn unto
religion" (p. 141). He repudiates this as anti-intellectual:
This ideology is intrinsically false and deceptive. That religious conscious-
ness in man's experience which is most profound and most elevated ... is
not simple and comfortable. On the contrary, it is exceptionally com-
plex, rigorous, and tortuous. Where you find its complexity, there you
find its greatness. Religion ... (is) a raging clamorous torrent of man's
consciousness with all its crises, pangs, and torments. (Soloveitchik, 1983,
p. HI)
Therapists practicing therapeutic spiritual counseling will do well to
heed the cautionary note inherent in the previous passage. This does not

;UDA;C THERAPEUTIC SPIRITUAL COUNSELING 121

negate using spiritual material to foster serenity and other traits described in
the book edited by Miller (1999). It does mean that therapists should not
expect spiritual counseling to be a panacea.

THREE GUIDING PRINCIPLES IN THERAPEUTIC

SPIRITUAL COUNSELING

Efficacious use of the concept of the unconscious in therapeutic spiri-

tual counseling is enhanced by introducing it as having been promulgated by
one of the great talmudists and ethicists of the 19th century, Rabbi Israel
Lipkin (Yisroel Salanter). He related the following hypothetical story. A
scholar has an apt student to whom he is strongly attached, and a son, a
wastrel whom he despises. They all reside in the same town and are asleep
when fire erupts. The scholar, awakened from a deep sleep and informed that
his son and student are in danger, will instinctively hasten to his son's rescue
rather than to his student. This is so because not being fully awake, he is not
in complete possession of his rational cognitive faculties. In this state the
instinctual "inner" forces are dominant and the rational "outer" forces are
unable to influence behavior. The concepts of inner and outer forces are
used to explain two apparently contradictory sayings of the sages recorded in
the Midrash (the non-Halachic, non-legal teachings found in the Talmud
and similar books, also called Aggadah). Abraham is described in one saying
as eagerly and joyously obeying God's command to sacrifice his son Isaac. In
a different saying, he is depicted as weeping. Rabbi Salanter resolves the
contradiction by explaining Abraham's behavior as a function of both inner
unconscious forces and outer conscious forces. On the conscious level he
cheerfully prepared to carry out God's wish, but inner instinctual forces caused
his weeping; they could not be denied their measure of grief. Inner uncon-
scious components of personality cannot be eliminated or controlled to the
extent that they will not be experienced. The inner forces are "unclear" forces;
the outer are "clear" forces. This distinction explains why the inner forces
are more powerful than the outer forces; they are not familiar and seem to
emerge from nowhere and overwhelm the unwary. My clients, especially those
who are familiar with the Talmud and its dialectical method of reasoning,
are usually receptive to the concept of the unconscious. Its use as a tool for
uncovering hidden material by paying attention to subtleties of thinking and
slight variations of behavior is similar to their method of textual analysis
(Handelman, 1981; Jennings & Jennings, 1993).
Introspection also reveals that my predilection for the other principles
guiding me, the importance of interpersonal relations and the concept of the
self-image, is also rooted in my religious philosophy. The very basis of Juda-
ism is communal. It can be reasonably argued that in this respect, Judaism is

122 AARON RABINOWJTZ

closer to the Far Eastern concept of communal cohesion than to Western
individuality, although the individual is of paramount importance.
Mine ordinances shall ye do, and My statutes shall ye keep, to walk therein: I
am the Lord your God. Ye shall therefore keep My statutes. . . ." (Pentateuch
Leviticus 18:4,5, Hertz translation, 1941)
The verses are in the plural, indicating that the nation, as a nation, is to
follow the Torah's ordinances. The individual (in this sense) is of conse-
quence only when part of the community (Meshoch Chochma in his com-
mentary). In his comments on Leviticus 23:21, he writes that mitzvot (com-
mandments) associated with the holidays bind individuals to one another
forming a community to serve Him. This is contrasted to the Sabbath mitzvot
that serve to bind each individual to God. We are taught that both the com-
munity and the individual play important roles in life's mosaic. The Ramban—
Nachmanides (a major medieval Talmudist and Bible commentator) focuses
on the language of the Ten Commandments. The Torah phrases the prelude
to the Decalogue in plural language, whereas the Decalogue itself is in the
singular. His interpretation is that the singular is used to emphasize personal
responsibility. One should not be deluded into thinking that punishments
for transgressions will be meted out only to the community as a whole and
not to individuals. It is striking to entertain the thought that perhaps indi-
viduals would not be punished for personal transgressions. This attests, on
one hand, to the importance of the community, and on the other hand that
nevertheless each individual is held liable for himself or herself.
Rabbi Dr. Soloveitchik (1965), a foremost Talmudist and profound
philosopher, develops the theme that prophecy is a communal phenomenon.
The prophet must bear in mind that he or she is only a messenger. Moreover,
the prophecy must contain a normative ethical message. Only then is proph-
ecy considered a manifestation of the covenant between God and Israel. I
presume that is also the sages' intent in their reading of God's command to
Moses to descend from Mt. Sinai when Israel sinned by adoring the golden
calf. They interpreted this to indicate that Moses may lose his special status.
Rashi (the most prominent medieval Jewish biblical commentator) quotes
the sages, "I bestowed greatness upon you only for Israel's sake" (Exodus,
32:7). The phenomenon of God's revelation to all the Israelites on Mt. Sinai
is compelling evidence of the importance of the concept of the community.
It is unique as a manifestation of a religious experience in that it is a national
experience in contrast to the individual religious experiences reported in the
literature. Clients having poor interpersonal relationships that interfere with
behavioral functioning and/or positive inner feelings benefit from therapeu-
tic spiritual counseling, drawing on the previously noted and similar material
culled from religious sources.
Patients whose self-image is flawed benefit from therapeutic spiritual
counseling stressing the uniqueness and worth of each individual as a conse-

JUDAJC THERAPEUTIC SPIRITUAL COUNSELING 123

quence of having been created in His image. Internalizing this rudimentary
principle fortifies the person's healthy inclination to follow a path he or she
chooses. It banishes frustration spawned from the feeling that one's fate is
dependent on preordained circumstances. This perception imposes a set of
values, a way of thinking, an approach to people that has as its core enor-
mous respect for the person. It also affects the relationship between therapist
and patient, defining it as an encounter between two people and not as a
doctor—patient or expert-client relationship. This may be so for nonspiritual
therapy as well, but it is mandatory for Judaic therapeutic spiritual counsel-
ing. This modus operand! is not confined to the spiritual facets of the person;
it recognizes that the earthly aspects are fully human. The Almighty saw fit
to combine spiritual and earthly entities into a complete whole. This engen-
ders empathy in that it highlights the complexity of personality which is a
joining of two opposites, spiritual and material. This juxtaposition was noted
by the sages (Midrash Kabbah, Tazria HA). They write that the human spirit
was created on the first day, whereas the body was formed on the sixth day
after all other forms of life were created. This teaches us that if humans prove
themselves worthy, they are considered the pinnacle of creation; if, however,
they do not conduct themselves properly, they are reminded that the lowly
gnat was created before humans.
The Talmud (Sanhedrin 37A) states that each individual is required to
feel that the world was created for his or her benefit. This is to impress on
individuals the value of each human life and the magnitude of one's ethical
and religious obligations. Hillel taught that "If I will not help myself, who
will help me?" (Sayings of the Fathers, chap. 1), referring to spiritual attain-
ments and fulfillment of ethical obligations. To this Hillel adds, "but of what
significance are they vis-a-vis my spiritual obligations?"—a gentle reminder
intended to curb one's arrogance.
The two principles, the concept of a communal religious experience
and the stress on the person's uniqueness, serve to modify one another. In
concert, they dictate the religious philosophy and world outlook of the or-
thodox Jew. He or she strives to develop and feel a personal bond or cov-
enant with God, but this sentiment is tempered by the knowledge that the
bond has already been formed. The Torah, which was given to the commu-
nity, has given substance to the shape and direction of the bond. Aspiring to
achieve holiness does not include, in the current era, developing a personal
dialogue with God. This possibility ceased to be shortly after the destruction
of the first Solomon's temple. A present-day Jew views his or her relationship
with the Almighty as being realized by heeding His commandments. Study-
ing Torah and following its precepts should be an all-consuming passion ful-
filling one's spiritual longings and needs. Judaic therapeutic spiritual coun-
seling has to mold itself to this perception. This entails dealing therapeutically
with material related to Torah ideals and observance, thereby touching on
the client's belief and trust in God. The two—spirituality and Torah obser-

124 AARON RABINOWITZ

vance—are inseparably linked. This should be reflected in therapeutic spiri-
tual counseling. The therapeutic spiritual goal is to achieve a harmonious
balance between the two factors. The therapist, and he or she can be Jewish
or non-Jewish, should be aware of this delicate balance. The discussions should
touch on both aspects with the realization that for these clients, the pre-
ferred direction, the path the therapy should follow, is to first examine the
client's perception of his or her commitment to Torah ideals and observance.
This will directly influence the client's understanding of the depth of his or
her belief and trust in God. The case material that I present in this chapter is
designed to show various ways in which the relationship is expressed.

CASE HISTORIES ILLUSTRATING THE PRINCIPLES

The following two case histories exemplify the principles cited previ-
ously. One stresses the role of the unconscious, the other stresses the impor-
tance of interpersonal relations. Both reflect the client's perception of him-
self as deficient in Torah observance.

Danny

Danny is a 17-year-old rabbinical student whose presenting problem

was that his progress in his studies was not commensurate with his capabili-
ties. Although he smiled and spoke clearly and fluently, an underlying sad-
ness was present. He is of above-average intelligence; his grasp of his envi-
ronment and knowledge of events and people seemed fitting for someone 4
or 5 years older than he. Danny's father, with his permission, said he was
convinced that his son was burdened with a problem, but he could not iden-
tify the exact nature of the problem. There was no indication of tension
between Danny and his parents or siblings. In the third session, Danny spoke
about his lustful feelings and occasional masturbation that perturbed him.
The concept of the unconscious was helpful in that it enabled him to under-
stand a recurring dream, which shall shortly be described. I presented the
concept as described here, adding another example. I felt it appropriate and
more meaningful to Danny, who is a member of a hassidic sect, to consider
an example found in hassidic literature. Hassidim are an integral part of or-
thodox Jewry who observe certain customs rooted in kabbalistic doctrine.
The "Sefat Emet" (a famous hassidic rabbi) writes of thoughts a person has of
which he or she is unaware and uses this to explain Joshua's behavior. The
sages criticize Joshua for waging what they consider unnecessarily prolonged
wars. They attribute this to Joshua's realization that the liberation of Canaan
and subsequent cessation of hostilities would signal his demise. The Sefat
Emet explains that prolonging the war was not a conscious decision. Joshua,
whom God calls His servant, would not consciously defer liberating Canaan

JUDAIC THERAPEUTIC SPIRITUAL COUNSELING 125

for personal gain. However, unconsciously, this influenced him and led to
postponement of the liberation, for which Joshua was punished (Sefat Emet,
Book of Numbers, Matot). Danny reported dreaming several times that he
observed the Sabbath law approximately 3 hours before sunset, which is the
appointed hour to commence observing the Sabbath. He was baffled by this,
especially because it kept recurring. I reminded him that we had discussed
methods suggested in rabbinic and hassidic literature for alleviating the harsh-
ness of the sin of masturbation. One of the tikunim (procedures that can be
followed to rectify the spiritual harm caused by sin) is intensified Sabbath
observance. Danny was then able to understand the significance of his dream
as an expression of his desire to be spiritually cleansed. This lowered his anxiety
level facilitating further therapy.

David

David is a 22'year-old student in a prestigious yeshiva. His presenting

complaint was that he could not fully concentrate on his studies. Because of
this, he stopped attending lectures although he continued to study on his
own, discussing difficult passages in Talmud with two senior lecturers. Al-
though students pursue their studies in a large study hall in dyads, David
preferred to study alone. He had previously attended other yeshivot, but they
were not to his liking, thus prompting him to leave. He prayed in local syna-
gogues rather than at the yeshiva, which is the accepted practice. The prayers
in the synagogue are recited more quickly, granting him more time to devote
to his studies. The Rosh Yeshiva (Dean) did not view this favorably. Family
history revealed that his mother is anxious about possible harm caused by
bacteria and this seems to have affected David as well, although to a lesser
degree. There is also a separation problem. David enjoys being in the ye-
shiva, but if he cannot be there, he experiences an intense desire to be with
his mother. David is aware of this problematic emotional attachment to his
mother, but in other matters, for example, attitudes toward religion, he iden-
tifies with his father's position. It pains him to see his parents arguing on
religious and other issues. Therapy centered on these problems and their
effect on his behavior and his attitude toward father figures. His habit of
distancing himself from his fellow students was also discussed.

Therapeutic Spiritual Counseling

Spiritual counseling focused on the importance of interpersonal rela-

tions and its role in forming a balanced healthy personality. Relevant mate-
rial presented above was discussed. The ramifications of lack of friendship
attachment were demonstrated by an analysis of Job's tribulations. Satan was
granted permission to afflict Job with all manners of hardships with the ex-
ception of causing his death. Job's friends came to comfort and counsel him.

J 26 AARON RABINOWITZ
Satan could have prevented them from coming, which would have increased
Job's pain to an even greater degree. Why, then, did Satan allow them to
come? An explanation favored by commentators is that this would be tanta-
mount to killing Job. This is based on the sages' statement, "either friends or
death" (Talmud, Tractate Taanis 23A), which they attribute to "Chomi
Hameagel," who slept for many years and awoke to find a new environment
inhabited by strangers. This approach led David to view his actions from a
spiritual religious perspective motivating him to seek change.
Further consideration of David's behavior leads me to ruminate whether
his refusal to study with others is an emotional problem, a strength of charac-
ter issue, or simple lack of humility. The line differentiating between them is
not always clear or definite. Some psychotherapists claim that therapy, aside
from alleviating emotional pain, influences patients to become better, kinder
people. Others contend that some forms of therapy make people even more
selfish and self-centered (Wallach & Wallach, 1983; Wicklund & Eckert,
1992). They argue that some therapies overemphasize the self to the exclu-
sion of others, resulting in endowing the patient's feelings with the exclusive
right to decide how he or she should behave. They marshal arguments that
they believe show that this is diametrically opposed to the Judaic-Christian
heritage that teaches, "Thou shalt love thy neighbor as thyself (Leviticus,
9:18). The lack of unequivocal empirical evidence to decide this issue places
therapists in a difficult position when confronted with situations such as that
of David. It seems to me that such situations are those best suited for thera-
peutic spiritual counseling. Weaving spiritual counseling into the therapeu-
tic process counteracts whatever deleterious influence (according to some
theoreticians) therapy exerts. The process may be perceived as do Richards
and Bergin (1997, p. 102) that getting in touch with one's spiritual core
facilitates the dissolving of the "mortal overlay" leading to the dissolving of
pathologies.

EXAMPLES ILLUSTRATING THE DILEMMA

The following two examples illustrate the dilemma and the unique prob-
lems it generates. They were similar in that their problems seemed to be
closely related to the special niche their families occupied in the religious
social hierarchy. One was a descendant of a prominent hassidic rabbi revered
by many followers. The second client traced his lineage to many highly re-
spected scholars of the past few centuries. The first was in his late 30s, the
second in his 20s. Both were happily married and devoted fathers. They both
felt that their distress was related to the families' social position.
The hassidic client told of his family being harassed by former friends.
He maintained that this was a result of an erroneous notion that the client's
immediate family was disrespectful to the tradition. The roots of the alleged

JUDAIC THERAPEUTIC SPIRITUAL COUNSELING 127

disrespect were ideological, but with the passing of time turned personal and
emotional. The client was not the instigator or chief protagonist and can be
considered a victim of unfortunate circumstances. He did not know how to
cope with the situation, became frustrated and slightly depressed on realizing
that his heretofore rosy future now seemed out of reach. During the two ses-
sions we met, he dwelled on his misfortune, leaving me with the impression
that he expected me to pity and comfort him. He did not return for further
sessions. My assessment was that he divined my intention to discuss the theo-
logical implications of not accepting the situation, of not gracefully acknowl-
edging God's intent and will. My assumption was perhaps mistaken. He may
have ceased coming because of factors in his psychological structure ame-
nable to treatment by dynamic therapy. Furthermore, even if the assumption
were correct, the intended therapeutic approach stressing theological-
religious aspects may have unnerved and intimidated him. Being accosted
with defects in that area may be more traumatic for him than facing person-
ality psychological blemishes. This case exemplifies difficulties a therapist
may encounter in such situations.
The second client, Jacob, felt that he was not true to his inner self, that
his behavior reflected an exalted ideal to which he aspired but which at present
was not authentic. This made him feel awkward and uncomfortable with
friends. He longed to be freer with them, to achieve easy comradeship. These
needs were stifled by a compulsion to live up to the very high standards of
scholarship and moral standards for which his family was known. Here, too,
I was faced with the dilemma. Was I to look for psychological factors, or was
this "pride" that should be addressed as a moral problem? The issue was re-
solved when further sessions revealed unhealthy behavioral patterns and pa-
rental marital tensions. The therapeutic approach adopted integrated dy-
namic therapy with spiritual counseling—therapeutic spiritual counseling.
Jacob was distressed and anxious, unsure whether to continue his present
lifestyle; changing it would startle family and friends. His present behavior,
in most respects, was above reproach, extreme in its suppression of anger
even when warranted. From a dynamic viewpoint, it entailed siding with one
of his parents who opposed the other parent's habit of denigrating others.
The denigrator's behavior was rationalized as not being tolerant of sham and
hypocrisy, which was true to some extent. It was, however, extreme and ag-
gressive, conducing to consternation and a sense of shame, influencing Jacob
to behave overly gentle. Jacob also followed a different course of study than
that of other family members. His independence took its toll; the strain im-
paired his powers of concentration and led to minor sexual transgressions.
Therapeutic spiritual counseling included bolstering his self-image, eas-
ing the way for him to follow his inclinations, not to feel obligated to trod in
the same paths of his forefathers. In addition to the material previously pre-
sented, I related a story told of a hassidic master. The rabbi was rebuked for
not following in his father's ways regarding modes of prayer, study, and so

128 AARON RABINOVWTZ

forth. He retorted that he does not deviate from his father's customs; his
father did not blindly follow in his father's footsteps and he as well does not
imitate his father. It was also emphasized that the sages taught that each of
the three patriarchs served the Almighty differently. Abraham is character-
ized as epitomizing the trait of chesed—loving-kindness; Isaac, the trait of
gevurah—literally, strength. This is understood as strength of will, focusing
only on achieving maximum closeness to God as befitting a sacrifice. Jacob
combined both traits so as to reflect God's glory. The lesson derived is that
within the Torah's parameters there is enough leeway for each person's spiri-
tuality to be expressed as he or she sees fit. This principle is vividly illustrated
by the "Chofetz Chayim's" (the acknowledged leader of religious European
Jewry prior to the Holocaust) interpretation of one of the sages' teachings.
They portrayed the future metaphorically as God sitting in the center of a
circle surrounded by the righteous. The center of a circle is equidistant from
all points on its perimeter. This teaches that all methods of serving God that
are grounded in justice and mercy are acceptable.
Jacob made slow but steady progress. He was fortunate in that his wife,
although disappointed when he told her of his tumultuous inner conflicts
and occasional sinful behavior, fully supported him. They are deeply attached
to one another. It was not feasible to meet with her regularly, but I was able
to counsel her from time to time. Her deep religious commitment provided
her with inner strength to cope with recurring exigencies. Our discussions
focused, in part, on the importance Judaism attaches to perceiving God as
merciful and not willful or capricious.

AN IN-DEPTH EXAMPLE OF THERAPEUTIC

SPIRITUAL COUNSELING

Norman is a 22-year-old yeshiva student. He enjoys studying and is

considered an apt student and a pleasant person by his teachers. He has diffi-
culty praying the thrice daily prayers required of every orthodox Jew. He is
plagued by doubts as to whether he concentrates adequately when praying,
especially when uttering God's name. Norman is bright, personable, and ac-
cepted by his peers. However, he seldom smiles during therapy; at times, he
sits with his head bowed as if carrying all the burdens of the world. He says
that he acts differently in school. Norman is the eldest of five children, is a
respectful son, and has good relations with his siblings. He comes willingly to
therapy, never missing a session or arriving late. However, he is not talkative
and rarely volunteers information. Several sessions elapsed before he felt free
to speak about his obsessive compulsions that revolve around religious ritual
requirements. His mother is not a warm loving person. It took much gentle
prodding to elicit this information. It took even longer for him to reveal that
many years ago, his mother had suffered a mild stroke and had been hospital-

JVDA1C THERAPEUTIC SPIRITUAL COUNSELING J 29

ized for a few months. Her speech was impaired, eventually improving, but
on returning home she was even more distant from her children. At this
point in therapy, he became distraught and cried. He broke out in tears a
second time when a sibling, to whom he feels very close, told him that their
father had verbally lashed out and humiliated him. Norman says that his
father is concerned about his children, means well, and helps them, but does
not show his love, is obstinate and insistent that his wishes be fulfilled. His
memory of his mother's illness includes his recollection that she suffered her
stroke after having argued with her husband. Norman feels greater attach-
ment to his father, although he cannot carry on a normal conversation with
him. They walk together in silence. When Norman is witness to a warm,
loving relationship between other parents and children, he feels envious. It
is difficult for Norman to talk about his relationships with friends or about
his daily routine. He feels it is irrelevant to understanding his problem.
Norman dismissed as meaningless the view that pathology is an integral part
and not an isolated segment of personality.
Norman's religious beliefs did not bestow on him peace of mind; on the
contrary, his laxity of observance (imagined or real) disturbed and caused
him pain. I felt that an in-depth probe of his religious commitment was called
for. This confirmed that his belief is authentic and important to him. I postu-
lated that his problems were rooted in and stemmed from psychological fac-
tors and that therapy should concentrate on developmental and dynamic
factors. However, the fact that his compulsions manifested themselves as
difficulties in prayer and observance of other religious rituals indicated the
need to include religious counseling.
This therapeutic plan was implemented by weaving into therapy the
religious significance of the concepts of the unconscious and self-image, as
explained earlier. There was slow progress and about 2 months later he real-
ized that he was angry at God whom he held responsible for his predicament.
Immediately he retracted and placed the onus on himself, declaring that
his difficulties are justified because of his lax religious observance. This
transformation is akin to what Pargament (1996) called "refraining the indi-
vidual." However, the speed and immediacy are suspect. There was not any
indication on Norman's part of profound reflection and, therefore, it seemed
to be a compulsive reaction rather than a reasoned conclusion. This self-
deprecation prevented him from connecting his love—hate relationship with
his parents to his behavior, to what seems to be the displacement of his anger
toward them, to God. I asked him how he perceives God, as warm and forgiv-
ing or stern and uncompromising. He indicated the latter, but again immedi-
ately retracted. He is aware that Judaism teaches that God is merciful, "And
the Lord passed by before him (Moses) and proclaimed: The Lord, the Lord,
God, merciful and gracious, long-suffering and abundant in goodness and
truth" (Exodus 34:6, Hertz translation). I felt that, although there certainly
is displacement of the anger at his parents onto the Almighty, this is not the

130 AARON RABINOWITZ

full explanation. His total commitment to religion and his deeply held belief
in God's mercy were genuine and, therefore, his contention that his psycho-
logical pain was warranted by his behavior could not be completely dismissed
as being solely a function of displacement.
The new developments called for broadening the scope of the spiritual
counseling dimension of the therapy and adjusting it to the specifics of the
situation. Aside from his difficulty in prayer, Norman viewed himself as lax in
religious observance in two areas: (a) lacking filial respect in that he allowed
himself to argue with his father and (b) lustful thoughts and occasional mastur-
bation. As to the latter, 1 refer the reader to the spiritual counseling method of
dealing with this from a Judaic standpoint (Rabinowitz, 2000, pp. 254-255).
As for the former, his negative perception of himself could not be divorced
from what I suspected was his feeling that he does not love his parents as he
should. Therapy intended to help him understand that this is a natural result of
his parents' personality and behavior was not successful in mitigating his dis-
tress. Norman's resolve to abide by the fifth commandment to honor one's
parents overwhelmed in its intensity any conceptual rationalization of his in-
ner feelings. Norman would be able to accept himself only if his entire self-
image could change, allowing him to assess his past from a more mature and
balanced position. To bring about this hoped-for change, I initiated discus-
sions of the following material. Tanya, a classic hassidic text, quotes the sages
(Sayings of the Fathers, chap. 2) that one should not consider himself wicked.
The significance of its being the opening passage of the book indicates its im-
portance as being central to the author's thesis. The text is a guide on how to
harness one's energies to serve God, how to forge a harmonious relationship
between the divine and earthly attributes of human beings. The author stresses
that a poor self-image, viewing oneself as a sinner, fosters sadness preventing
serving God with joy, which is a biblical bidding (Deuteronomy, 28:47). Rabbi
Zadok of Lublin, a later hassidic master, taught that believing in oneself is a
necessary step to follow after establishing belief in the Creator. He explains
this amazing statement as meaning that it is imperative to realize that humans
are important to Him and that He is concerned even with individuals' mun-
dane preoccupations. A useful method of differentiating between sadness that
obstructs serving God and bittersweet sorrow (merirut) which, on the contrary,
is a positive feeling leading to increased maturation to serve Him, was de-
scribed in a previous publication (Rabinowitz, 2000, p. 254). Norman has im-
proved, becoming more in touch with his inner feelings. His symptoms have
decreased, but they have not at this point completely abated.

A COMPOSITE CASE REPORT OF SPIRITUAL COUNSELING

The following case report is a composite of therapy with three clients:

two men and one woman. Their common feature is a pronounced reluctance

JUDAIC THERAPEUTIC SPIRITUAL COUNSELING 131

to form meaningful social relationships. They are relatively young people, in
their 20s and 30s.
Ehud
Ehud had been under psychiatric care for 5 years following a psychotic
episode. He was not hospitalized, drugs were prescribed, and he is still taking
antipsychotic and antianxiety medication. The psychiatrist confined herself
to the physiological medical aspects. She did not do psychotherapy. Ehud did
not confide in or wish to be advised by her in religious or sexual issues. I
suspect that she was not averse to this arrangement, a convenient one for a
harassed psychiatrist. When I attempted to engage him in a therapeutic con-
versation, he was very reluctant. His advisors had cautioned him not to ac-
cept advice in matters pertaining to religion or sex from a nonrabbinic per-
sonage. I was certain that this did not apply to me and asked him to check
with them. He did and they permitted and urged him to be frank and forth-
coming with me.
Ehud's parents are simple, religious people not as devout as he. When
in his early teenage years he decided to devote himself exclusively to study-
ing the Talmud, his parents were not enthusiastic. Aside from preferring that
he study secular subjects as well, Ehud's choice meant adopting a lifestyle
different from that of his parents or his siblings, all of whom were older than
he. It meant eschewing television, motion pictures, and so forth, and they
assumed correctly that this would affect them as well. Ehud railed against
having a TV at home. At first, his parents refused to comply with this re-
quest, but relented when he experienced the psychotic episode. Prior to the
breakdown, he was an excellent student devoting many hours to study. His
diligence, however, prevented him from forming friendships. Therapy re-
vealed that his reluctance to forge friendships was also motivated by the fear
that close relationships would lead to friends knowing that his parents had a
TV in their home. He was anxiety ridden that this revelation would lead to
expulsion from his yeshiva, a premise that had no basis in reality. It is reason-
able to assume that the anxiety contributed to his breakdown. Viewed thusly,
the psychotic episode is an example of secondary gain—removal of the TV
set. Incidentally, it took some years for him to realize that many other stu-
dents as well had TV sets in their homes. Ehud's devotion to study did not
diminish after the breakdown, but his progress was arrested. His concentra-
tion was impaired, perhaps this was also a result of medication, and his level
of understanding the depth and intricacies of talmudic analysis was reduced.
His self-image was such that any deviation in conforming to the norms of his
circle seemed catastrophic. Difficulty controlling his sexual urge aggravated
his poor self-image.
Therapeutic spiritual counseling concentrated on the intrinsic impor-
tance of each individual in God's eyes. It was emphasized that each person is
judged solely on his or her merits and actions. Numerous examples of biblical

132 AARON RAB1NOWITZ

and talmudic figures were cited to support this contention—for example, the
matriarch Rebecca who, according to the sages, was reared in a morally flawed
household. Her brother Lavan is viewed as a conniving, immoral person,
whereas Rebecca is a paragon of virtue and loving kindness (chesed). Rabbi
Akiva, who is considered as one of the Talmudic giants, was also cited as an
example who transcended a religiously flawed background to achieve un-
usual prominence. The examples bolstered and improved his self-image. This
led to his becoming involved in meaningful social relationships that pro-
vided him the opportunity to display his positive attributes. For example, he
was asked to speak publicly on festive occasions that afforded him great plea-
sure and initiated a healthier lifestyle.

Benjamin

Benjamin is a tall, fine-looking, bright young man. He is artistically

inclined, which is unusual in his circle. This does not interfere with his com-
mitment to Torah study. The presenting problem was his lack of being at-
tracted to women. He insisted that his preference for the company of men
was not sexual, but he was nevertheless concerned whether this meant that
he had homosexual tendencies. He is the oldest of several brothers. His par-
ents are observant orthodox Jews, his father having become more so in the
past few years. This is one of several issues causing friction between the par-
ents. Benjamin identifies with his father's religious level, but is closer emo-
tionally to his mother whom he considers warmer and more sophisticated
than his father. He enjoys his studies in the yeshiva, but savors the feeling of
freedom he experiences when returning home at night. He prefers sleeping
at home, although entitled to free dormitory lodgings. He explained that this
enables him to enjoy his artistic pursuits. Therapy revealed that being at
home gives him a measure of control, the opportunity to interfere and calm
his parents when they argue. During the course of therapy, one of his parents
left home. Benjamin suspected that the parent had entered into a romantic
extramarital relationship. He was hurt and greatly distressed, triggering him
to seek comfort and understanding from a male friend. This flowered into a
partial sexual relationship not including full intimate contact. Spiritual coun-
seling helped him confront the fact that his frustration led to behavior in-
consistent with his beliefs. Benjamin is a totally committed religious person.
Discussing his behavior did not elicit a defensive reaction, and consequently
an elaborate "working through" period was not needed. The discussion was
crucial in that it opened avenues of introspection relevant to his interper-
sonal relations, resulting in marked improvement in his reaching out to oth-
ers. He began to plan and go on trips with friends.
The incident led me to wonder whether his reluctance to sleep in the
dorm was not prompted by an amorphous fear that it might lead to undesir-
able sexual contacts. It should be noted that yeshivot, dedicated to talmudical

JUDAIC THERAPEUTIC SPIRITUAL COUNSELING 133

study and research, are all-male schools. Students who attend this type of
institution usually belong to a circle in which separation between the sexes is
the norm until marriageable age. A positive development that can be viewed
as a result of the incident was Benjamin's conclusion to begin dating women.
He realized that confronting his problem required this move and indeed his
attraction to men declined with a consequent heightened interest in women.

Deborah

Deborah is a young woman recently divorced from her husband of a few

months. She did not initiate the divorce proceedings and could not specify
why he wanted the divorce, merely saying without explaining that they were
incompatible. She maintains that she did not want to marry him. Her father
pressured her to do so, which is one of the many reasons she does not get
along with him. Her mother died when Deborah was in her late teenage
years and her father remarried. There are several siblings from her parents,
and younger brothers and sisters from her father's second marriage. She was
close to her mother; her relations with her siblings vary, with some better
than with others. She says that she was a better student than her siblings and
that this engendered jealousy. Her father did not want her to return to his
home after her divorce. She boards with a family, paying with funds she re-
ceives as rental from an apartment she owns. She is a licensed teacher, but
could not find employment. She has little support financially or emotionally
from her father or extended family.
Deborah entered therapy as a result of her inability to establish good
relations with the family with whom she lived. They were not ready to con-
tinue the arrangement if her behavior would not improve. She also neglected
her relationships with former friends. Therapy helped in improving relation-
ships with the family with whom she lived. Therapeutic spiritual counseling
centered on the concept of accepting God's will. In principle, Deborah ac-
cepted this, but nevertheless wanted to know and understand its parameters.
When is acceptance called for and when, on the contrary, should one strive
to actively change the situation? I was able to elaborate on this point quoting
relevant sources. This was then discussed touching on her personal, sensitive
inner feelings. The therapy motivated her to study computer programming
with the avowed purpose of acquiring a different profession. Her father of-
fered to finance the cost of studying.

Elaboration and Summary of the Therapeutic Spiritual

Counseling of the Three Cases

This section summarizes the spiritual counseling techniques imple-

mented in the therapy. The importance of the feeling of belonging to a group
was emphasized. It was made clear that this is not the same as cultivating

134 AARON RABINOWITZ

friendships. The feeling of belonging is the sensation of having a place in the
sun, of being a cog however small, and of being able to influence events in
the stream of life. This fits in with a theistic approach and was not difficult
for religious clients to apprehend. The concept of a community of people
bound together by a common belief in a Divine Creator and committed to
serving Him seemed natural to them. This was linked to "friendship" in that
both belonging and friendship realize God's will that people live harmoni-
ously in a community devoted to serving Him. The despondent feelings were
addressed by quoting the material on joy discussed previously, as were the
concepts of community and friendship. The approach was effective in that it
provided a fresh perspective, releasing them from their heretofore restrictive
perception of themselves and their environment.
Further reflection led me to consider that the spiritual counseling af-
fected the men differently than it did the woman. The men's difficulties and
resultant sadness were rooted in their self-perception as lacking in spiritual-
ity. Counseling reinforced the principle that God's love is nonconditional
and present notwithstanding spiritual imperfections. The woman's belief in
God's goodness did not need bolstering. She felt unloved by people, except
by her deceased mother and this fostered a tarnished self-image. In her case,
spiritual counseling helped in that it demonstrated that His love embraces
all, regardless of their circumstances, misfortunes, or other people's assess-
ments. I have found this gender distinction in some other instances as well.
It is consistent with a principle enunciated by the Maharal of Prague (16th
century): Emunah—faith or trust—is entrenched in women. Deborah found
the verse (Psalms 27:10) especially meaningful: "Though my father and mother
have forsaken me, God will gather me unto Him." Another verse that clients
are touched by is from Psalms 34:19: "God is close to the broken-hearted,
and those crushed in spirit He saves." Reciting Psalms at home, identifying
with the yearning for the Almighty's closeness, has a salutary effect. Some of
the material and concepts presented in the following section were also inte-
grated in the therapy.
I trust that these cases have demonstrated the contribution and role of
therapeutic spiritual counseling. Therapy that would not have included the
spiritual elements would have been barred from relating to crucial issues rel-
evant to the client's emotional pain. These issues were discussed utilizing
concepts and language familiar and meaningful to the client. He or she felt
understood, thereby reducing tension, and provided him or her with cogni-
tive, conceptual and spiritual tools with which to confront the problem.

TESHUVA—REPENTANCE—AND THERAPEUTIC
SPIRITUAL COUNSELING
The following sections expound on concepts vital to understanding and
practicing therapeutic spiritual counseling with orthodox Jews. I believe that

JUDAIC THERAPEUTIC SPIRITUAL COUNSELING 135

the core of the concepts are applicable to all clients, non-Jews as well as Jews.
The cases that follow are not intended to be full accounts, but rather to
briefly illustrate the ideas presented. They are presented to familiarize thera-
pists, Jewish and non-Jewish, with the concepts so that they can be of use to
them. Although it is not feasible to enumerate all the references or examples,
the concepts can fruitfully be used by all therapists.
Teshuva—repentance—occupies an important niche in spiritual coun-
seling. It signifies considerably more than erasure of sin. Teshuva's literal
meaning is "return," returning to the Almighty. Teshuva was "created" be-
fore the creation of the cosmos, thereby endowing it with the importance
and power of primacy. The sages teach that teshuva cannot be understood
rationally; reason is not capable of explaining how an event can be eradi-
cated. They teach that God, metaphorically, bore a hole under His throne to
accommodate baalei'teshuva—penitents. Furthermore, the penitent is con-
sidered on a higher spiritual plane than one who has not sinned (Maimonides:
The laws of Teshuva, chap. 7:4). Teshuva is a formal positive commandment
(mitzvah); consequently its parameters are defined by Jewish law (Halacha).
However, even when not all formal requirements are met, it is still accept-
able (Mabit, Beit Elokim). This paradox and the seemingly irrational basis of
teshuva prompted the exiled Jews of the prophet Ezekiel's generation to doubt
its acceptability (Ezekiel, chap. 33). Scripture relates that only God's swear-
ing that it is always acceptable allayed their doubts. Some clients, however,
have to have the concept personalized, spelled out even more clearly. I do
this by quoting the prayer for forgiveness, which is part of the tefilat amidah—
the central prayer of the daily services. The prayer addresses God as one who
continually forgives. The commentators (Tanya, Iggeret Hateshuva) explain
that there is no limit to His forgiveness.
Jonathan, a young man in his late teenage years, was plagued by obses-
sive thoughts during prayer. He imagined that his bowing was directed to his
genital area. Therapy was a prolonged affair, exploring many aspects of his
development, including his reaction to not having complete physical con-
trol of one arm. He was beset by doubts, on the one hand questioning facets
of his religious faith, and on the other hand agonizing over his occasionally
lax religious observance. This was partly caused by conflicting parental mes-
sages regarding religious commitment. It was not surprising that he harbored
anger toward God and his parents. Spiritual counseling focused on his intrin-
sic worth in God's eyes. Jonathan's lapses in his religious obligations were
addressed by discussions of teshuva—repentance—as outlined previously. An
intriguing aspect in his and other cases is that guilt feelings stem not only
from perceived sinful behavior but also from insufficient time devoted to
Torah study. Being knowledgeable and studying Torah are so important and
central to living a full Jewish life that not complying with this mitzvah—
commandment—causes anxiety and guilt feelings. Spiritual counseling low-
ered his anxiety level, easing his guilt feelings. He entered a prestigious uni-

13 6 AARON RABINOWITZ
versity program that allowed him to devote a sizeable portion of his time to
religious Torah studies. There was a marked improvement in his social life
notwithstanding his physical deformity, attesting to his improved self-image.
Teshuva is a rich mosaic of ideas and concepts. Rabbi Dr. Soloveitchik
(1983, p. 110) invests teshuva with the halo of creation, self-creation. Teshuva
implies change; the sages advised the penitent, under certain circumstances,
to move to a different location and adopt a new name. This signifies that he
or she is a new, different person. Rabbi Kotler (1998, Mishnat Rebi Aharon,
vol. 2, p. 193) elaborated on the concept of Rosh Hashana—New Year, as a
new beginning. Rosh Hashana inaugurates the 10 days of repentance culmi-
nating on Yom Kippur—the Day of Atonement. The sages point out that the
Torah phrases the obligation to offer sacrifices in the temple on Rosh Hashana
using language in a different manner than it uses to describe other sacrifices.
The language clearly indicates that the Torah perceives Rosh Hashana as a
new beginning for all, even for sinners who have not as yet repented. The
psychological value of this realization is that it facilitates the decision to
change. Once this decision is reached, the person can devote himself or her-
self to cleansing oneself of the spiritual blemish of the transgression on Yom
Kippur—the Day of Atonement.
The positive potential of these concepts was used in the therapy of
three young singles, two men and one woman, who engaged in forbidden
sexual relations: the men with prostitutes and the woman with a casual male
acquaintance. This knowledge breathed new hope into them, restoring their
sense of worth and rejuvenating their desire for future spiritual growth.
Analyzing teshuva's role in spiritual counseling is incomplete without
discussing the concept of forgiveness. Only the Almighty can forgive sins
committed against Him. This implies total reliance on Him; omitting God
from our perception of reality is impossible. There are some who misinterpret
one of the sages' teachings, reading into it the idea that it is acceptable to
deny God providing one lives and acts according to His precepts (see, e.g.,
Blazer, 1998, p. 89). This misinterpretation seems to be based on a partial
reading of the sages' teachings (Midrash, Lamentations). The full text is as
follows: "I (God) prefer that people leave or ignore me, if (on condition)
they continue to observe my Torah, for the light of Torah will influence
them to return to goodness"; meaning that this is preferable to acknowledg-
ing God, but not His Torah. The misinterpretation is in stressing the first
part and ignoring the latter part. The sages referred to a process, ways of
behaving, for those who have strayed from the righteous path. Torah obser-
vance, they believed, will infuse them with spirituality that eventually will
lead them to return to God—the giver of the Torah. Observing Torah and
not affirming God who commanded its observance is foreign to Jewish doc-
trine. Torah minus God is an oxymoron. Not realizing this can seriously ham-
per the therapist's efforts to help the client. The client is apt to feel that his
or her belief in the Almighty is questioned. This is a legitimate issue if the

JUDAIC THERAPEUTIC SPIRITUAL COUNSELING 13 7

therapist feels that this may be. However, it is not, from the patient's view-
point, proper to suggest that this is an acceptable Jewish view. Doing so may
create a chasm between the therapist and the orthodox Jewish client.

OTHER RELEVANT ISSUES

Some clients question the principle that God is merciful. They cannot
reconcile it with the magnitude of evil present in the world. It is perhaps
superfluous to note that this is a highly charged emotional issue for Jews
whose memory, personal or collective, of the Holocaust is still vivid. My
response is that theodicy is a major theological issue addressed by thoughtful
people throughout the ages and is the essence of the book of Job. I quote the
Talmud (Berachot 7:A), which interprets Moses' request (Exodus 33:13) that
God show him His ways, as referring to the enigma of the suffering of the
righteous, whereas evildoers prosper. I do not engage them in a protracted
theological debate, preferring, if need be, to refer them to rabbinic authorities.
Other clients are perturbed by a feeling of being unworthy of God's
beneficence. This is characterized by a general sense of moral or ethical inad-
equacy, rather than a feeling engendered by specific instances of having sinned.
Counseling the sinner is, as outlined previously, based on the concept of
teshuva. The former seems less grave, but is much more convoluted, indicat-
ing a feeling of mediocrity. Therapeutic spiritual counseling is geared toward
understanding how this developed. The spiritual religious dimension of the
poor self-image is addressed by stressing the uniqueness and individuality of
each person as presented here. I also discuss a basic principle taught by Rabbi
Yisroel Meir of Radin (Chofetz Chayim). He commented on the dialogue
between Joshua and Caleb on the one hand, and the Israelites who hesitated,
out of fear, to go forth and conquer the Canaanites. Joshua and Caleb ad-
monish the Israelites: "Only rebel not against the Lord" (Numbers, 14:9).
This is interpreted by the Chofetz Chayim to mean that to benefit from God's
benevolence, one does not necessarily have to be highly spiritual—not re-
belling is sufficient. Clients are profoundly affected by the simplicity and
empathic perception of human nature expressed by this concept.
I have also found the following concept useful with clients whose self-
image is tarnished by a sense of spiritual failings. The basic theme is that evil
or banality found in people is not to be viewed as reflecting the real or au-
thentic person. The "evil inclination" (yetzer hara) is not the totality of the
person. Judaism teaches (Tanya, chap. 9) that humans have two souls
(neshamot), an earthly one and a spiritual one. They are inimical to one an-
other and engage in continual conflict. The earthly and certainly the evil are
not the entire "I." Rabbi Elijah of Vilna (Gra) teaches that the "person," the
"I" is the ruach (spirit). This is a segment of the soul (neshama) that is en-
trusted with the power of choice and is influenced by one of the two inclina-

138 AARON RABINOWZTZ

tions, the good or the evil (Orot Hagra, p. 198). This approach helps the
client see himself or herself as basically a worthy person.
Joseph, a man in his late 20s, was disheartened with his spiritual stature
and accomplishments, castigating himself for his real or perceived failures.
Therapy exploring the roots of his self-concept was not successful in getting
him to figuratively step back and view himself objectively. He was then asked
to define who the "I" is whom he is blaming. Joseph was familiar with the
concept of good and evil inclinations. The question, which in effect chal-
lenged him to look closely at himself, led him to the realization that the
inclinations are merely instigators of behavior; they do not define the per-
son. He was then able to accept that they are in conflict, each of them vying
for control over him, at times one gaining superiority and other times relin-
quishing control to the other. His self-perception changed from a simplistic
one to a more sophisticated view allowing him to accept himself. For him,
this meant understanding that his "I" is a spiritual entity and that his occa-
sional lapses of proper religious observance are a function of the continual
inner conflict common to all people.

REFERENCES

Blazer, D. (1998). Freud vs. God. Downers Grove, IL: InterVarsity Press.
Elijah of Vilma. (1986). Mipayrushai hagra al hatorah. Jerusalem: Asher Steinmetz.
(Original work published 18th century)
Handelman, S. (1981). Interpretation as devotion: Freud's relation to rabbinic herme-
neutics. Psychoanalytic Review, 68(21), 201-218.
Hertz, J. (Ed. & Trans.). (1941). Pentateuch and Haftorahs. New York: Metzudah.
Jennings, J., & Jennings, J. P. (1993). I knew the method: The unseen midrashic
origins of Freud's psychoanalysis, journal of Psychology and Judaism, 17(1),
51-75.
Kotler, A. (1998). Mishnat rebi aharon. Lakewood, NJ: Mochon Mishnat Rebi Aharon.
Miller, W. R. (Ed.). (1999). Integrating spirituality into treatment. Washington, DC:
American Psychological Association.
Pargament, K. I. (1996). Religious methods of coping. In E. P. Shafranske (Ed.),
Religion and the clinical practice of psychology (pp. 215-239). Washington, DC:
American Psychological Association.
Rabinowitz, A. (1999). Judaism and psychology: Meeting points. Northvale, NJ: Jason
Aronson.
Rabinowitz, A. (2000). Psychotherapy with orthodox Jews. In P. S. Richards & A. E.
Bergin (Eds.), Handbook of psychotherapy and religious diversity (pp. 237-258).
Washington, DC: American Psychological Association.
Rabinowitz, A. (2001). Halachic Judaism's influence on the practice of psychotherapy.
Journal of Psychology and Judaism, 24(3), 193-204-

JUDAIC THERAPE LJTIC SPIRITUAL COUNSELING 13 9

Richards, P. S., & Bergin, A. E. (1997). A spiritual strategy for counseling and psycho-
therapy. Washington, DC: American Psychological Association.
Soloveitchik, J. B. (1965, Spring). The lonely man of faith. Tradition, 5-67.
Soloveitchik, J. B. (1983). Halakhic man. Philadelphia: The Jewish Publication Soci-
ety of America.
Wallach, M., & Wallach, L. (1983). Psychology's sanction for selfishness. San Fran-
cisco: Freeman.
Wicklund, R. A., &. Eckert, M. (1992). The self-knower: A hero under control. New
York: Plenum Press.

140 AARON RABINCWITZ

INTEGRATIVE SPIRITUALLY ORIENTED
8
PSYCHOTHERAPY: A CASE STUDY OF
SPIRITUAL AND PSYCHOLOGICAL
TRANSFORMATION
LEN SPERRY

DESCRIPTION OF THERAPIST

Len Sperry is currently a clinical professor of psychiatry and behavioral

medicine at the Medical College of Wisconsin and professor and coordinator
of the doctoral program in counseling at Barry University. Sensitive to the
spiritual dimension, he has practiced clinical psychology and psychiatry for
more than 30 years. Dr. Sperry is 58 years old, White, married, and a lifelong,
Roman Catholic layperson. He has earned doctorates in psychology, medi-
cine, and theology.
Dr. Sperry is a diplomate of the American Board of Psychiatry and Neu-
rology, the American Board of Preventive Medicine, as well as a diplomate
in clinical psychology of the American Board of Professional Psychology. He
has more than 300 professional publications, including 40 professional books.
These include Spirituality in Clinical Practice: Incorporating the Spiritual Dimen-
sion in Psychotherapy and Counseling, Ministry and Community: Recognizing,

141
Healing and Preventing Ministry Impairment, and the Handbook of Diagnosis
and Treatment of the DSM-IV Personality Disorders. He edited a special issue
of the journal Psychiatric Annals on "Spirituality in Clinical Practice." A re-
cent recipient of the Harry Levinson Award, a lifetime achievement award
from the American Psychological Association, he is also a fellow of Division
36 (Psychology of Religion) of the American Psychological Association, a
fellow of the American Psychiatric Association, and a member of the Com-
mittee on Psychiatry and Religion of the Group for the Advancement of
Psychiatry.

SETTING

The client was seen in a private practice located in a southeastern met-

ropolitan community. This is a practice that includes both psychotherapy
sensitive to the spiritual domain with individuals and couples as well as psy-
chiatric consultation to individuals and organizations.

CLIENT DEMOGRAPHIC CHARACTERISTICS

Gwen is a 45-year-old White woman who began treatment nearly 3

years ago. At the present time Gwen has been married to Jason for almost 23
years. They have a son, Alex, who is 22, and a daughter, Nancy, who is 21.
Gwen is currently a guidance counselor in a local private high school, and
Jason is a senior vice president at a local bank. Gwen indicated she had been
a lifelong member of the Catholic Church. She attended a private elemen-
tary school and high school and after graduation immediately went on to the
state university to major in English literature. She married Jason, whom she
had met in her sophomore year at the university, soon after they graduated.
Gwen is the older of two siblings. Her younger sister is an insurance
underwriter who has never married and has little, if any, "religious senti-
ment" according to Gwen. Both of Gwen's parents are alive and have lived
in the same house for the past 39 years. Although they are relatively healthy,
Gwen's father was recently diagnosed with early stage prostate cancer and
has been treated for high blood pressure for more than 20 years. Her parents
were reportedly active in their church for several years. Her father had served
as the chair of the church's finance committee for nearly 30 years, and her
mother was a religious education teacher in the church's Sunday school pro-
gram for several years.
For 10 years prior to beginning treatment with me, Gwen indicated
that she had not been active in her church congregation. She explained that
she "didn't feel comfortable around those people anymore." When asked what
she meant, she noted that after her son had grown and moved away her

142 LEN SPERRY

desire to serve on church committees with the friends of his parents had
greatly diminished. Later, it would come to light that she felt "unworthy"
around these same individuals "after I messed up my life" at the time of her
inpatient hospitalization. This attitude toward her church congregation per-
sisted until it was processed during the course of therapy.

PRESENTING PROBLEMS AND CONCERNS

Gwen was referred by her family physician for evaluation and treat-
ment of "chronic depression" of approximately 5 years duration. She had
been given a trial of an antidepressant by her family physician, which "had a
lot of side effects but didn't work." Previous to beginning the antidepressant
she had consulted with two psychotherapists for two and three sessions re-
spectively, before terminating treatment. She claimed that neither had un-
derstood her and "probably couldn't help me anyway."

CLIENT HISTORY

Six years prior to onset of the treatment she had been hospitalized for
an eating disorder, primarily involving bulimia. She had used exercise, self-
induced vomiting, and laxatives as "control" measures. That short hospital-
ization—she left against medical advice—was apparently precipitated by
marital conflict and increasing suspiciousness about Jason's motives. Hospi-
tal records also mentioned some initial suspiciousness about the motives of
the treatment team. When I first evaluated her, she presented with promi-
nent obsessive and perfectionistic traits as well as some narcissistic and para-
noid features. She denied any family history of psychiatric or substance abuse
treatment, although there may have been a distant aunt, her father's second
cousin, whose early death was thought by some to have been by suicide fol-
lowing periods of up and down moods.

ASSESSMENT AND DIAGNOSIS

Records for the previous hospitalization were sent for and reviewed.
Results of a Minnesota Multiphasic Personality Inventory (MMPI) adminis-
tered to her during her inpatient hospitalization revealed a 9-4 pattern. On
projective testing, consisting of Thematic Apperception Test (TAT) and
Rorschach, considerable anger directed at her parents was elicited. TAT
themes included fathers as demanding individuals whose expectations were
impossible to meet as well as daughters not noticed by fathers. There were
also themes of mothers who were ungiving, incompetent, and wanting to be

SPIRITUAL AND PSYCHOLOGICAL TRANSFORMATION ] 43

taken care of by daughters. The report concludes that she "deals with her
anger by being resisted in a child-like way rather than constructively by tak-
ing control of situations."
At the beginning of the treatment Millon Clinical Multiaxial Inven-
tory-II (MCMI-II) and the Beck Depression Inventory (BDI) were adminis-
tered. The MCMI—II suggested dysthymic disorder and somatoform disorder,
NOS as well as obsessive—compulsive personality disorder with paranoid, nar-
cissistic, and histrionic features. The BDI score was 17, suggestive of moder-
ate degree of depression. She met criteria for the following Diagnostic and
Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiat-
ric Association, 1994) diagnoses: Axis I diagnoses were mood disorder, NOS
(296.50), and eating disorder NOS (307.50) by history. On Axis II, a diag-
nosis of obsessive-compulsive personality disorder (301.4) with narcissistic,
histrionic, and paranoid features was given.
The formal practice of her religion had diminished considerably since
her son Alex had graduated from a nearby Catholic high school. She indi-
cated that she only kept up church attendance and traditional spiritual prac-
tice "to set a good example for my son." For the past several years her spiri-
tual practices had included daily formula prayer, occasional scripture reading,
and Sunday worship services. She had once tried to meditate but had given
up after about a week or so, "because I was just too distracted and flooded
with worrisome thoughts." At the outset of treatment, she described her im-
age of God as "judge and taskmaster." On further inquiry, God was described
as an elderly man who "made hard demands, who checked up on you and
wasn't easily pleased." He was also emotionally withholding, unsupportive,
and critical. Not surprisingly, but not recognized by Gwen at the outset of
our therapy, her image of God was a composite description of both her own
parents.

TREATMENT FOCUS AND MODALITIES

Gwen initially wanted medication and therapy with me but indicated

that making a commitment to remain in treatment would be difficult for her.
I agreed to meet with her weekly, more often if needed, and to carefully
prescribe and monitor medications and involve her in all treatment deci-
sions. It was mutually decided that the focus of the therapy would be on
reducing the stressors related to her depression and eating disorder. I care-
fully avoided the kind of transference "traps" that were likely to result in her
being sufficiently threatened to prematurely leave therapy. For nearly a year
prior to our therapy she indicated only two instances of using laxatives or
inducing vomiting, but she admitted to exercising vigorously every day. In
time she agreed to refrain from any purging behaviors and to switch to a

144 LENSPERRY
more moderate exercise plan, an agreement she would keep throughout the
course of treatment.
Combined treatment consisting of psychotherapy and medication con-
tinued, but therapy became more directed toward the spiritual aspects of her
drivenness and perfectionism as they related to her parents and her image of
God. She described her father as strict, demanding, and verbally and emo-
tionally abusive, and her mother as self-preoccupied and emotionally with-
holding. As noted earlier, her image of God was demanding, critical, and
withholding. Her guidance and counseling practicum experience surfaced
unfinished business with her estranged son, issues that were processed in her
therapy and eventually led to a reconciliation.

TREATMENT PROCESS AND OUTCOMES

First Year of Treatment

After 6 months of weekly sessions she was sufficiently stable and confi-
dent to consider "going on with life" as she put it. For some time she had
entertained the thought of going back to school to become a high school
guidance counselor or possibly an addictions counselor working with eating
disorder patients. Prior to her marriage she had taught for 2 years and had
enjoyed the challenge of working with adolescents in a junior high school
setting. She believed that staying at home alone only fostered her depressed
thinking and ruminations and wanted to "get out and do something with my
life." She had been accepted in a masters-level counseling program. Although
she could attend full time, she opted for a part-time program of study because
she feared that she could not be as good a student as she needed to be if she
took more than two courses at a time. She also wanted to reduce session fre-
quency from weekly to monthly sessions. Reluctantly, I agreed to this request.

Second Year of Treatment

Approximately one year later, when she was nearly halfway through
her graduate program, she mentioned attending a weekend spirituality work-
shop at a Catholic retreat center. It was a retreat based on focusing, the expe-
riential approach developed by Gendlin (1981). Something about this expe-
rience touched her deeply, but she had difficulty describing this experience
and the feelings it triggered. She also indicated reading an article on spiritu-
ality that I had recently published and wondered if our sessions could include
the religious and spiritual dimension. She said the prospects of starting a
counseling practicum in a nearby high school was disconcerting to her and
she was ready to resume weekly sessions. She entertained the thought of par-
ticipating in additional spirituality retreats in the coming year.

SPIRITUAL AND PSYCHOLOGICAL TRANSFORMATION J 45

Third Year of Treatment

Over the next year she became somewhat less self-critical and driven
and more centered and at peace with herself. She attributed much of this
centeredness and peacefulness to the regular practice of the focusing strategy
she had learned during her various retreats. Her moodiness—now appearing
more like a dysthymic disorder than major depression—seemed to have mod-
erated considerably. As a result, we endeavored to wean her off the antide-
pressant and to monitor her without medications for the next few months. It
appeared that she no longer needed the medication. Three years later she
remains off medication.
She and her husband became more actively involved in their church
community, with both involved in leading a youth group. With some trepi-
dation, she took a job as a guidance counselor that fall. Just after Thanksgiv-
ing she experienced a brief relapse with her eating disorder. The next spring
her husband opted for early retirement and announced that it was time for
her "to be the breadwinner now." The prospect of taking such responsibility
initially overwhelmed her as she feared somehow making a mistake and not
being the perfect wife and guidance counselor. These concerns were pro-
cessed from both a psychological and spiritual perspective. In time, sufficient
progress was made and sessions were reduced to monthly and then quarterly.
Three years after beginning this process it was mutually agreed to ter-
minate ongoing treatment. In the year since termination she has been stable
and without depressive or eating disorder symptoms. She reports that her
cravings for stimulating situations and substances are markedly reduced. And,
when cravings do arise, Gwen quickly looks for internal and external stres-
sors and attempts to address them directly and immediately. Gwen reports
leading a more centered and paced life, continues to enjoy her work as a
guidance counselor, and is now coordinating youth retreats for her church
community. Interestingly, as she grew psychologically, her image of God gradu-
ally shifted to that of a smiling, caring grandmother.

THERAPIST COMMENTARY

What accounts for these therapeutic changes in Gwen? In this section

I speculate on this change process and briefly describe my approach to spiri-
tually oriented psychotherapy.

Integrative Spiritually Oriented Psychotherapy

One point of difference between a traditional psychotherapeutic per-

spective and the integrative spiritually oriented perspective that I practice
involves different treatment goals, particularly with regard to individuals with

146 LENSPERRY
personality disorders. Although the goal of traditional psychotherapy for in-
dividuals with personality disorders is typically symptom remission and re-
turn to baseline functioning, the goal of integrative spiritually oriented psy-
chotherapy is personal and spiritual growth and well-being. More specifically,
the goal is psychological and spiritual transformation.
I conceive of spiritually oriented psychotherapy as an integrative ap-
proach (i.e., a biopsychosocial approach that incorporates the spiritual di-
mension) that is developmentally focused (Sperry, 2001). This means that
clients' needs and concerns are conceptualized on a continuum or develop-
mental line from pathological states to growth states. Three distinct ranges
on this developmental line can be specified: the disordered range, the ad-
equate range, and the optimal range. Accordingly, the goal of traditional
psychotherapy for individuals with personality disorders often focuses on
moving the client from the disordered range to somewhere within the ad-
equate range of functioning. When that point is reached, therapy is assumed
to have been successful. However, from a spiritual perspective, such a goal
for change or growth can be limiting. Instead, I would contend that the goal
of spiritually oriented psychotherapy can extend as far into the optimal range
of functioning as is possible.
With regard to the obsessive-compulsive personality style that charac-
terized Gwen, three ranges of functioning have been noted. In the disordered
range, the individual is characterized by perfectionism and feelings of avoid-
ance that interfere with task completion and relationships. The individual's
thinking and attitudes are overly rigid and they tend to be pessimistic and
include feeling avoidant. In the adequate range of functioning, individuals
are less perfectionistic and there is rigidity in tasks and relationships with
some degree of emotional involvement and responsivity. In the optimal range,
individuals are conscientious but not driven, and they are more spontaneous.
They are individuals who display a balance of personal integrity with gener-
osity, hopefulness, and kindness.

Goal of Therapy

The overall goal of therapy with Gwen was to modify her obsessive-
compulsive style first from the disordered range to the adequate range, and
then, by mutual agreement, from the adequate to the optimal range. Specifi-
cally, this meant attempting to transform her basic perfectionistic pattern so
that she might become more comfortable with affects, less reliant on her
thinking function, and thereby become more spontaneous and playful. Her
core beliefs or schemas about being hardworking, good, and avoiding mis-
takes to feel accepted and worthwhile were examined and processed as well
as her need to be in control and overly responsible. Interpretation and cogni-
tive restructuring were the main therapeutic strategies used to modify the
affective, cognitive, and relational aspects of her obsessive style. The specific

SPIRITUAL AND PSYCHOLOGICAL TRANSFORMATION 147

goal was to increase her capacity for emotional involvement. This is repre-
sented as "average" level of functioning on the obsessive developmental line.
As treatment progressed and she was no longer symptomatic, was less
driven, and felt much better about herself, we discussed the future. We agreed
that she had achieved her stated treatment goals. We discussed two options:
moving into a maintenance mode preparatory to termination or shifting the
treatment focus to "growth" goals in therapy, that is, moving toward the
optimal range of functioning. With little hesitation she chose to focus on
growth goals. At the time, I recall making the predictive interpretation that
she might find it difficult to discern the difference between true growth and
more subtle perfectionistic strivings. Yet, I indicated that one of my roles on
this journey would be to help her discern these differences.

Therapeutic Strategy
The general therapeutic strategy for fostering Owen's movement from
the adequate to the optimal range involved both reconstructive strategies
and developmental strategies. With regard to reconstructive strategies, an
initial treatment focus is to help the client specify those limited number of
situations where it is reasonable or necessary to be especially goal-directed
and conscientious. For Gwen this would mean 8:00 a.m. to 3:00 p.m. Mon-
day to Friday, 9 months a year for her job, and perhaps another 10 hours a
week on household duties and volunteer activities in her church. It would
also mean that she would be prompted to practice becoming more spontane-
ous and less rigid in important and meaningful relationships in which she
feels reasonably safe, such as with her husband, her boss, and her pastor.

Psychological Transformation
Several specific strategies were used in working toward this goal of psy-
chological transformation. These included focusing on the theme of perfec-
tionism in a fine-grained and focused manner. For example, Gwen's self-
view or self-schema was, "I am responsible if something goes wrong," whereas
her underlying view of the world was, "Life is always unpredictable and ex-
pects too much. So, I must always work hard, be in control, right, and not
make mistakes." Characteristic of the disordered range is the absolute con-
viction that she must be responsible in all situations, that life is always un-
predictable and demanding, and that she must do her best in all situations.
At the average range, however, her schemas would be less absolute, which
means that there are a limited number of circumstances and situations in
which she could let down her guard with regard to conscientiousness, rigid-
ity, and feeling avoidance. The rest of the time she was likely to be on her
guard. In the optimal range, these convictions are still operative but are highly
situation specific, meaning that Gwen could be more spontaneous and play-
ful in many situations.

148 LENSPERRY
 Another useful strategy was to help her master some of her subtle and
persistent perfectionistic patterns, that is, those trigger events or thoughts
that initiate a sequence of perfectionistic thinking—including self-righteous-
ness—and behaviors and related responses. Three of Owen's more subtle
perfectionistic patterns involved safeguarding her money, being overly fo-
cused on time, and dealing with mild cravings.
With regard to money, her husband affectionately referred to her as
"my little tightwad" because she shopped for bargains, used coupons, and
looked for discounts. The transformation of this attitude of stinginess is
generosity.
With regard to focus on time and deadlines, she set her watch and clocks
in her home and car 20 minutes ahead so that she could be "on time," which
was quite interesting because she would still be 5 to 10 minutes late for some
of our sessions. Her packed schedule allowed no time for traffic delays—
which were not supposed to happen in a perfect world. Needless to say, Owen
was extremely conscientious of time and resented others wasting her time.
The transformation of this attitude of time conscientiousness is becoming
more spontaneous and playful.
A third concern involved the way she dealt with cravings. When she
felt stressed, tired, emotionally deprived, or queasy, she reached for caffeine—
particularly chocolate, colas, and coffee—or sought out situations that were
stimulating, such as high-adventure movies and TV programs. The resulting
"adrenaline buzz," as she called it, temporarily appeased her cravings. She
would immediately feel better but would soon feel like a worthless failure.
While small doses of caffeine were preferable to full-scale binging and purg-
ing, the end result was the same—she felt she had failed and resolved to try
harder to be perfect. Reframing her cravings as growth motivators and estab-
lishing a relapse prevention strategy allowed her to short circuit this vicious
cycle.
Similarly, being fun loving and carefree was very difficult for Gwen. A
common underlying maxim for her was "I must do it and do it exceedingly
well." The transformation of this attitude of duty and conscientiousness would
involve achieving a degree of balance in her life among conscientiousness,
spontaneity, and integrity. In addition, she tended to live in the future rather
than in the present. Accordingly, the transformation of this pattern involves
the prescription to live in the present moment.
Not surprising, focusing exercises were initially quite difficult for Gwen
given her ruminative cognitive style. She was constantly processing new and
old concerns, so much so that she became overwhelmed by this mental chat-
ter and background noise, which made it all but impossible to focus on the
present. Because both centering meditation and focusing require a quieting
or derailing of this ruminative style, she learned to use a simple prayer
word—some would call it a mantra—"Jesus" to effectively derail this men-
tal chatter.

SPIRITUAL AND PSYCHOLOGICAL TRANSFORMATION / 49

 Characteristically, Gwen was very demanding of herself as well as of
others. She constantly monitored the actions of others against social norms
as well as her own personal norms. Not surprising, few people matched up to
her standards and she would judge others as being irresponsible. The actions
of others triggered her moral indignation; hence others perceived her as judg-
mental and sometimes moralistic. For Gwen the transformation of this over-
all attitude would be hopefulness and kindness. Although these perfectionistic
strivings are somewhat subtle and are not only acceptable but also reinforced
in our culture of achievement and success, Gwen began to recognize that
they were inhibiting her personal and spiritual development and that chang-
ing them would be challenging.
Such a therapeutic direction with Gwen was effective to the extent it
focused on these fine-grained dimensions of perfectionism with the goal of
becoming a conscientious but spontaneous person who could balance per-
sonal integrity with generosity, hopefulness, and kindness. In other words,
instead of being compulsively perfectionistic in all matters, she might inten-
tionally strive for a high level of excellence in a few selected areas of her life
but not in other areas.
For Gwen, modifying the triggers for her perfectionistic pattern was
essential in transforming this dynamic. On closer examination we found that
self-righteous thoughts such as "That's not right" or "That's sloppy work"
inevitably triggered her perfectionistic pattern. Subsequently, we worked to-
gether to find ways of neutralizing such triggers and replacing them with a
nonrighteous thought: "This moment is as perfect as it can be." Such a neu-
tralizing thought became like a mantra that Gwen repeated whenever she
was in "high-risk" situations that might possibly trigger her perfectionistic
pattern. With a little experimenting Gwen also found that if she hummed to
herself while going into "high-risk" situations she could also derail the
perfectionistic pattern.

Spiritual Transformation

As noted earlier, several spiritual disciplines were incorporated into

the treatment process. These included prayer (particularly centering prayer
and meditation), spiritual joumaling, and participation in a healthy religious
community. This participation provided her social support as well as a cor-
rective emotional experience regarding some of her harsh and perfectionistic
religious beliefs and attitudes. Spiritual discussion of her life situation and
stressors in light of their spiritual meaning was a part of the therapeutic pro-
cess. Furthermore, cognitive restructuring of dysfunctional religious beliefs
appeared to influence a shift in her image of God.
Developing virtue and building on strengths was another focus of
therapy. For Gwen efforts to further develop the virtues of patience and se-
renity facilitated movement to the optimal range of functioning. Gwen was

150 LENSPERRY
quite receptive to focusing on these two virtues. Interestingly, Gwen came
across a few research articles on "positive psychology" about the virtues of
patience, which served to reinforce and validate her efforts in this area.

Interplay of Psychological and Spiritual Dynamics

It is interesting to speculate on the interplay between Gwen's per-

fectionistic pattern and her religious and spiritual beliefs and behaviors. There
was little question that Gwen's religious upbringing confounded matters by
unwittingly reinforcing certain obsessive-compulsive beliefs. For example,
in the "faith" versus "works" view of salvation, her religious tradition seemed
to emphasize "works," that is, the individual's own striving to make himself
or herself worthy so that God would see fit to save him or her, over "faith,"
that is, wherein salvation comes from believing that God will save an indi-
vidual despite his or her sins and failings. In our discussion of her compulsive
work habits, she initially insisted that "God helps those who help them-
selves." Gwen could not conceive of leaving anything to chance, much less
her prospects of eternal salvation.
For Gwen, faith had meant believing there was a God, and the rest was
up to her. She had to work hard and be perfect or she would be viewed as
worthless in the sight of God and in the sight of those in her parish. It is not
surprising then that she felt "uncomfortable" in her church community when
her world was falling apart before and after she was hospitalized.
Unfortunately, her perfectionistic beliefs that she was "never good
enough" were ego-syntonic with her religious beliefs (i.e., "God helps those
. . ." and "God is always watching and seeing your sins"). It should not be
surprising that Gwen's image of God was that of judge and taskmaster. Fortu-
nately, as treatment continued, these beliefs that supported her self-view
began to moderate, and along with it, her image of God.
What Gwen brought to treatment were her brokenness and cravings as
well as her intelligence, tenacity, and related strengths. Viewing therapy from
the perspective of developmental lines, I focused treatment to reconfigure
her basic obsessive-compulsive personality style and to build on her gifts and
strengths. Not the least of these was her religious tradition. From the per-
spective of her religious tradition, her sense of brokenness and cravings served
as the basis for spiritual transformation. My role was to support her efforts
toward spiritual growth, particularly when she became discouraged. My role
was also to refocus and reframe her cravings as motivators or prompters of
spiritual and psychological growth. Because her religious tradition also holds
that a community of believers (i.e., parishes, retreats, etc.) can be an instru-
ment of healing and growth, it was important that I looked for ways of incor-
porating this community dimension, and particularly spiritual resources within
the community, into the therapy process. Consequently, I supported her de-
sire to participate in quarterly focusing retreats. Similarly, I encouraged her

SPIRITUAL AND PSYCHOLOGICAL TRANSFORMATION 151

efforts to bring the focusing method and journaling "home" with her. Ini-
tially, she began practicing focusing with her husband on Sunday evenings.
In time, they invited some friends to join them. Later, I supported her as she
transitioned back to her parish community.

Influence of Theistic Beliefs on Treatment Process and Outcomes

It appears that theistic and spiritual beliefs—mine as well as Owen's—

did influence the therapeutic process and outcomes. It is likely that some of
my own religious and spiritual beliefs influenced my work with Gwen. Pre-
sumably, my faith in God as well as my sensitivity to spiritual and religious
issues positively predisposed me to accede to Owen's request to include dis-
cussion of spiritual issues as a part of treatment. It also predisposed me to
prescribe and encourage several spiritual interventions that were helpful to
her treatment progress.
Owen's faith in God led her to request that spiritual issues be included
in her treatment. Her faith led her to engage in various spiritual practices
such as prayer, focusing, and spiritual journaling. It seems that Owen's faith
and spiritual practices facilitated the process of transformation including
overcoming her perfectionistic and obsessive-compulsive tendencies, as well
as her bulimic behaviors.
Would the process and outcomes of Gwen's therapy have been differ-
ent with a secular therapist who did not believe exploring spiritual issues was
important? I assume that it very likely would have differed. For instance, in
secular therapy it is unlikely that Gwen's religious beliefs and community
would have been used as a resource during therapy. In fact, her initial nega-
tive attitude toward her religious community may have been reinforced. Fur-
thermore, Gwen would not have experienced the benefits of praying, medi-
tating, and participating in a healthy religious community.
In retrospect, it appears that a definite shift has occurred in Gwen's
personal and spiritual world. Whereas, at one time Gwen's religious tradition
only seemed to reinforce her personal pathology and her parish community
appeared to be a source of suspicion and discomfort, now she perceives this
tradition and community to actually be supportive of her journey of psycho-
logical and spiritual growth. This shift and journey is the basis of psychologi-
cal and spiritual transformation.

REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
Gendlin, E. (1981). Focusing. New York: Bantam.
Sperry, L. (2001). Spirituality in clinical practice: Incorporating the spiritual dimension in
psychotherapy and counseling. New York: Brunner/Routledge.

152 LEN SPERRY

 9
A PSYCHODYNAMIC CASE STUDY
EDWARD P. SHAFRANSKE

DESCRIPTION OF THERAPIST

Edward Shafranske is Professor of Psychology, Charles and Harriet

Luckman Distinguished Teaching Fellow, and director of the doctoral pro-
gram in clinical psychology at Pepperdine University. He is a member of the
faculty of the Southern California Psychoanalytic Institute and is a training
and supervising psychoanalyst at the Newport Psychoanalytic Institute.
Having received doctoral degrees in clinical psychology and in psycho-
analysis, his clinical practice is informed by both disciplines as well as by
contributions from neuroscience. Shafranske is a fellow of the American Psy-
chological Association (APA), twice president of APA Division 36 (Psy-
chology of Religion), former chair of the California Psychological Associa-
tion Division of Education and Training, and served as editor of Reiigion and
the Clinical Practice of Psychology (Shafranske, 1996), coeditor of Spiritual!)!
Oriented Psychotherapy: A Contemporary Approach (Sperry & Shafranske, in
press), and coauthor of The Practice of Clinical Supervision: A Competency-
Based Approach (Falender & Shafranske, in press). His research interests con-
cern clinical and applied psychoanalysis, the psychotherapeutic process, clini-
cal supervision, and the psychology of religion. He maintains a private practice
in clinical psychology and psychoanalysis in Irvine, California. Shafranske,

153
who is a Roman Catholic, has a long-standing interest in religion as a variable
in mental health and psychological treatment. His personal faith, in addition
to his scholarship, informs his appreciation of religious sources of meaning and
the salience of spirituality in the orienting systems of many clients.

SETTING

The client was seen in a private practice setting in southern California.

Shafranske was a member of a multidisciplinary and multitheoretical group
practice of individual clinicians representing psychology, psychiatry, and so-
cial work.

CLIENT CHARACTERISTICS

The client, who I call Joan, was a 38-year-old Caucasian woman. She
was married and the mother of three daughters whose ages ranged from 8 to
12 at the time of intake. She was a college graduate and had enjoyed a profes-
sional career in a business-related field before becoming a mother and choos-
ing to focus her attention exclusively on her family as a homemaker. She
appeared to be in good health, consistent with her self-report. She concluded
that her marriage was generally satisfactory, although she commented that
she had recently been feeling less interested in her husband, particularly in
respect to their sexual relationship. She was very involved in her children's
lives and supported their many school, club, and athletic activities.
Joan was raised as a Roman Catholic and, although she infrequently
participated in her parish community, she described her worldview as "essen-
tially Catholic." She moved with her husband, following their marriage 16
years ago, from a large city on the east coast of the United States to the
suburbs of southern California. She felt isolated from her family and reported
missing both the support of her extended family and the sense of community
she had experienced as a child in her close-knit ethnic neighborhood.

CLIENT HISTORY

Joan was the third-born child and the first daughter in an intact Ital-
ian-American, Roman Catholic family; she had two older brothers, two
younger sisters, and a brother. Her father worked at the shipyards, initially as
a laborer and later as a dock supervisor employed by the port authority; he
often took on additional part-time jobs to pay for the monthly expenses. She
described her father as somewhat distant and "emotionally removed," yet at
times he would be overcome by sentiment at weddings and funerals. Her

154 EDWARD P. SHAFRANSKE

father was an alcoholic who would periodically "fly into rages when drunk"
and "terrorize" the family by breaking things or physically striking her broth-
ers. He was often depressed and agitated and regularly complained about the
pressures of supporting such a large family. Joan reported her mother to be a
quiet, religious woman, who also could become emotionally upset when the
pressures of the family situation became overwhelming. In such moments
she would cry uncontrollably and then retire to bed, pray a novena to Mary
the Blessed Mother, or leave the home and stay a few days with her sisters or
mother who lived in the neighborhood. These situations of emotional
dysregulation increased both in frequency and intensity over time. She re-
called as a teenager being shuffled off with her younger siblings to one of her
aunts' homes for weeks at a time when her father's drinking and outbursts
escalated. Conflicts between the children would easily become out of control
with aggressive outbursts because they lived in crowded quarters. The picture
that Joan painted was of a chaotic, enmeshed family. She described herself as
a child to be a quiet, shy, "little bookworm," who was easily frightened by her
older brothers and the boys in the neighborhood. She recalled taking com-
fort in spending time with her maternal grandmother and staying at girl-
friends' homes for dinner and sleepovers. She sought the peace of "normal"
families. Although not particularly outgoing, Joan developed close relation-
ships with her cousins and had a best girlfriend at school. She characterized
herself as an average yet industrious student, who generally enjoyed school
and found it to be a safe environment.
During adolescence, she became increasingly more confident in her re-
lationships and occupied herself with activities outside of the home (e.g.,
school, work, and social involvement in the neighborhood Catholic parish).
She maintained a small but close group of friends, and dated infrequently.
She described high school as a time when it became more possible to live life
outside of the family. She reported keeping her feelings generally to herself
particularly in respect to the conflicts in her family and concerning her in-
creasing disappointment and disengagement from her parents. She was an
above average student in high school and was fortunate to be awarded a par-
tial scholarship to attend a Catholic college in a neighboring city. She de-
scribed college as a fulfilling time. She worked tirelessly in her academic
studies and supported herself through part-time employment. She began dat-
ing a classmate whom she met while working at the Student Union. She
described their relationship as a friendship that kind of "grew on her." When
they became sexually intimate Joan experienced anxiety over the possibility
of being discovered and guilty about her sexual impulses and behavior. She
solved this conflict, in part, by vowing that she would marry her boyfriend.
She completed college and shortly after her graduation they married. On
later reflection, she remembered that, although she put on the appearance of
confidence and optimism, she actually felt anxious about what life would
bring and that she hoped that the security marriage would bring would as-

A PSYCHODYNAMJC CASE STUDY J 55

suage her worries. Marriage also allowed her to be sexual without guilt. She
recalled that she felt both critical and envious of her girlfriends who "played
around" sexually and seemed to not require a committed relationship. She
was mostly satisfied with her marriage because she knew that her husband
was a stable and caring man and that he would work hard to support his
family. She particularly appreciated that he was unflappable; nothing ever
upset him. She saw marriage as affording the opportunity of having her fam-
ily different from her own. Shortly after their marriage, a career opportunity
led to their move to California. Joan was excited about the move; however,
she viewed this at the time as being temporary, almost like a vacation. She
expected that they would return to the east coast, where she desired to raise
their children in the company of many cousins, aunts, and uncles. However,
once her husband's career became established, she acceded to his desire to
stay in California. She marked the births of her children as the highlights of
her life. She enjoyed her pregnancies and found pleasure in the "simple things"
of raising her children, particularly when her daughters were babies and tod-
dlers. She longed for the less complicated relationships she had experienced
when her children were younger in contrast with the often-challenging mo-
ments of prepubescence and adolescence.
Religion played an essential role in Joan's intrapsychic life. Joan's iden-
tification with her mother included an internalization of her mother's piety
and beliefs in God, particularly in respect to providence and autonomy. Many
of her inhibitions and conflicts involved fears of judgment and retribution
and were related to implicit religious beliefs and the dynamic construction of
her primary God representation. Her Catholic upbringing, including moral
proscriptions and prescriptions, was enhanced by the central position that
the parish played in the ethnic borough in which she and her extended fam-
ily lived. Although she was a nonpracticing Catholic when she entered treat-
ment, a religious thread was woven throughout her psychological experi-
ences and in many respects was central to both the conflicts she was facing
and their ultimate resolution.

PRESENTING PROBLEMS AND CONCERNS

The precipitant for Joan's request for a consultation concerned recur-
rent headaches, which were evaluated by her primary care physician and a
neurologist as including a psychological component. In the initial session,
she was caught off guard by a spontaneous outpouring of sadness. She was
surprised by her tears, apologized profusely for crying, and attempted to re-
gain composure by directing her attention to conjecture about the causes of
her headaches. When I gently commented that she seemed to move away
from feeling her emotions, she burst out in tears, saying that she was sorry but
that she could not help but cry. In the initial assessment phase, I came to
understand that there were several difficulties that Joan was facing in her

156 EDWARD P. SHAFRANSKE

marriage and in her relationships with her children and others. These diffi-
culties were characterized by an inability, or put more psychodynamically, a
conflict in which she could not acknowledge or express feelings of frustra-
tion, disappointment, or anger in the face of situations in which others had
let her down her in some fashion. Sadness was the emotion that she most
readily experienced and expressed. She felt stuck in her situation and re-
called with embarrassment that her mother had warned her before her mar-
riage that "she had better be sure . . . that she would have to live the rest of
her life in the bed she had made for herself." She described "feeling that she
had been caught" when she expressed disappointment and could not tolerate
the idea that she was not very happy.

ASSESSMENT AND DIAGNOSIS

The assessment process was conducted through clinical interviews and
included consultation with her neurologist. Her ability to utilize an explor-
ative psychotherapeutic approach and the early demonstration of the psy-
chodynamics contributing to the development of symptoms were sufficient
to arrive at an initial assessment and provisional diagnostic impression. It
was noteworthy that in the initial consultations, she would report pressure
building in her temple and following her talking about her emotional re-
sponses to a given situation and obtaining a measure of catharsis, she would
report a cessation of pain. In addition to my ongoing assessment, her physi-
cians conducted neurological and endocrinological workups and ruled out
the nonpsychological conditions that would cause her symptoms. She was
also prescribed a medication that was found to be effective in the treatment
of migraine headaches. The preliminary Diagnostic and Statistical Manual of
Mental Disorders (4th ed., DSM-IV; American Psychiatric Association, 1994)
diagnosis was 316: Stress-Related Psychophysiological Response Affecting
Migraine-Like Headaches. This was concluded in consideration of her
neurologist's opinion that Joan had a biologically based susceptibility to mi-
graine headaches and through my assessment of her history, which found
that psychological factors involving external and internal stress exacerbated
her symptoms. Although diagnoses were not obtained under the DSM-IV
criteria, it was apparent that underlying and leading to psychic conflict, Joan
experienced both depression and anxiety.
A psychodynamic diagnostic approach was also utilized in assessing her
level of personality organization and character structure (Gabbard, 2000; see
also McWilliams, 1994, 1999). A psychodynamic diagnosis builds on and
goes beyond the descriptive approach of DSM—IV and aims to understand
how the patient is ill, how ill, how she became ill, and how her illness serves
her (cf. Menninger, Mayman, & Pruyser, 1963, cited in Gabbard, 2000, p.
79). In addition, an emphasis was placed on understanding the symptoms or
psychological disturbance within the context of personality functioning.

A PSYCHODYNAMIC CASE STUDY 157

Observations of her psychological functioning in session, together with her
self-reported history, suggested that this client's personality organization would
be classified within the neurotic spectrum (Kernberg, 1967). Reality testing
was intact and it appeared that she primarily used higher order level de-
fenses, including intellectualization, rationalization, undoing, and repression.
Her personality structure was oriented toward repression and control of im-
pulses and emotional expression. Cognitive processes were overvalued and
were used in the service of repression and suppression. A psychoanalytic for-
mulation (Perry, Cooper, & Michels, 1987) was developed, which consid-
ered her symptoms to be manifestations of a pervasive conflict between the
expression and repression of thoughts, affects, and impulses that produced
signal anxiety. From the perspective of ego psychology, I hypothesized that
the headaches in part symbolized and expressed the intrapsychic conflict
concerning the expression of dysphoric affective states and impulses as well
as failures in her defensive operations to maintain repression. The headache
reflected the intrapsychic strain in Joan's attempt to repress unacceptable
thoughts and impulses. Similar to a clinical case study reported by Luborsky,
Auerbach, and McLellan (1996), a review of the contexts in which Joan's
headaches frequently occurred revealed a pattern of subjectively experienced
pressure as feelings of anger surfaced. When frustrated or angered, Joan would
defend against the conscious experience of anger, inhibit direct expressions
of aggression, and assume a conflict avoidant interpersonal stance. In these
contexts, Joan would often develop the symptoms of a headache and would
retire to her bedroom, ostensibly removing herself from the situation of con-
flict. Her withdrawal from the family not only removed her from the scene of
conflict but also could be seen as a passive expression of aggression in which
her husband would bear the consequences of having offended or disappointed
Joan. These response tendencies, although maladaptive in present circum-
stances, were in childhood effective maneuvers to manage aggression in the
chaotic and emotionally dysregulated family system. Her responses also re-
flected a partial identification with her mother, in which Joan observed behav-
iors reflective of repression and isolation as her mother would retreat from
situations of conflict. Her early religious training reinforced prohibitions against
the expression of aggression, yet it also provided a template for the potential
benefits of an expressive form of psychotherapy in which confessional aspects
of disclosure might usefully support the treatment process. The therapist's fa-
miliarity with this religious tradition assisted in understanding of the potential
religious influences on the treatment process, such as early confession experi-
ences and attitudes toward the expression of aggression.

TREATMENT PROCESS AND OUTCOMES

The practice of psychoanalytic psychotherapy is informed by the scien-
tific, clinical, and intellectual traditions within psychoanalysis. Although

158 EDWARD P. SHAFRANSKE

such treatment does not fully employ the techniques common to formal psy-
choanalysis, for example, frequency of sessions and the use of the couch, an
authentic psychoanalytic experience can be obtained in psychotherapy. The
following discussion presents an overview of the treatment approach, the
psychoanalytic clinical orientation to religious content, an exemplar session,
and a summary of process and treatment outcome.

Psychoanalytic Approach

Central to the psychoanalytic approach is the thesis that unconscious

mental functioning, derived from critical developmental interpersonal events,
organizes present experiences and shapes behaviors. Outside of awareness,
meanings are constructed under the influence of unconscious invariant orga-
nizing principles (see Stolorow & Atwood, 1987, 1992) and internalized ob-
ject relations, which produce response tendencies built into the neurobiol-
ogy of the individual (see Ledoux, 1996; Schore, 1994; Siegel, 1999).
Compromise formation occurs in which the motivations of expression and
safety are conjoined; symptoms result from inadequate and conflicted attempts
at achieving a synthesis of aims.
Contemporary psychoanalysis draws on multiple theoretical perspec-
tives in explicating these processes, each of which orients the attention of
the psychotherapist and guides the treatment process. Rather than consider-
ing such multiple perspectives to be a cacophony of voices, these theories
contribute additively to a comprehensive psychoanalytic understanding
(Rangell, 2000) and provide a common ground focusing on clinical practices
that allow for the exploration of unconscious mental processes, particularly
in respect to the transference (Wallerstein, 1990).
Although the conceptualization of Joan's symptoms was primarily based
on ego psychology, perspectives drawn from self psychology and object rela-
tions theories were regularly applied. For example, self psychology contrib-
uted to the understanding that Joan's defenses were intended, in part, to
prevent disintegration of her self and that "intensity" in and of itself posed a
threat to her cohesiveness. Any experience of heightened sensation would
provoke defensive withdrawal and attempts to isolate affect. She was not
defending against the conscious experience of anger per se, but rather to the
disintegrating effects that any intense experience of affect or impulse would
provoke. This understanding allowed for a careful monitoring of her states of
mind and the use of interventions to ensure that the intensity of her affect
states would not lead to disintegration anxiety.
Psychodynamic psychotherapy was recommended with the intent of
modifying her personality functioning to increase her ability to consciously
experience and express more completely her thoughts, affects, and impulses.
Such structural change would aim to eliminate maladaptive defensive opera-
tions, which were contributing in part to her presenting symptoms. Such

A PSYCHODYNAMIC CASE STUDY ] 59

modifications would bring about "a significant shift," according to Kernberg
(1992), "in impulse/defense configurations, with a reduction of defenses that
restrict the ego, a shift from repression to sublimation, and the incorporation
of previously repressed drive derivatives into ego syntonic behavior" (p. 119).
This would be accomplished through empathic understanding of her self-
experience, the development of insight, further resolution of conflicts origi-
nating in childhood, and through the analysis of the organizing principles
and defenses shaping her experience of the therapeutic and other relation-
ships. Through understanding and corrective emotional experiences obtained
in treatment, Joan would have the opportunity to address more effectively
her psychological needs.
Religion played a central role in the orienting system in Joan's family
and neighborhood, shaping and reinforcing beliefs, attitudes, and values. Lying
outside of conscious awareness, internalizations of a religious nature con-
jured unconscious fantasy and contributed to the mental set against which
Joan perceived, registered, interpreted, remembered, and responded to her
affects and impulses (cf. Arlow, 1985). I turn now to the theoretical and
technical considerations in addressing religious issues in psychodynamic psy-
chotherapy.

Psychoanalytic Clinical Approach to Religious Experience

Psychodynamic psychotherapy involves the analysis of the conscious

and unconscious meanings that individuals construct, and the dynamic forces
and unconscious organizing principles that shape and delimit such construc-
tions. For many people, if not most, religion plays a salient role in ascribing
meaning to life events. Freud recognized the importance of religion particu-
larly in respect to superego functioning and centered his critique of culture
on its role in establishing moral order (Reiff, 1959; Van Herik, 1982). The
psychoanalytic study of religion initiated by Freud (1927; see also Shafranske,
1995) has been more fully developed in recent scholarship by Rizzuto (1979,
1998), Meissner (1984,1992), Jones (1991,1996), Spero (1992), and others.
These works built on and revised Freud's central thesis that the God concept
is solely a projection originating in human need and religious beliefs are ulti-
mately illusions.
Of particular interest to psychoanalysts has been the formation of per-
sonally held God representations. Contemporary theory posits that God rep-
resentations are complex phenomena incorporating conscious and uncon-
scious mental processes, which may include both symbolic and sensory
representations. Through the sum of conscious and unconscious experience,
internalizations of objects, learned concepts, and imagination, God repre-
sentations are dynamically created as virtual objects for the believer and serve
multiple psychological functions. Although drawing on the internalizations
of primary maternal and paternal objects, "the God-representation," as Rizzuto

160 EDWARD P. SHAFRANSKE

(1979, p. 46) states, "is more than the cornerstone upon which it was built. It
is a new original representation which, because it is new, may have the varied
components that serve to soothe and comfort, provide inspiration and cour-
age—or terror and dread—far beyond that inspired by actual parents." In
addition to God representations, other forms of religious association are per-
tinent to the psychotherapeutic process. Religious associations often articu-
late deeply held beliefs about the self in the world, causality, and purpose;
reveal unconscious pathogenic beliefs; point to specific developmental events
and epochs; or furnish a narrative to express ineffable states of mind.
Implicit assumptions about life, although not expressed by the patient
in explicit religious language, may originate in early religious education and
reflect internalizations of religious ideas and principles. For example, Joan's
heightened anxiety and defenses against the conscious awareness and ex-
pression of anger and aggression and other impulses originated not only in
prohibitions established by her parents but also were reinforced by religious
instruction. Complementing her parents' injunctions against her expression
of anger and aggressive impulses was the Catholic prescription to be pure in
"thought, word, and deed." Early religious instruction contributed to Joan's
implicit moral orientation, which considered murderous thoughts to be the
moral equivalent of murderous deeds. Further, in the course of her treat-
ment, it became clear that inhibition and self-restraint were consciously held
virtues that were based in part on unconscious identifications to idealized
religious objects. To suffer in silence was elevated to the meaning of suffering
with Christ; the ability to suppress one's desires was equated with holiness
and purity. Self-sacrifice and abstinence were not authentically chosen vir-
tues but rather involved functions of undoing and performing penance to
resolve intrapsychic conflict as well as behavioral expressions reflecting her
ego ideals.
Culturally available religious leitmotifs provide for many people a source
of identification and a means to construct and express meaning. Religious
narrative may provide a means to bring subjective experience into conscious
expression.

Further, religious language provides in particular a mother tongue for

the expression of affective experience in those familial and cultural set-
tings in which religion has played a central role ... although the richness
of religious language is universally available, it holds particular signifi-
cance for certain individuals in light of the unique function that religion
served in their childhoods as well as in present life. That function con-
cerns the expression of deeply felt states of mind and the articulation of
psychic realities. (Shafranske, 2002, p. 246)

Associations of a religious nature in psychotherapy serve as avenues to

deeply held beliefs and values and unconscious identifications, which shape
meaning and ultimately influence behavior.

A PSYCHODYNAMIC CASE STUDY 161

 Religions provide rituals for the resolution of moral transgression or
sin. For example, the Sacrament of Reconciliation, commonly referred to as
confession, for many Catholics becomes internalized as the quintessential
model of a psychological process for the resolution of guilt and conflict
(Shafranske, 2000). Jackson (1999, pp. 143-162) in his comprehensive study
of psychological healing, surveyed the anthropological literature and found
the confessional act to be an aspect of modern psychotherapy common to all
cultures and therapeutics throughout history. Joan's early experiences of con-
fession were filled with anxiety and shame. She recalled as a child standing
in the confessional line with mounting fear as she readied herself to recount
her sins and to remember the proper verbal script to pray with the priest for
forgiveness. At times in session she associated with anxiety that she would
not find the right words and that she feared that I would be critical and that
she "hadn't done it right." Although such a construction was undoubtedly
multidetermined, her memories confirmed an associative link to these early
religious experiences. She commented that something seemed to be missing
following her disclosures of impulses she found troubling; she anticipated
and in fact desired that I require her to do something (viz, penance). It was
difficult initially for Joan to accept those affects and impulses that she had
been brought up to consider as bad and to resist constructing a ritual of re-
pentance to assuage the anxiety and guilt she felt. The therapeutic aim dif-
fered from her internalized model of resolution. Through the therapeutic
process she came to accept the responsibility for determining her values and
to establish what she believed was appropriate. With this came greater ac-
ceptance of her affects and impulse life and she established in her mind the
distinction between spontaneously occurring ideas and deliberate actions. In
sum, a patient's religious background contributes in like manner to that of
other developmental features.

Technical Approaches to Religious Contents

Associations of a religious nature in psychoanalytic treatment serve the

same functions as do other associations and are treated in a similar manner.
Such associations are not a privileged class of psychological phenomena but
rather are associations to be analyzed. Such content bears the same potential
to articulate multiple levels of meaning, including references to past events,
current object relations, present transferences, and so forth. Consistent with
psychoanalytic practice, such associations are considered to be multide-
termined and emphasis is placed on understanding the relevance to the thera-
peutic relationship and to transference rather than to any excursion into
theology, religious counseling, or spiritual direction.
The appearance of God representations in dreams, memories, and asso-
ciations is also taken up as content for analysis. A facile clinical approach
allows for the presence of such objects within a transitional mode of experi-

162 EDWARD P. SHAFRANSKE

ence in the reverie of free association. Although not assigned to the catego-
ries of reality or fantasy, God representations as objects within the patient's
representational or internal world (Sandier & Rosenblatt, 1962) are consid-
ered in terms of their role in psychodynamics.

PSYCHOTHERAPEUTIC PROCESS
The course of treatment consisted of one session per week of psychody-
namic psychotherapy with occasional increased frequency to two sessions. A
psychodynamic form of expressive-supportive psychotherapy (Gabbard, 2000)
was conducted in which interpretation was emphasized within the context
of a supportive therapeutic relationship. Joan was encouraged to use free as-
sociation, and the process was facilitated through a range of interventions
including empathic validation, encouragement to elaborate, clarifications,
confrontations, and interpretations. Essential to the psychoanalytic enterprise
was the effort, through vicarious introspection, to empathically relate to Joan
and to facilitate her ability to speak of her experience (Kohut, 1959). A thera-
peutic alliance was mutually created, which provided the foundation for the
clinical work. This relationship served as a microcosm of her world in which
the unconscious and conscious meanings she brought to life experience could
be understood and new modes of relating initiated (cf. Stolorow, Atwood, &
Ross, 1978, p. 250). The analytic relationship provided the opportunity for
Joan to experience a new "object relationship" with her therapist (Loewald,
1957/1980) and in particular to be able to experience and to express her affects
and impulses in the immediacy of the therapeutic relationship.
Resistance to the spontaneous expression of thoughts, affects, and im-
pulses in the moment provided an avenue by means of transference interpre-
tation to understand the origins of the conflicts she was experiencing. Such
moments constituted a test of the therapist and the therapeutic relationship:
Would the therapist react like past objects to her expressions of affect and
impulse (Weiss, 1993)? Through the interpretive process, insight was ob-
tained and subsequently used to initiate new behaviors. New experiences,
supported within the therapeutic relationship, led to safety rather than anxi-
ety over the course of treatment (Rangell, 1992). Joan gradually developed a
new way of being with herself and with others. She was less often in a state of
intrapsychic conflict, dominated by unconscious anxiety. Summoning de-
fensive strategies to maintain repression and safety, she would be enabled to
experience and express the totality of her affects and impulses and her head
would no longer hurt.

Early Phase of Treatment: An Exemplar of the Therapeutic Process

An opportunity to explore the psychodynamics of her symptoms came

early in treatment. While reporting the events of the week, she began to

A PSYCHODYNAMIC CASE STUDY 163

associate to an incident in which her husband had disappointed her by com-
ing home late and had not called to inform her of his change in plans. As she
began telling the story she noted that pressure was building in her temple
and she immediately shifted focus to a more pleasant account regarding her
children. I commented that she had abruptly changed topics. She returned
to the matter involving her husband in response to my intervention and
complained to me that she was coming down with a headache. She related
that she had also gotten a headache at the time and had gone to bed early,
which left him to put the children to bed. I commented that she had related
her disappointment to me with little affect. I interpreted that rather than
experience disappointment or other emotional reactions, it seemed that she
was now in a state of intrapsychic conflict, the symptoms of which were ex-
perienced as a buildup of pressure in her mind as she struggled between ex-
pression and denial. This intervention drew attention to her defenses and
reflected the ego psychology axiom of interpreting defense before content.
She nodded and then began to cry uncontrollably. I quietly sat with her. Her
mood shifted and she began an outpouring of emotional complaints; she re-
lated how angry she was at him for disregarding her feelings (and perhaps at
me for disregarding her defenses). She associated to other like situations, of
how miserable and dissatisfied she was in much of her life, and then she fell
silent. She apologized for becoming upset, yet added that she felt better. We
explored further the contents of her silence and her need to apologize. She
said that she felt anxious and ashamed, and countered that she should be
grateful for what she had in her life, that she had been foolish, and that she
did not really have anything to complain about compared to others. In time,
we would understand that this reaction constituted transference phenomena
related to persistent experiences with her mother, who would tell her when-
ever she voiced a complaint that she had "nothing to cry about compared to
living with Joan's father." We would later understand that her remarks were
in part preemptive; she was trying to forestall what she anticipated would be
my criticism or disinterest in her troubles, which in turn would then trigger
aggression toward me inciting an even more dangerous situation. The dan-
gers involved in expressing her aggressive feelings were reflected in a series of
dreams early in treatment in which buildings were being burned down, huge
waves destroyed villages, and all sorts of vicious dogs and menacing people
would chase after her.
This session exemplified a psychological process that would be repeated
numerous times in the early phase of treatment; little by little more of her
psychological experience could be accepted into consciousness and gradually
her guardedness and feelings of anxiety dissipated as a result of empathic
understanding and interpretation. She gained confidence in the therapeutic
alliance and became more aware of the unconscious fears and transference
manifestations, which prompted her use of defenses. Focus was placed on the
manifestations of transference shaping the content and process of our clini-

164 EDWARD P. SHAFRANSKE

cal work together (Gill, 1979). As the therapeutic work deepened, the mul-
tiple influences that shaped and constituted her unique psychic reality came
clearer into focus.

Middle Phase of Treatment

After about 8 months of treatment, the therapeutic course took a de-

cided turn to a deeper exploration of childhood experiences and her subjec-
tive responses within the transference. With increased trust, Joan entered
into an "analytic space" in which memories, fantasies, affects, impulses, and
physical sensations became more readily available in her conscious associa-
tions. She recounted situations of intense affect, of fear and shame, and be-
gan to discover memories and impulses previously isolated from awareness.
Among her associations were memories of early religious experiences, which
suggested important identifications with the Virgin Mary, idealized aspects
of her mother, together with split aggressive and depreciating reactions to
her father. She remembered trying to be perfect in her prayers, longing to be
selected as the May Queen, and being fascinated with the lives of the saints.
Her mother was pleased by her interest in religious devotions; she was so
unlike her older brothers. She recalled that this period was interrupted by
repeated bouts of her father's drinking binges and she remembered "shutting
down" emotionally. The surfacing of these memories brought increased anxi-
ety in the therapeutic relationship. At the end of a session in which she
had expressed considerable hurt and anger in respect to her father and the
turmoil in the home, she turned while leaving to ask if she could see me the
following week. Her question was unusual in that we had a standing ap-
pointment; subsequent analysis revealed fears about expressing aggression
as well as disappointment and hurt toward her father. Religious associa-
tions surfaced in which she recounted fears of being condemned to the
"fires of hell" and memories of lying in bed, reciting prayers in the night on
hearing fighting between her parents. She reported feeling unsettled dur-
ing the day, somewhat disoriented, and felt increased concern about how I
felt about her. She had a fear that something would happen to me; that I
would be in an accident. This marked an intensification of focus on our
relationship as she worked on the ambivalent feelings she experienced to-
ward her father and consequently with other men, including me. She re-
ported nightmares of catastrophe—earthquakes, tornados, hurricanes; im-
ages of Christ being crucified ran through her mind. She recalled being
afraid of certain Catholic rituals in which incense was burned and made
her nauseous. With the provision of increased sessions, she processed the
intense feels of disorientation that were revisited from the past. Feelings of
fear and anger were dysregulating as well as the trust, which she was now
investing in me and in the analytic process. She was able to recount vivid

A PSYCHODYNAMIC CASE STUDY 1 65

details of anxiety as a child, fears she related particularly to the aggression
and chaos in the family. She spoke of how she never let anyone see how she
was feeling, that her mother had made it clear that she was not interested
in hearing any more complaints. Throughout the middle phase of treat-
ment, Joan processed the events from the past and became more willing to
share her feelings and to confront areas of dissatisfaction in her marriage.
She no longer experienced any headaches or other physical symptoms. She
was able to work intensively in psychotherapy and simultaneously to make
practical improvements in her lifestyle. She began to develop a genuine
interest and investment in her sexual life with her husband; he was also
responding positively to her needs and they began to enjoy their relation-
ship and children in ways that they had not before. She described toward
the end of the middle phase that she was feeling psychologically "lighter"
and with less pressure. Toward the end of a session she casually mentioned
that her family had begun to attend a local Christian church. She believed
that it would be a good thing to join as her children were in the orbit of
adolescence and there was an active youth group, which she believed might
provide a place of values. She was reminded of the sense of community she
obtained in her parish when she was a teenager. It seemed that the God she
had once feared, with whom there was trepidation and anger, receded to be
replaced with a more benign presence in her mind. She was becoming a
more spontaneous, trusting person. She no longer felt the same degree of
apprehension about her impulses and affects.

Termination Phase

As she became aware of how her life had substantially improved, she
expressed gratitude to me and began to talk about her sadness that she would
have to leave psychotherapy in the future. She wondered whether there would
be anything wrong with j ust continuing forever. The focus of treatment shifted
naturally to processing her feelings about our relationship and her experi-
ence of psychotherapy. She spoke of how I was in her mind and associated
that perhaps death was not really a complete end of relationship. She re-
called with great poignancy how she felt a loss when each of her children
entered kindergarten that she would no longer have the young children whom
she so loved and enjoyed. She spoke of the death of her father, years ago, as
well as mourned more fully that she would not live her life in her childhood
neighborhood. The problems of living did not evaporate; however, she no
longer feared the contents of her mind and was better able to address con-
flicts. She realistically understood that psychotherapy could not erase the
hurts of the past nor undo decisions she had made. She was now better able
to live her life with greater awareness, acceptance, and gratitude. We ended
psychotherapy after almost 4 years with an appreciation for each other and
for the process, which honored the substance of her experience.

J 66 EDWARD P. SHAFRANSKE
 COMMENTARY
Every clinical case provides an opportunity to consider the theories and
practices that inform psychological treatment. Although the findings of such
inquiry do not allow for a formal evaluation of efficacy nor meet the stan-
dards of science to establish empirical support, case studies provide illustra-
tions of selected aspects of the therapeutic process considered salient by the
clinician and complement findings obtained through clinical-quantitative
methods. Several factors contributed to the positive outcome in this case.
Consistent with the research literature (Bergin & Garfield, 1994; Galatzer-
Levy, Bachrach, Skolnikoff, &Waldron, 2000) the quality of the therapeutic
relationship (Lambert & Barley, 2001), alliance (Horvath, 2001), and empa-
thy (Greenberg, Elliott, Watson, & Bohart, 2001) were seen as crucial to both
the process and outcome. In my view, the psychodynamic approach, with its
emphasis on vicarious introspection and close attention to affect states and to
the subjective experiences co-constructed within the relationship, was par-
ticularly well suited to establish a relationship that would produce the thera-
peutic results. Further, psychoanalytic theory offered explanatory models that
described psychological mechanisms involved in the production of this patient's
presenting symptoms. The systematic analysis of defenses and the identifica-
tion of the interpersonal contexts in which early compromise formations de-
veloped enabled Joan to make sense of her response tendencies and with in-
sight to more readily attempt alternative solutions. Joan's intelligence and
motivation, as well as other psychological capacities, born in part out of a
secure maternal attachment, prepared her to participate fully in an analytic
experience. In keeping with psychoanalytic practice, the amelioration of symp-
toms was accomplished through interventions aimed at the level of personality
functioning and included changes in her internalized objects and regulation of
self-esteem.
This clinical discussion also provided an example of a clinical approach
to religious material disclosed in psychotherapy. Although the presenting
problem did not suggest religion to be the primary source of her difficulties,
Joan's beliefs, experiences, and objects derived from religious experience were
important features in her psychological life. Psychoanalytic theory allowed
for consideration of the multiple sources that contributed to her creation of
God representations as well as explication of the dynamic functions that
God representations, religious beliefs, and moral instruction served. Through
maintaining a clinical perspective, in which all mental contents were in-
cluded in the analytic discourse, the religious dimension could be appreci-
ated as important in psychological life.

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170 EDWARD P. SHAFRANSKE

 CROSSING TRADITIONS:
10
IGNATIAN PRAYER WITH A
PROTESTANT AFRICAN
AMERICAN COUNSELING DYAD
DONELDA A. COOK

This chapter presents a brief counseling case in which meditative prayer

and spiritual imagery methods from a Catholic spiritual tradition, Ignatian
spirituality, were used in a counseling dyad consisting of a Protestant African
American counselor and client. Both the counselor and client were from
worship traditions very expressive in their praise of God (i.e., singing, clap-
ping, shouting, dancing) and relatively charismatic (i.e., invoking the power
of the Holy Spirit through communal prayer). Interestingly enough, both
also participated in spiritual retreat experiences of extended periods of silent
meditative prayer, introduced to them through their employment (the coun-
selor) and matriculation (the client) at a Jesuit college and university. Dis-
cussion of the brief counseling case will address how Ignatian prayer meth-
ods, though not a traditional aspect of either the counselor's or the client's
religious backgrounds, was integrated into the counseling experience, and
the impact on the process and outcome.

173
 DESCRIPTION OF THERAPIST

Donelda A. Cook, an African American woman in her mid-40s, is cur-

rently assistant vice president for student development and director of the
Counseling Center at Loyola College in Maryland. She is also an adjunct
faculty member in Loyola's pastoral counseling department. Cook, a licensed
psychologist, received her doctorate in counseling psychology and has been
practicing in university settings for 20 years. She has published several jour-
nal articles and book chapters in multicultural counseling and psychotherapy,
and supervision and training. Cook is coauthor of a book with Janet Helms
entitled, Using Race and Culture in Counseling and Psychotherapy: Theory and
Process (2nd ed., Helms & Cook, in press).
Since childhood, Cook has been affiliated with African American Bap-
tist churches; however, she considers herself to be ecumenical in her religious
faith and minimally orthodox. In 1998, she became affiliated with an African
Methodist Episcopal church, Mt. Calvary A.M.E. Church, in Towson, MD.
She serves on the church's ministerial staff under a nationally recognized pas-
tor, Rev. Dr. Ann Lightner-Fuller, as a licensed preacher and director of the
Ministry of Prayer and Spiritual Formation. Cook conducts meditative prayer
retreats and workshops for clergy and laypeople, and on occasion, provides pro
bono brief counseling for individuals as a follow-up to retreat experiences.
Cook's theoretical orientation is informed by multicultural psychology
and spirituality. Her approach is person centered, engaging the whole per-
son, including all aspects of one's social identities (i.e., race, age, gender,
sexual orientation, and spiritual orientation) in the counseling process. She
is also interpersonally oriented, addressing the interaction between the client's
and the counselor's aforementioned social identities. Cook integrates family
and societal dynamics in client conceptualization. She understands the nega-
tive influences of societal oppression and the positive influences of spiritual-
ity in the cultures of many African American, Asian, Latino, and Native
American individuals. Consequently, Cook incorporates clients' racial iden-
tities and spiritual beliefs, traditions, and resources in the counseling and
psychotherapy process.
As a therapist, Cook personally silently prays to invite God into all
aspects of the therapeutic process, recognizing the power of the Spiritual
Presence in the therapeutic process and outcome. She uses vocal prayer in
therapy only when and if the assessment of the client's spiritual orientation
calls for such.
Cook was introduced to the Spiritual Exercises of St. Ignatius (Fleming,
1978) in 1997 through the retreat programs sponsored by Campus Ministries
at the Jesuit college where she is employed. Impressed by the spiritual growth
potential of the retreats, she sought opportunities to learn more about Ignatian
spirituality. Cook enrolled in seminary coursework, sought personal spiritual
direction, engaged in independent study with Rev. Tim Brown, S.J., and con-

174 DONELDA A. COOK

tinued personal retreat work based on the Spiritual Exercises (Fleming, 1978).
She currently serves as a spiritual director for the college's 6-day Ignatian
retreat.

SETTING

The setting for this counseling case was Cook's office at the college
where she is employed as an administrator. Her office is housed in a beauti-
fully stoned (comparable to the adjacent chapel), three-story building on the
manicured quadrangle lawn of the Catholic campus. The building houses the
offices of the college's senior administrators. The client was seen after regular
business hours.

CLIENT DEMOGRAPHIC CHARACTERISTICS

The client, Grace, a 39-year-old, single African American woman, was
affiliated with an African American Baptist church. She was assessed at a
minimal level of religious orthodoxy. She obtained a master's degree in school
counseling and was employed as head of a high school counseling depart-
ment. Grace was a recently licensed minister in her church and in a ministry
formation process toward ordination. She was also a part-time graduate stu-
dent in a master's of theology program. The client was first introduced to the
Spiritual Exercises (Fleming, 1978) through the Jesuit university where she
conducted graduate studies.

PRESENTING PROBLEMS AND CONCERNS

Grace was a participant in a weekend Scripture-based meditative prayer

retreat for persons entering ministry, which I conducted. The silent retreat
included four meditative prayer periods each day and daily individual spiri-
tual direction sessions with me. The client's presenting concerns emerged
during the retreat and related to the demands of her life, including full-time
employment, church ministry, and seminary. Grace had little time for her-
self. Because of her passion for ministry and her need for approval from her
pastor, she put forth as much effort and energy in her part-time unpaid church
ministry as in her full-time paid employment. Grace also had unresolved
issues over having not yet married nor had children.

CLIENT HISTORY

Grace was the youngest of two children raised in an intact middle-class

family. Both of her parents were still living, her mother a retired teacher and

CROSSING TRADITIONS 175

her father a retired postal service worker. Her older sister was a married teacher
with two daughters. Grace was raised in an African American Methodist
church, where she attended church regularly with her family and partici-
pated in Sunday school and the youth choir until she went away to college.
Grace became affiliated with her current church, an African American
Baptist church, when she relocated after completing graduate school. Through
her experiences with this church, she became more expressive in her wor-
ship, praising God through singing, clapping, shouting, dancing, and laying
prostrate in prayer. She reported having developed more of a personal rela-
tionship with God, and experiencing joy in expressing her love to God. Grace
became a Sunday school teacher for adolescents, and was later asked by the
pastor to oversee the Christian education department. She accepted the for-
mal call to ministry, to become an ordained preacher, 3 months before the
spiritual formation retreat.
Socially, Grace has always maintained a small group of intimate friends,
most of whom she met through work or church. She has been involved in a
few long-term romantic relationships; however, she reported that they ended
either because the men were not ready for marriage or they were not spiritu-
ally compatible. Grace reported that over the years, she has spent more of
her free time involved in church activities and there are few single men in
the church.
Grace has always excelled academically. She went to graduate school
after teaching for a few years. As an adult seminarian student, Grace found
school to be more of a challenge, which was due to other demands on her
time.

ASSESSMENT AND DIAGNOSIS

Because of the time-limited counseling and the client's presenting con-

cerns, empirical assessment instruments were not used. A "Level 1
multisystemic assessment," as described by Richards and Bergin (1997, p.
187), was conducted. During the initial session, the client's physical, social,
behavioral, intellectual, educational—occupational, psychological—emotional,
and religious-spiritual systems were assessed. The client reported a moderate
to high level of functioning in each system. Lower levels of functioning were
reported: (a) physically, in frequently feeling fatigued; (b) socially, in limited
social outlets; and (c) spiritually, in a diminished prayer life. Grace was re-
ferred for a medical evaluation, which revealed no medical problems related
to her fatigue. After assessing Grace's eating, sleeping, and work habits and
schedule, it was assessed that her fatigue was related to poor habits in each of
these areas. Similarly, her diminished social and spiritual capacities stemmed
from lack of time devoted to these areas.

176 DON ELDA A. COOK

 A clinical interview assessment of the client's religious-spiritual orien-
tation and resources was conducted. Grace was actively involved in worship,
service, and community fellowship in her church. She reported that each of
these aspects of her church affiliation were emotionally uplifting. Grace typi-
cally engaged in spiritual disciplines such as meditative prayer with Scrip-
ture, Bible study, fasting, journaling, and listening to gospel and spiritually
meditative music. In recent months, however, she had become too busy to
devote time to most of these disciplines. Grace initiated counseling with me
because the retreat reminded her of the spiritual power that she obtained
from her spiritual disciplines, and she wanted help in recommitting to her
spiritual life. She found the meditative prayer methods and journaling help-
ful during the retreat. Furthermore, unresolved issues emerged, which she
wanted to continue to process after the retreat.

TREATMENT PROCESS AND OUTCOMES

Ignatian prayer methods were used during the spiritual formation re-
treat. As a result of Grace's response to this method during the retreat,
Cook believed that the meditative prayer practices of Ignatian spirituality
would be useful in integrating spiritual disciplines with Grace's psychologi-
cal functioning.
Meditative prayer is a practice of physical and mental relaxation and
surrender of control to a higher spiritual power. As Richards and Bergin (1997)
explained, the practices of meditation, contemplation, and spiritual imagery
"require a trusting, passive attitude of release and surrender of control, isola-
tion from distracting environmental noise, active focusing or repetition of
thoughts, task awareness, and muscle relaxation" (pp. 205—206). Meditative
prayer has been associated with well-being and happiness (Richards & Bergin,
1997). Richards and Bergin (1997) have reported on research that shows
psychotherapists use contemplation, meditation, and spiritual imagery in-
frequently with clients, perhaps because of the lack of training in spiritual,
as opposed to secular, meditation practices. I did seek training in Ignatian
meditative prayer practices. Although contemplation and meditation are
often associated with Eastern spirituality, it is also a cornerstone of Catho-
lic spirituality.
Ignatian spirituality, developed by St. Ignatius of Loyola, the founder of
the Jesuit order of Catholic priests, uses spiritual imagery in meditative prayer
to draw individuals into deep personal relationship with God. Through peri-
ods of meditative prayer with Scripture, particularly Gospel scenes, individu-
als use all of their senses to imagine seeing, hearing, smelling, and physically
feeling or touching all that is going on in the Scriptural scene (Endean, 1990).
St. Ignatius originally developed the Spiritual Exercises of St. Ignatius (Fleming,
1978) as a 30-day silent retreat experience for spiritual formation of novice

CROSSING TRADITIONS 177

priests. However, the Spiritual Exercises (Fleming, 1978) have been adapted
to various formats for laypeople and for use ecumenically. Formats include
3-, 6-, or 8-day silent retreats, or daily prayer within the context of one's
routine life. In the latter format, one meditates daily with Scripture, usually
for an hour, and participates in weekly spiritual direction for approximately 6
months.
Using Ignatian prayer in this case, I instructed Grace to focus her at-
tention on God through prayerful relationship with Jesus, cognitively, be-
haviorally, and affectively. Within the counseling process, Grace experienced
(a) psychological practice of consciously attending to her thoughts, behav-
ior, and feelings; (b) mystical experience of a personal and intimate relation-
ship with Jesus; and (c) decreased physiological arousal through meditation.
Prior to continued discussion of the case, further explanation of Ignatian
spirituality and prayer methods is provided, as well as its potential use in
counseling and psychotherapy.

Ignatian Prayer Methods

The Spiritual Exercises of St. Ignatius (Fleming, 1978) encourages indi-

viduals to recognize the presence of God in all things and to closely follow
Jesus in seeking to live out the will of God. As theologian Monika Hellwigg
(1991) explained, "Ignatian spirituality is grounded in intense gratitude and
reverence. It begins with and continually reverts to the awareness of the
presence and power and care of God everywhere, for everyone, and at all
times" (p. 14). Thus, the core value of Ignatian spirituality is therapeutic in
helping individuals to seek the loving presence of God in all things and in all
aspects of an individual's life.
One of the basic premises of the Spiritual Exercises (Fleming, 1978) is
that through the experience of meditative prayer one gains a sense of the
here-and-now:
Understanding of oneself as a created being and to bring appreciation of
one's life as a gift. . . and cultivate a holy indifference toward things of
the world to be free to respond to them appropriately. Retreat directors
typically encourage one to realize all the things of the world as gifts of
God, created in love, and also to recognize how much God has gifted the
retreatant individually. These experiences establish a basis for valuing
oneself sufficiently to be open to the tensions. . . . They can be consid-
ered analogous to establishing a relationship of reasonable comfort and
trust with one's psychotherapist to feel safe enough to work on the issues
that brought one to therapy. (Meadow, 1989, pp. 175-176)
Barry (cited in Meadow, 1989) reported another therapeutic occurrence
in Ignatian prayer: "We find that many psychologically 'normal,' hard-
working, faith-filled people have been staving off feelings ... by overwork,

178 DONELDA A. COOK

alcohol, pills, the piling up of experiences . . . the continual seeking after
companionship. .. . The first few days of prayer remove these 'defenses,' and
the feelings come to the surface" (p. 177).
Empirically, Sacks (1979) conducted a study of the effect of a 30-day
Ignatian retreat on the integration of self-systems or ego development of
Jesuit retreatants. He hypothesized that the spiritual exercises would "result
in increased cognitive integration for the individual, as measured by Loevinger
and Wessler's test of ego development" (p. 47). Although results suggested
the experience had an overall positive effect of increased self-systems for the
Jesuit retreatants, it was impossible to identify which aspects of the retreat
contributed to the positive results, due to lack of controls in the investiga-
tion (Sacks, 1979).
Meadow (1989) presented a conceptual comparison between Ignatian
spirituality and Jungian psychotherapy. Regarding counseling and psycho-
therapy interventions, Ignatian spirituality uses various methods of prayer
that may be helpful, including (a) imagery, (b) prayer of the senses, (c) col-
loquy or conversation, (d) rhythmic breathing, and (e) examen of conscious-
ness. Through the use of imagery, one prays with one's imagination entering
into Gospel scenes with Jesus. Through the spiritual power and grace of prayer,
one may experience personal fellowship with Jesus (Bunker, 1986). Richards
and Bergin (1997) cited research suggesting that the use of spiritual imagery
and an individual's spiritual faith in a higher healing power may have more
powerful healing effects than secular meditative practices.
To heighten the use of imagery, Ignatius recommended using prayer of
the senses (Endean, 1990) in the Gospel scenes. In focusing all senses (e.g.,
seeing, hearing, smelling, and touching) and imagination in cognitive, be-
havioral, and affective interaction with Jesus, Lonsdale (1990) suggested:
We are able to open our hearts and minds to hear the word of God as full
as possible, to allow it to sink into our consciousness and to influence our
feelings and our most important commitments and choices. ... It can
mould and change us ... and can reach our innermost hearts, the most
fundamental attitudes and dispositions which ... give shape to our lives,
(p. 88)
The imaginative prayer concludes with a conversation with Jesus or
God, "a conversation in which the person praying expresses freely and with
confidence the feelings that have been aroused by the contemplation, 'as one
friend speaks to another' "(Lonsdale, 1990, p. 88). This can be therapeutic as
Jesus becomes more accessible in His divinity and humanity. As clients be-
gin to access the power and compassion of Jesus, therapists can encourage
them to use prayerful imagery to invite Jesus into the scenes of their own
lives. As they practice this method of prayer within and outside of therapy
sessions, clients may engage in psychological mindfulness of Jesus accompa-
nying them in their lives. Jesus might be perceived as a transitional object

CROSSING TRADITIONS ] 79
between therapy sessions or as a spiritual cotherapist. Furthermore, clients
may invoke a spiritual manifestation of Jesus' divine power and grace.
The behavioral use of rhythmic breathing consists of alternating one's
focus on a prayerful word and one's breathing, thereby giving full attention
to breathing slowly with a spiritual image (Bunker, 1986). This can be par-
ticularly useful in reducing clients' anxiety, and helping clients to get cen-
tered and cognitively block irrational thoughts. As Bunker (1986) explained,
"Ignatian meditation demands systematic, active concentration of one's en-
tire mind, beginning with a period of preparation involving prayer and recol-
lection of purpose" (p. 207).
Finally, the examen of consciousness helps integrate prayer and life. It
is a ritual of looking back over the events of one's day and noting affective
responses to the events, to "become more in tune with the presence and
leading of God in all aspects of daily life" (Lonsdale, 1990, p. 98). Such con-
scious inventory of affective responses to the daily events in life can be very
therapeutic, particularly for clients who tend to disconnect or disassociate
from their feelings. The examen can help clients to discern how their incli-
nations toward and away from God, within the daily events of their lives,
may be associated with healthy or unhealthy cognitive, affective, and behav-
ioral reactions.

Ignatian Prayer Methods Integrated in Counseling Case

The aforementioned prayer methods were used in the case with Grace.
The goals of counseling included (a) helping Grace to recommit to her spiri-
tual disciplines to achieve balance in her ministry and personal life, (b) ad-
dressing her need for approval from her pastor as related to her tendency to
overextend herself in service to the church, and (c) addressing her unre-
solved issues regarding her life as a single woman. Counseling was limited to
eight weekly sessions with daily spiritual discipline assignments between ses-
sions. Grace's previous experiences of daily Scripture meditations, focusing
primarily on Gospel scenes, had been helpful in establishing a personal and
intimate relationship with God through the person of Jesus. Thus, the coun-
seling process began by inviting Grace to meditate on her current relation-
ship with Jesus.
Through the use of rhythmic breathing, Grace was asked to choose a
prayerful word, and alternate focusing on that word and her breathing, until
she reached a relaxed state. Grace chose the word "Jesus." As Grace's breath-
ing became slow and relaxed, I asked Grace to meditate on the Scripture, I
Cor. 6:19 NIV, "Do you not know that your body is a temple of the Holy
Spirit, who is in you, whom you have received from God?" Through this
meditation, Grace was able to get in touch with the Spirit of God that lives
within her. She became increasingly relaxed and less focused on distracting
thoughts.

180 DONELDA A. COOK

 Next, I invited Grace to enter into a meditation in which she would
converse with Jesus, as with an old friend, beginning by asking Jesus the
question, "How is it with us?" Grace indicated that because of her dimin-
ished prayer discipline, she felt more personally distant from Jesus. There-
fore, I wanted her to begin with a conversation with Jesus addressing her
relationship with Jesus, how she felt, and how Jesus was feeling in the rela-
tionship. Grace silently meditated with this conversation for 20 minutes.
I asked Grace to share what happened during the meditation, and Grace
reported that she initially asked Jesus why she was having such a difficult
time being in His presence, and she wondered how she had been rejecting
Him. Then Grace asked Jesus to forgive her for filling her mind, heart, and
life with her ministry and her relationship with her pastor, more than with
Jesus. She was able to articulate how she had become so preoccupied with
seeking guidance, approval, and acceptance from her pastor. Grace ended by
asking Jesus to lead her back to their relationship, to remind her of who Jesus
had been to her, and of the intimacy that she used to experience with Jesus
through prayer. I pointed out that the meditation was a monologue rather
than a dialogue. Grace indicated that she was most aware of her own feelings
of missing a personal relationship with Jesus, and she could not hear Jesus'
response.
During the remainder of the session, Grace and I discussed her relation-
ship with her pastor. This discussion included how the relationship evolved,
the feelings that she had in the relationship, and her typical thoughts, feel-
ings, and behaviors in the relationship. I recommended daily scriptural medi-
tative prayer during the week before their next session.
When Grace returned for the next session, she was excited because
she was led to pray with Scriptures from the Song of Solomon, which drew
her into an intimate connection with Jesus. Grace reported that she "just
ended up" reading the Song of Solomon and that she had never prayed
with this Scripture before. She perceived this as Jesus answering her prayer.
Grace stated, "the Holy Spirit inspired me to pray my mind free with this
Scripture."
During this meditation Grace reported that "Jesus quieted my cluttered
mind . . . kissed away the fears I speak . . . and deposited His Peace into me,
far surpassing a drink of wine," all references to the Scripture text. Grace
continued to report on the intimate connection that she experienced with
Jesus. She described in detail how she experienced the presence of Jesus with
all of her senses, including sight, sound, smell, and touch. She also described
interactions that were initiated by Jesus. For example, at one point she be-
came distracted with thoughts during the meditation, and Jesus "gently
touched my eyes and closed them" and brought her attention back to Jesus'
Presence with her. Grace also reported on a conversation that she had with
Jesus, articulating how she tended to avoid Jesus during times of emotional
pain. She reported that Jesus explained to her that He runs toward her and

CROSSING TRADITIONS 18]

patiently waits for her to invite Him into her pain. This was also in reference
to the Scripture text with which she meditated.
This degree of personal connection with Jesus remained with Grace
beyond the prayer period. Consequently, she was able to call on Jesus' Spiri-
tual Presence through the course of the routine events of her week. This was
particularly important in interactions with her pastor, when she could prayer-
fully consult with Jesus rather than immediately agreeing to do all that the
pastor asked of her. Grace found that the more time that she spent in prayer,
the more she was able to discern what God was calling her to do. Thus, she
was able to limit the additional responsibilities that her pastor was asking her
to perform. She began to put forth more boundaries in her relationship with
her pastor.
As Grace resumed her daily prayer discipline, Jesus became a transi-
tional object that provided her with support between counseling sessions. As
Jesus was invited into meditations on various situations in Grace's life, she
received comfort, support, and at times challenge. Within a few weeks, Grace
trusted Jesus enough to share her deeper vulnerable feelings, including her
anger toward God and Jesus.
During the fourth counseling session, Grace shared with me the empti-
ness she felt in not having a significant romantic relationship, and having
never married and had children. Grace reported that she had dealt with this
loss in previous counseling, and functioned very well with her life, despite
not having such significant relationships. However, there were times when
she felt a deep emptiness and loss. Grace had accepted the possibility that
she might never marry and have children, but during her prayer times with
Jesus, she realized that she wanted more. She felt a sadness that she articu-
lated as "dried up hope."
I invited Grace to enter into a meditative prayer with Jesus, to converse
with Him regarding these issues. At the beginning of the meditation, Grace
wrote down what she desired from the meditation. She wanted to open her
deepest desire and longing to Jesus. Her prayer was "for openness, help me to
invite Jesus into my deepest pain, into my barrenness, into my inner woman,
help me to speak to Jesus from my womb and allow Jesus to speak back to me.
Holy Spirit, I need You desperately to move in this prayer. I want the grace of
God to come out of this prayer. I want to be healed of my feelings of barren-
ness, and want this prayer time to be Holy Spirit led. Amen."
This prayer speaks of how real Jesus had become to her, how she be-
lieved that she could interact with Jesus personally and intimately, and how
she had developed the courage to name her deepest pain. It also revealed her
faith in all parts of the Trinity, God, Jesus, and the Holy Spirit, and her faith
in the healing power of the Holy Trinity. During the meditation, Grace in-
teracted with God in all persons of the Holy Trinity. She found herself in the
delivery room, lying on the birthing table, with Jesus at her head, holding her
hand. She reported that "God, the Father" was at the foot of the table situ-

182 DONELDA A. COOK

ated high against the wall, and the Holy Spirit was below God. She did not
recognize any physical form for either of them, but she recognized each One's
Presence.
A very intimate interaction proceeded, in which Grace spoke openly
and frankly to God and Jesus about her longing and her anger that they had
not provided for her, despite her faithfulness. She named her "dried up hope"
and how she distanced herself from social situations because of it. She said
that she wanted to be "open and life-giving" with others. As Grace shared
her true feelings in the meditation, God and Jesus spoke back to her in very
real and honest ways, both comforting and confronting. Grace reported that
after conversing with them in the meditation, Jesus placed His hand on her
womb and asked her to focus on the feeling of the "dried up hope" within
her. Grace reported that after experiencing an internal physical sensation of
"dried up hope," Jesus breathed the Holy Spirit into her and a radiant spar-
kling ball of life came from her womb. She reported that Jesus "held my hand
and stroked my forehead and said, 'See what we can do together?' "
I witnessed visual signs of Grace's affect changing throughout the medi-
tation. Periodically, I would gently ask Grace what was happening and Grace
would speak about the experience and feelings she was having. Her feelings
ranged from sadness, to anger, to joy over the course of the meditation. I
asked Grace to journal about her experience of this meditation through the
course of the week. The next week, Grace read from her journal entries,
revealing an attitude of expectancy in the ways that she would be life giving
in her interactions with others, and how she intended to embrace her life, to
"stand tall and vibrant and walk in life." She articulated the difference in
being a caregiver and being life giving, in that she would give from her heart
rather than taking in other people's concerns and expectations; she would
"project outwardly rather than absorbing inwardly." Grace wanted to remain
mindful to "keep Jesus in the delivery room . . . together we can create new
life!"
By the end of the 8 weeks, Grace felt confident that she would resume
her disciplined prayer life. As she set more boundaries in her relationship
with her pastor, she created more of a balance in her ministry and personal
life. However, balancing a full-time job, part-time ministry, and seminary
continued to overextend her. She committed to scheduling time with her
family and friends as well as time alone for rest and relaxation. Grace had
developed the discipline of performing the examen of consciousness, in looking
back over the events of each day and noting her affective responses to the
events to help her to assess when she was becoming overwhelmed.
Grace's previous experience with Ignatian spirituality through a 6-day
silent retreat and continued daily prayer with Scripture made her an ideal
candidate for using Ignatian prayer in brief counseling. She was familiar with
the prayer methods and was motivated toward their use; consequently, Ignatian
prayer methods were used immediately. My theoretical and practical under-

CROSSING TRADITIONS 183

standing of Ignatian spirituality made her comfortable with the mystical ex-
periences that Grace was having in her meditative prayer periods. Delusional
thinking had been ruled out in the initial assessment phase. Both the client's
and the counselor's faith in spiritual healing powers facilitated the use of
nontraditional methods in the counseling process.

THERAPIST COMMENTARY

It is difficult to articulate, in psychological scholarship, the powerful

imprint left from an encounter with God and the healing power of experi-
encing a deep sense of unity with God. It speaks to my personal spiritual
development, that as a therapist I would so unashamedly speak of Jesus in
such a personable and real manner. Furthermore, I would never have imag-
ined myself sharing my faith life in public scholarship. However, it was through
Ignatian spirituality that I personally came to experience Jesus' healing power.
I know firsthand the mystical experiences that can occur in spiritual medita-
tive prayer. Thus, I was neither skeptical nor intimidated by the mystical
reports of the client.
I believe the psycho-spiritual nature of the counseling process would
not have occurred without my spiritual faith and theoretical and practical
knowledge of this spiritual meditative prayer form. I believe that Grace could
have worked through the issues with which she presented with a purely secu-
lar approach to therapy. However, her presenting concerns were so inter-
twined with her faith and her vocation to ministry that my faith and knowl-
edge of her religious tradition gave us common ground from which to work.
Furthermore, my belief in the Spiritual Presence and power of Jesus encour-
aged me to take a back seat and allow the therapeutic interactions between
Jesus and the client to evolve.
My personal recognition of the unconditional love of God frees me to
take risks in incorporating spirituality in counseling and psychotherapy. The
Spiritual Presence that is with me in therapy sessions is as nonjudgmental as
the humanistic approach to therapy from which I practice. Regardless of pre-
senting problems, social identities, or lifestyles, clients can engage with their
own God images, seeking consolation or reconciliation. I openly state my
own bias, that God created each of us in God's own image, and God loves
each of us unconditionally.
The techniques of Ignatian prayer are not prescribed for secular use in
psychotherapy but for working with the transforming God experience that a
client may have obtained through an Ignatian retreat. A therapist with knowl-
edge and experience in Ignatian spirituality, who has an understanding that
clients have been changed by the retreat experience, could continue build-
ing on the growth that transpired from the retreat.
Lonsdale (1990) described the signs of growth from Ignatian prayer:

J 84 DONELDA A. COOK
 As people become increasingly contemplative in the midst of activity,
what happens in prayer gives both impetus and shape to the rest of life,
and particularly to the choices that they make. Their lives begin to change.
... the changes appear most clearly in the quality of a person's responses
to events and people who are already part of his or her daily life. (p. 90)

Ignatian prayer and psychotherapy are about healthy choices, life

changes, and improved interpersonal relationships. As a retreat director and
a retreat participant, as a therapist and a therapy client, I have experienced
such life changing outcomes in both arenas.
In my limited experience directing Ignatian retreats, I have witnessed
individuals with various forms of psychological disturbances and distress
struggle with God during a retreat and make positive emotional shifts by the
end of the retreat. However, I do not know how these individuals have fared
in the aftermath of the retreat, as they returned to the circumstances of their
lives. I do believe that some people, like Grace, could benefit from counsel-
ing and psychotherapy that continues spiritual and therapeutic work on the
issues raised during the retreat. God initiates a spiritual and therapeutic work
in the retreat, and through meditative prayer, God is invited to continue
working in the counseling or psychotherapy process after the retreat.
The use of Ignatian prayer methods in psychotherapy can provide an
integration of spirituality and psychotherapy. Psychiatrist Gerald May (1974)
proposed such integration in his seminal works of the 1970s, arguing that
psychotherapists "can begin more directly to help others enhance their spiri-
tual lives as well as solve their psychological and interpersonal problems"
(p. 90). As a therapist who integrates spirituality and psychotherapy, I have
come to realize that the therapist's and the client's spiritual faith can be key
factors in the therapeutic process.

REFERENCES

Bunker, D. (1986). Ignatian spirituality in the work of Morton Kelsey. Journal of

Psychology and Theology, 14, 203-212.
Endean, P. (1990). The Ignatian Prayer of the Senses. The Heythrop Journal, 31,
391-418.
Fleming, D. (1978). The spiritual exercises of St. Ignatius: A literal translation and a
contemporary reading. St. Louis, MO: Institute of Jesuit Sources.
Hellwigg, M. (1991). Finding God in all things: A spirituality for today. Soujourner,
10, 11-16.
Helms, J., & Cook, D. (in press). Using race and culture in counseling and psycho-
therapy: Theory and process (2nd ed.). Boston: Allyn & Bacon.
Lonsdale, D. (1990). Eyes to see, ears to hear: An introduction to Ignatian spirituality.
Chicago: Loyola University Press.

CROSSING TRADITIONS 185

May, G. (1974). The psychodynamics of spirituality. The Journal of Pastoral Care, 28,
84-91.
Meadow, M. J. (1989). Four stages of spiritual experiences: A comparison of the
Ignatian exercises and Jungian psychotherapy. Pastoral Psychology, 37, 172-191.
Richards P. S., & Bergin, A. E. (1997). A spiritual strategy for counseling and psycho-
therapy. Washington, DC: American Psychological Association.
Sacks, H. (1979). The effect of spiritual exercises on the integration of self-system.
journal of the Scientific Study of Religion, 18, 46-50.

186 DONELDA A. COOK

 11
THE PERILOUS PRANKS OF PAUL:
A CASE OF SEXUAL ADDICTION
CAROLE A. RAYBURN

DESCRIPTION OF THERAPIST

Carole A. Rayburn is a clinical, consulting, and research psychologist.

She has four degrees, including a doctorate in psychology and a Master of
Divinity in ministry. She is a 65-year-old White woman and a third-genera-
tion American. A Seventh-day Adventist for the past 32 years, she was pre-
viously a United Methodist for more than 20 years. In terms of religious
orthodoxy, she is fairly orthodox on biblical issues and moderate to liberal on
traditional matters—particularly gender issues and equality of participation
at all levels in the ecclesiastical hierarchy. She has been in private practice
for 31 years, and besides serving as a consultant to various Montessori schools
and professionals, she has been a staff psychologist for District of Columbia
and Maryland facilities for adjudicated juvenile delinquents and emotionally
disturbed populations. She also has been doing research for more than 22
years and has developed inventories on subjects such as religiousness, spiritu-
ality, morality, clergy stress, peacefulness, life choices, the relationship be-
tween work and the Supreme, body image and intimacy, and leadership, and
has proposed the new field, theobiology. Her therapeutic orientation is cogni-

187
tive and psychodynamic. Her theistic worldview—she considers herself to be
a Christian feminist, a religious and spiritual person who practices being gen-
der fair—influences her theoretical orientation and therapeutic approach in
that all psychological theories must fit in or be in basic agreement with bib-
lical teachings of a God-centered, Christ-centered, spiritual caring-for-
others world. However, whenever those coming to her for psychotherapy
hold a secular worldview or have not expressed a desire for a theistic psycho-
logical approach for help with their problem and resolution, she does not
deal with their situations in a theistic framework. Rayburn does all humanly
possible not to judge her patients or clients but to reflect to them what they
are thinking and doing and what environmental and worldview influences
may influence them and their decisions.

SETTING

The client was seen in a private practice office in the northeastern sec-
tion of the United States. Primary services offered in this setting were indi-
vidual and family psychotherapy, marital therapy, addiction treatment, per-
sonality assessment, and career counseling.

CLIENT DEMOGRAPHIC CHARACTERISTICS

The client was a 52-year-old White man. He was a Southern Baptist of

moderate devoutness. He had a master's degree in computer science and taught
at a junior college. The client was from the upper-middle socioeconomic
status. The early years of his life were spent in the west coast of the United
States, but his adolescent through adult years were spent in the eastern part
of the country.

PRESENTING PROBLEMS AND CONCERNS

Paul presented an obsessive concern with why his family and friends
had not accepted his extramarital lover of 3 years. Even his coworkers who
knew of the relationship did not accept the woman. He indicated that he was
still legally married to Cathy, age 51, to whom he had been married for 34
years. At the beginning of the extramarital affair, he spent most of his time
and lived with his lover, Fritzi, age 48. Only recently had he moved out of
the house that he purchased for a dwelling for himself and Fritzi and moved
into a house with one of his three daughters. Fritzi remained in the house in
which both of them had been living, claiming that she would not let him
share a place with her until his friends, family, and coworkers accepted her as

] 88 CAROLE A. RAYBURN
his significant other. She had been married three times before, and two of
her husbands died while she was married to them. The third husband di-
vorced her and died a short time later. Although Paul had been in marital
therapy with Cathy before, claiming that she and definitely not he was at
fault for any problems in the marriage, his one other excursion into therapy
was with a male therapist whom family members had reported that Paul man-
aged to tell only half-truths and so distorted realities that the therapist could
be of little help to Paul. That therapist, however, had managed to see through
Paul's convoluted relationships enough to advise him against staying with
Fritzi. However, Paul completely ignored that advice. Nonetheless, he re-
ported to Fritzi his therapist's advice about leaving her, then assuring her
that he would never desert her—at the same time building up points for
himself in courting Fritzi's loyalty to him. Paul became increasingly frus-
trated with the nonacceptance issue concerning Fritzi, and one of his friends
suggested that he might find the answers of how to better understand women
if he sought therapeutic help from a female therapist. This he decided to try.

CLIENT HISTORY

Paul, a fairly attractive man looking somewhat younger than 52 years

old, was the youngest child in a family of two older sisters. Though he was
pampered by his seductive and domineering mother and favored by his tradi-
tional and conservative father, Paul firmly believed that his parents favored
his sisters. Before her marriage, his mother was a professional woman. His
father was a blue-collar worker. The family finances allowed them to live
quite comfortably. Although there did not seem to be evidence of physical
sexual abuse by Paul's mother, her verbal seductiveness and possessiveness of
him were a type of sexual abusiveness. She kept Paul as dependent on her for
as long as she could, and she closely monitored his chances for dating.
At school, Paul believed that he lived in the shadow of his two aca-
demic-minded sisters. Teachers were always comparing him unfavorably to
his sisters. He compensated for this somewhat by being very popular with his
peers. Too, he had a strong desire to please others. Underneath this wanting
to please others, however, was an equally strong sadistic sense of humor. For
instance, he seemed to get great pleasure from distorting social situations in
such a way that two girls or women would verbally or physically attack one
another. Once, when he was about 14, his sisters overheard his telephone
conversation in which he instructed another male adolescent on how to have
sex with a female adolescent. He had managed to have this conversation
within hearing of his sisters to irritate them, chuckling in great amusement
at their indignation, embarrassment, and rage.
When he was 18, he met Cathy. She was from a different neighborhood
and came from a broken home. She was quite different from the fragile, de-

SEXUAL ADDICTION 189

mure girls whom he attracted most often. Cathy was an aggressive and domi-
neering person, but she wanted to hold onto Paul—the one really meaning-
ful relationship in her life. Paul, perhaps seeing this relationship as his ticket
to gaining his freedom from his dominant mother who was smothering him
with her affection, got Cathy pregnant and was married by a justice of the
peace. He lived at home for another year because he was afraid to tell his
parents about the marriage until the baby was born, which gave him the final
excuse for needing to be married and to live away from home. Occasionally
he attended church with his wife, but he was not particularly devout. He was
successful in his job, rarely drank or smoked, but he admitted to having many
extramarital affairs during his marriage. He was quite determined to have his
wife stay at home and not pursue her own vocation. He wanted a submissive,
subservient mate, even though he had been fully aware that his wife's per-
sonality was very different from his image of what a wife should be.
His wife had pleaded with him to go into marital therapy throughout
their troubled marriage. He would only enter into psychotherapeutic ses-
sions, however, with the understanding that there was absolutely nothing
wrong with him and that he was only going so that she might get herself
corrected. In his mind, he could never do any wrong; he was the strong and
perfect spouse. Yet, even when he was having his affairs, he managed for his
wife to find out, such as charging gifts to other women on their credit card.
After 31 years of marriage, Paul met Fritzi through his wife. Fritzi and her
husband were their neighbors and Cathy had met Fritzi at several neighbor-
hood children's parties and at church. Fritzi, claiming that her husband and
she were having a lot of problems, came not to Cathy but to Paul for conso-
lation. Very much wanting to rescue Fritzi and be a hero among men, he
started taking Fritzi out to dinner and buying her gifts. Cathy and Fritzi al-
most came to blows in a public place, delighting Paul. He loved to have
women fight over him. After 3 years of arguing over separation and divorce,
Paul moved in with Fritzi but neither Fritzi nor Paul was divorced from their
spouses. Finally, Fritzi got a divorce from her husband, but Paul did not go
through with his divorce though everything was financially worked out and
enforced. Fritzi and Paul continued to attend church, with both of them
giving the appearance of being married to each other. Too, in the house that
Paul had bought, Fritzi created the impression for the neighbors and for her
coworkers on her job that she was married to Paul. That, however, was not
enough to satisfy her: She forced herself on Paul's family, friends, coworkers
and acquaintances, though they intensely disliked her repulsive, demanding
ways and crude manners. She insulted Paul at every opportunity, criticizing
his sexual prowess and appearance and anything else that she could. Paul,
who had had diabetes and some heart problems and was taking medication
for these conditions, had become impotent. Although Fritzi was cruel in her
insults to him, he was still stinging from the affair that Cathy had with a
younger man—mainly in retaliation for Paul's many affairs. That behavior

J 90 CAROLE A. RAYB URN

just did not fit in with his scheme of things: Men, not women, were to be
allowed to wander off the marital course and to sow wild oats. He only felt
comfortable and in charge of his life when he had the women in his life
fighting each other, preferably over him.

ASSESSMENT AND DIAGNOSIS

Assessment and diagnosis were made through a thorough interview and

case history. Although Paul presented with what initially appeared to be an
obsessive concern with his relationship with Fritzi and his intense fear that
she would end their relationship if his family, friends, coworkers, and others
did not accept her as his significant other, it soon became apparent that he
had other and even more serious problems. From the clinical history that
evolved during several sessions, it became clear that Paul was experiencing a
sexual addiction involving intense feelings of inadequacy about his sexual
performance—aggravated by his health problems—and his repeated sexual
relationships with lovers whom Paul viewed primarily as objects to be used
for his pleasure. The Diagnostic and Statistical Manual of Mental Disorders (DSM;
4th ed., American Psychiatric Association, 1994) states this as

302.9, Sexual Disorder Not Otherwise Specified. This category is in-

cluded for coding a sexual disturbance that does not meet the criteria for
any specific sexual disorder and is neither a sexual dysfunction nor a
paraphilia. Examples include: (1) marked feelings of inadequacy con-
cerning sexual performance or other traits related to self-imposed stan-
dards of masculinity or femininity, and (2) distress about a pattern of
repeated sexual relationships involving a succession of lovers who are
experienced by the individual only as things to be used. (p. 538)

When he was younger, Paul enjoyed using women as objects even more.
However, as he grew older, his possibilities for manipulating women and not
having them realize what he was doing were diminishing. He was also expe-
riencing greater conflict in his wanting to please others and in his wanting to
control women.
Paul's religious and spiritual background essentially involved a conser-
vative and traditional stance on girls and women. Men were held to be the
priests of the family and girls and women were to follow the lead of the male
head of the family. In his childhood family, however, his mother and not his
father was the dominant parent, and he thought that his sisters and not he
were the family favorites. So he believed that his family was out of the path
that should be religiously followed. He then could see himself as getting even
with girls and women and righting wrongs whenever he manipulated and
used them. He would be the man to reestablish the "male-order of things."
Often he would maintain relationships with several women at the same time,

SEXUAL ADDICTION 191

never letting any one of them think that she was his one and only. Reli-
giously and spiritually, he believed that girls and women were only second
best in a man's world. That, he thought, was the God-given order of life.
Within the branch of his religious denomination, Paul searched for a church
in which he perceived the ministerial staff to take the most conservative
patriarchal view toward the position of girls and women. He then would use
his perception as justification to treat girls and women as inferior beings and
boys and men as supremely superior persons.
As the therapist, my theistic worldview influenced my conceptualization
of Paul and his outlook very intensely. Believing in the equality of men and
women from the creation of life (Genesis 1:27, "in the image of God he
created him, male and female he created them"; Galations 3:28, "there is
neither male or female, for you are all one in Christ Jesus"; female images and
identity of God, such as El Shaddai, "the breasted one"; Biale, 1982; Rayburn,
1995; Rayburn & Richmond, 1998, 2000, 2002), I sensed very strongly the
severe theological and sociopsychological distortions that Paul was making
to justify his misuse and abuse of women. To treat Paul most effectively, I as
his therapist needed to contrast for him his goals in drawing close to the
Christian community of believers and to God, and his unacceptable behav-
ior in the eyes of God as detailed in scripture and of the religious community.
He was seriously compartmentalizing his religious and spiritual aspirations,
his very secular sexual misconduct and addiction, and his deceit toward him-
self and others. My worldview questions giving such importance to sexuality
for the sake of sexuality per se and so little attention to the spiritual and the
emotional side of sexuality and caring for others (Exodus 20:14; Deuteronomy
5:18; Galatians 5:19; 1 Thessalonians 4:30). Sexually using others as objects
and in ways that would pain them would be antagonistic to caring for others
and showing them loving kindness and spiritual concern. Such treatment
would be degrading, because the woman would be seen as something less
than human and less than a coequal in the creation of persons by God. The
symbolism of the rib of Adam, in which the rib is one of a pair of cartilagi-
nous or curved bony rods that stiffen the walls of the body and protect the
viscera, is that man and woman are equal, partners in every sense, and both
were created in the image of God (Rayburn, 1995). Jesus certainly taught
Mary of Bethany in the same way that he taught his other disciples. Just
because her sister Martha was a traditional homemaker did not mean that
Jesus did not accept women disciples and give them the opportunity to ben-
efit fully and directly from his teachings. Nowhere is there evidence that
Jesus treated women as anything other than equal to men (Swidler, 1971,
1979). Certainly Jesus never encouraged or condoned abuse or misuse of
women. Therefore, if Paul were using his own slant on conservative and tra-
ditional religious and spiritual beliefs to support his treating women as sexual
objects, as toys for his amusement, he was missing the point of true Christian
love. He was also allowing himself to be misguided in joining an unholy

J 92 CAROLE A. RAYB URN

alliance with those who would battle in a gender war that would never really
be won nor be pleasing to the Creator who made man and woman in the
divine image of God. Consequently, Paul was not only deluding the women
in his life, but as important he was deceiving himself—he was not really
pleasing and loving others but was deceiving and hurting them. He would
not be a hero to God for this deception but be one in need of repentance and
humility before his Creator (Psalm 50:19, 101:7, 102:2; Proverbs 12:20,14:8,
26:24-26). Paul's lack of loving kindness and the fallen angels were the true
enemy, not women. As in Cervantes' Don Quixote, the therapist had to hold
up a mirror before Paul, though with mercy, concern, and compassion, to
allow him to see for himself how he had veered off the course to a more
spiritual and sanctified life. He had to be helped to reflect on what he es-
poused to believe and what his actions were living out, and to then be better
able to separate the "wheat from the tares" (Matthew 13:24-30) or the good
from the bad. Initially, he had so separated his adultery, fornication, decep-
tion, and other lies from his church attendance and listening occasionally to
conservative religious radio programs. As an assignment, he was asked to
read through scripture to see if he could find any justification for his sexual
behavior and deception, as well as reading what scripture taught about these
matters. Midway in his therapy, he thought that maybe he was atoning for
his addictive behavior and deception by church attendance and religious
programs. Only later did he realize that he needed to change a lot in his
behavior to grow spiritually and religiously and to get back on the track that
he wanted to follow.

TREATMENT PROCESS AND OUTCOMES

After good rapport was established with Paul, the therapist was able to
get a better picture of the real dynamics of Paul's personality. Paul not only
freely admitted that he had had several affairs at the same time, but he seemed
to derive pleasure in the shock value of revealing these liaisons to the thera-
pist. In fact, shocking others with his manipulation and controlling of women
and his response to their retaliating toward him were a large part of the games
that Paul liked to play in a compulsive way.
Paul had a love-hate relationship with both his mother and father. For
his mother, he felt admiration for her education, accomplishments, and ego
strength. He admired his father for his sense of personal strength of character
and his old-world traditionalism. Nonetheless, he had accepted his father's
and society's biases against women and intensely disliked his mother's domi-
nant role in the family and her control over his life. Just as strongly, he de-
tested and disrespected his father's failure to place his mother in a subservient
position within the family and to take over the reins of control. He did not
sense his father's support for him and his rightful place of power as the only

SEXUAL ADD/CTJON 193

son in the family. Although his parents maintained a dysfunctional rela-
tionship much of the time, arguing over almost everything, Paul sought
consolation from male peers who held his same male chauvinistic philoso-
phy of life. Probably the single most determining event in Paul's life was his
memory of walking in on a scene in which his mother was making love to a
man who was a family friend. Paul was 6 years old at that time and, though
shocked by this happening, never shared this with anyone except his wife
Cathy and his latest lover, Fritzi. His mother had a far superior education to
his father, and she attended church. The similarities to Paul and his situa-
tion, with the exception of his sexual behavior being addictive, were strik-
ing. Although his sisters tried to maintain a peaceful and even protective
stance toward Paul, he saw them as competition for his parents' affection and
for status and honors in the outside world. Most usually, however, he man-
aged to just barely cover up his anger by a facade of charm and goodwill.
Understandably hurt when his mother did not encourage his succeeding in
school as she had his sisters, he made his own rules and successes by being the
class clown, failing in an area in which his mother took pride in accomplish-
ing much, and in carving out his own niche with charm, talent, and skill.
Along with Paul's tremendous need to please others, he longed for be-
ing truly appreciated—especially for his generosity. He often was very gener-
ous to those outside his family but stingy to his family. This puzzled others.
He did not think that his family appreciated fully what he did for them but
that they took him for granted. Therefore, he went to extremes and denied
his family many things that he spontaneously did for others. Furthermore, if
he were to befriend an especially needy person, one who had very few other
friends—such as Fritzi—he could feel particularly secure in his rescuer posi-
tion and even enjoy a sense of martyrdom if others thought him to be sacri-
ficing himself for someone not worthy of his gifts and attention. The more
that his relatives, friends, coworkers, and others were repelled by Fritzi, which
was primarily due to her coldness, selfishness, and pushiness, the more Paul
was convinced that he should protect and defend her. Then, because others
could not at all understand Paul's attraction to such a woman, they grew to
disrespect Paul and to seriously question his judgment. When Paul's health
problems and the medications that he had to take brought on sexual impo-
tence, Paul considered this the end of the world as he had known it. To him,
sexual prowess was the sine qua non of masculine identity and male superior-
ity and strength. Although he needed Fritzi to comfort and support now more
than ever, she insulted him and threatened his masculine image by making
fun of his sexual performance. Initially, she was more supportive and atten-
tive to Paul, hoping to woo him away from his wife. But, when she realized
that Paul had no intention of giving up even the remnants of his ailing mar-
riage (only to find himself controlled by a mean-spirited and self-serving
woman), she became even more ferocious in her dealings with and demands
on Paul. Paul acted out his anger toward Fritzi by openly maintaining a con-

194 CAROLE A. RAYBURN

nection with his wife Cathy and their children. There were other women to
whom he related at that time also, especially women who had physical prob-
lems and for whom he could serve as a knight in shining armor. Using ratio-
nal emotive behavior therapy (REBT) to tease out the irrationalities in Paul's
thinking and feeling, as well as transactional analysis and scriptural teach-
ings on what is really important in being a person in the eyes of God and the
community of believers, the therapist drew out more realistic self-images from
Paul and helped him to be more comfortable and at peace with himself.
Using psychodynamic and cognitive—behavioral therapy, the therapist
encouraged Paul to look at his relationship with his mother. At first, he was
highly resistive, denying that he had anything but love and respect for her.
The therapist also analyzed the reaction that his mother had when she found
out that Paul was dating and then married Cathy. He had a setback for 2
weeks, deciding to absent himself from therapy sessions. Encouraged by his
daughters, who thought that he was improving, he came in the following
week. He had an insight into feeling some satisfaction that his mother was
angered by his marriage. To him, this established that he and not she was in
control of his life. Achieving this "one-up" with his mother, he could now
see this was a payoff for getting Cathy pregnant and getting married and thus
out of the reach of his mother's control. With that insight, he began to change
his thinking and feeling and to experience personal growth.
Considering himself to be a religious and spiritual person, Paul attended
church services on a fairly regular basis and professed his belief in God and
Christ. Although he justified his treating women as second-class citizens and
as inferior to men by what he believed he was being taught in his Baptist
church setting and from scripture, he isolated the fact that he was living with
Fritzi while she was still married to Steve and while Paul was still married to
Cathy. He did not want to talk about adultery and seemed in real pain to
even consider that he was doing something wrong and not moral in the teach-
ings of his church or scripture. In therapy, this inconsistency was pointed out
to him, but he initially ignored it and would not seriously accept the discrep-
ancy between religious teachings and his behavior. He was also helped to
confront his penchant toward manipulation of women and his anger and
annoyance at himself in wanting and needing to please others so much in
order to gain their constant approval. Paul was asked to think how Christ
would look at adultery, at controlling others by seeming to please them but
being angered at them and holding them in disdain. He was also challenged
to better understand his parents and sisters and to accept them more, seeing
some ways in which they showed their love and respect for him, even though
they may have had difficulty in showing these feelings more clearly and ap-
propriately. Reflecting on his childhood, he could see more instances when
his parents and sisters showed such love and concern for him, though his
anger often got in the way of the more positive feelings directed his way.
Furthermore, through REBT and transactional analysis, Paul was helped to

SEXUAL ADDICTION 195

build more confidence in himself and to realize that he was more than a
penis and scrotum. In a gestalt exercise, he was asked to envision himself as a
giant penis and scrotum and to experience how he would be feeling and think-
ing as these sexual organs. From this exercise, he could experience the sense
of male strength and dominance but also of shame, fear, vulnerability, and
threat of impotence. He could readily see the limits of restricting himself to
thinking and feeling as these bodily parts alone.
Encouraged to pray about his problems, to really think about what he
wanted from life and what he wanted to be and become as a creation of God,
he began to see himself in a newer and more healthy light. As he gained self'
confidence, really thought about what adultery and an excessively active
sexual lifestyle meant, and realized that his parents and sisters saw some good
in him, he saw that Fritzi was after all not good for him. He began to depend
far less on superficial relationships and to substantially decrease his time spent
with Fritzi and other women. He spent 50% more time with his family. Real'
izing that he is a child of God and that God never rejected him, he knew that
he himself was blocking off several roads in his life to God and the Holy
Spirit. He has much less need (less than 60%) to compartmentalize areas of
his life. He is experiencing far more peace than he has had in a very long
time. This has helped in lowering his anxiety, depression, and blood pres-
sure. Paul spends most of his time staying with one of his daughters, going to
see Fritzi only on one or two weekends a month and not being very enthused
about seeing her but only responding to her severe demands. Growing in-
creasingly aware of her self-interests and deleterious demands, he became
more aware of what others had perceived about Fritzi from the beginning of
their relationship. Paul began to talk more to his minister about what was
happening in his life and to get yet another view of what he was doing.
Initially, however, he was more prone to seeing blame in Cathy and in
Fritzi but little or no responsibility for his own involvement in the convo-
luted relationships.
Because Paul gave much importance to his father's male chauvinism as
well as the male biases of society at large, and because he had sought out a
specific church that he perceived as upholding male superiority, he dismissed
and discounted the caring that his mother and sisters had shown him through-
out his life—protecting him from neighborhood bullies, helping him with
his homework, buying him gifts, and giving him money when he really needed
it. Because he believed that men should be in an undisputed superiority posi-
tion in the family and in the community at large, anything less than full
deference from the women in his life would be seen as insufficient. Thus,
even when he was getting much love and attention from women, he felt
insecure and neglected. Further, any wish on the part of women to establish
a position of equality would be regarded by Paul as wrong, sinful, and outra-
geous. Yet, having lived with a strong mother and strong sisters, he admired
such strength while thinking that he had a mission to reform these girls and

196 CAROLE A. RAYBURN

women and to help them to become subservient to boys and men as he thought
they were created to be. As long as he remained in that competitive position,
he slowed any progress in personal growth.
In therapy, Paul was asked to look deeply into his real image of himself
and how he thought God looked at him. Initially, he verbalized that he loved
himself and accepted himself as a child of God. He thought that God had
made him, as other men, superior to women, and that any attempt on the
parts of girls or women to be equal to men was not only wrong but also evil.
The therapist's worldview, however, stressed belief that men and women were
created as equals by God. The therapist asked Paul if he thought that God
would desire a superior creation to be linked meaningfully—as in marriage
and procreation—to an inferior creation. He was not sure about this. Paul
was asked if he would want his wife, daughters, or other women friends and
acquaintances to restrain their skills and talents to appear less skilled and
talented to the men in their lives. He related that, even if they did have
certain abilities, they should not outshine men. He denied that he might
have let his biases influence how he graded women in his classes. Paul was
asked if he believed that God would be so cruel as to create women with
capabilities equal to men and then ask the women to hide their skills and
talents while requiring men to feign superiority over women and to live a
lie throughout life. Most important, did Paul believe that God would not
really love him if he were not superior to all women at all times? Could he
not love and respect himself and could not God fully love and accept him
if he were performing in superior ways with some but in inferior ways to
some other women? Was his life to be a living hell, constantly comparing
himself to women and having to distort reality in some instances? Was
such imagined conditional love of himself and of God the path of content-
ment? Over several therapy sessions, he thought through these matters and
decided that such perpetual competition was unnecessary and tormenting.
Furthermore, Paul realized that he had been living a no-win situation. If he
did his best to accomplish his goals in life, he could accept that others—
women included—could also be worthy. He could establish a win-win situ-
ation. He saw that he had envisioned God as a very cruel patriarchal figure
who demanded nothing but perfectionism in performance every moment
of his life. This contradicted the picture of a loving Creator. Seeing God as
more loving and accepting toward him, he was able to be more loving and
accepting toward himself. He was not as obsessed with having to please
others or having to manipulate and embarrass women. Paul now allowed
himself to be less critical of others and of himself as well. In terms of his
impotence, he was reexamining the need and the dosages of medications
for his health in general, of medications to render him more potent, and
getting information on penile implants. He was able to be more objective
once his defensiveness about how masculine he was with his impotence
was lessened.

SEXUAL ADDICTION 197

 THERAPIST COMMENTARY

In addition to having a sexual addiction in which he treated women as

sexual objects or play toys, Paul was addicted to finding a religious and spiri-
tual setting that would uphold his prejudice against women. Historically, the
Southern Baptists have been divided on the inclusion of women in the pas-
torate and on high-level but nonclergy church positions. When men in such
a setting interpret the teachings of the branch of their denomination as fa-
voring men over women, this can hamper a more healthy and spiritual out-
look of men in general. Using God and distortions of what God demands are
not enabling for men to truly understand their relationship with God nor
with their cocreatures. Such attitudes do not bode well for marital relation-
ships, because to fulfill these beliefs of female inferiority necessitates that a
man marry a woman whom he believes to be inferior to him in most ways or
whom he can subjugate into being subservient and not resenting such treat-
ment. Yet, such denial of a woman being able in many ways but having to
hide this from her man will bring about open or hidden resentment. Such a
"battle of the sexes" goes a long way to dooming any marriage and harming
optimal growth and development of any children in the family. Any rela-
tionship that asks one of the significant persons to pretend to be inferior to
the other significant person is asking the two people to live a terrible lie. To
be in an "I'm okay, you're not okay" position is a loser position. There is
nothing "okay" about feigning inferiority or in having to make another per-
son less worthy to feel more worthy oneself.
Paul was psychologically caught in the middle of resenting while ad-
miring superior, intelligent women—primarily due to living with his very
capable mother and sisters—and seeing them as special challenges to be put
down and made to accept positions of inferiority to men. Although he had
not been to a woman therapist before and had been able or willing to tell the
men therapists only what he wanted them to know, he took the current situ-
ation as an interesting challenge of manipulating a woman therapist into
thinking that he was charming and quite emotionally healthy. In the latter
pursuit, he quite certainly failed.
In Paul's case, his religious and spiritual involvement were highly rel-
evant to his treatment, particularly for the contradictions that he was living:
believing himself to be following all of the commandments of his faith and
yet remaining in a doubly adulterous situation, admiring and resenting
women's capabilities, seeing God's love and acceptance being highly condi-
tional and based on successful performance as a superior man, and wanting to
charm and protect women and at the same time manipulate and embarrass
them.
Religious and spiritual interventions were useful in Paul's treatment
because his belief system took the religious and spiritual into account and
used them to justify his male chauvinism and his wanting to subjugate women.

198 CAROLE A. RAYBURN

Too, because he felt only conditional love from God and others, such inter-
vention was helpful. One ethical concern and challenge associated with this
case was the challenge to his perception of the traditional in his faith system.
But was justifying a second-class citizenship of women a healthy situation for
Paul, even though he might have thought that this was engendered by his
church? The ethics of gender-fair psychotherapy—and the interpretation that
many religious and spiritual people discern of scripture and inspiration—
requires treatment of men and women as equals. To agree to support a preju-
dicial position of a client or patient would support an unhealthy lifestyle and
belief system.
The theistic worldview of the therapist influenced the treatment pro-
cesses and outcomes with this client in beneficial ways. The equality of the
genders (supported by scripture as well as feminist tenets) is most usually
seen as a healthier stance than an inferiority of men and women. In fact, it
was this misbelief in the inferiority of women and the superiority of men that
engendered and maintained Paul in his sexual addiction and even his obses-
siveness in remaining with Fritzi for so long: He could martyr himself and
vacillate between an "I'm okay, she's not okay" position and an "I'm not
okay, she's not okay, and in fact, the whole world is not okay either." Thus he
could make a self-fulfilling prediction—that women were evil and could bring
men down to ruin, but that he—men—were heroic and would sacrifice them-
selves to right the wrongs and save the world from girls and women. It was
essential that the religious and spiritual be brought into this case and used to
deal with the underlying problems and beliefs. The positive treatment and
outcome depended on such intervention.
The therapist's theistic beliefs influenced the therapy process and out-
comes in that her belief in God, Christ, the Holy Spirit, and salvation were
vital to both the process and the outcome in dealing compassionately and
knowledgeably with a seeker of salvation who needed to get his religious/
spiritual/ psychosocial house in order. A nontheistic therapist might not have
been sensitive enough to the nuances of what was happening to successfully
deal with the problems presented by a sexual addict with religious ties. A
theistic therapist also has a heavier burden, in dealing with religious and
spiritual matters in psychotherapy, to avoid being judgmental or having the
appearance of sitting in judgment.
The client's theistic beliefs influenced his problems in that his thinking
and feelings were at times quite confused and convoluted and having to be
unraveled sensitively and gently at times and firmly and decisively at other
times. The onus on the therapist to be nonjudgmental is vital for the theistic
client.
The process and outcomes potentially would have come out differently
in the absence of a theistic spiritual perspective. If there were no reference to
Christian admonitions against adultery, deceit, lies, and other maladaptive
behavior, there would have been different and perhaps fewer motives for the

SEXUAL ADDICTION I 99
client to change his behavior: He might have been encouraged to look mean-
ingfully at his self-deceptions, compartmentalizing, and sexual addiction in
terms of secular, healthy human development. However, to fully gain aware-
ness of such problems and solutions regarding healthy and religious and spiri-
tual behavior, the theistic spiritual perspective served as the sine qua non.
Current feminist literature (Lerman & Porter, 1990), as well as much reli-
gious and spiritual commentary (Swidler, 1971, 1979; Rayburn & Richmond,
2000) would support working to change Paul's male chauvinism. As for get-
ting him to examine more closely what his particular church and its minis-
ters were teaching boys and men about girls and women, Paul was encour-
aged in his therapy to think more for himself and not to hide behind the
clerical cloak of what he perceived his denominational branch and its staff
members to be saying and teaching. Indeed, a most important element of
working with one's addictive behavior is clearing away the cobwebs between
impulsive acting-out behavior and rational thinking before acting. As his
spiritual behavior and insights became more real and meaningful, so too did
his relationships with others and his respect for and more realistic apprecia-
tion of himself and his place in the universe as a child of the Creator.

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental

disorders (4th ed.). Washington, DC: Author.
Biale, D. (1982). The God with breasts: El Shaddai in the Bible. History of Religions,
20, 240-256.
Lerman, H., & Porter, N. (Eds.) (1990). Feminist ethics in psychotherapy. New York:
Springer.
Rayburn, C. A. (1995). The body in religious experience. In R. W. Hood, Jr. (Ed.),
Handbook of religious experience (pp. 476-494). Birmingham, AL: Religious Edu-
cation Press.
Rayburn, C. A., &. Richmond, L. J. (1998). "Theobiology": Attempting to under-
stand God and ourselves. Journal of Religion and Health, 37, 345-356.
Rayburn, C. A., &. Richmond, L. J. (2000). Women, whither goest thou? In L. H.
Collins, M. R. Dunlap, & J. C. Chrisler (Eds.), Charting a new course for feminist
psychology (pp. 167-189). Westport, CT: Praeger.
Rayburn, C. A., & Richmond, L. J. (2002). Theobiology: Interfacing theology and
science. American Behavioral Scientist, 45(12), 1793-1811.
Swidler, L. (1971). Jesus was a feminist. South East Asia Journal of Theology, 13(1),
102-110.
Swidler, L. (1979). Biblical affirmation of women. Philadelphia: Westminster Press.

200 CAROLE A. RAYBURN

 12
HUMANISTIC INTEGRATIVE
SPIRITUAL PSYCHOTHERAPY
WITH A SUFI CONVERT
WILLIAM WEST

DESCRIPTION OF THERAPIST

I am a White man, and I have been a member of the Religious Society

of Friends (Quakers) since December 1992. Prior to that, I was a member of
the Church of England, but I more or less gave up church membership when
I enrolled in a university at the age of 18. However, I retained a keen interest
in spirituality. I regard myself as fairly devout, attending Quaker Meetings
for Worship every Sunday with my wife and child whenever possible, and I
have served as an Elder of my previous Quaker meeting while living in Leeds,
England.
Quakers are a religious group founded around 1652 by George Fox. There
are currently about 20,000 Quakers in England and approximately 200,000
members worldwide. Quakers are a noncredal group; in England, many Friends

This case study would not have been possible without the active, ongoing, and informed consent of
Matthew. My two supervisors, Anne Littlewood and Jim Davis, played an invaluable role in ensuring
that my work with Matthew was as effective as possible.

201
would regard themselves as Christians but not all would do so. Quakers put
great emphasis on what they call "the light within" their inner spiritual ex-
perience (Gillman, 1988). Their meetings take the form of sitting in silence
and waiting on the Spirit. If anyone feels moved by the Spirit to speak, he or
she may do so. This is referred to as ministry, and it should be spontaneous
(Dandelion, 1996). In the United States, some Quaker meetings follow this
British style of worship, which is called unprogrammed. Other meetings have
a pastor and a more formal or programmed form of worship, although a period
of silence is usually part of such meetings. Friends have a strong tradition of
good works within both the therapeutic and other caring professions, as well
as of peace-making.
At the time I began working with clients 1 was 29 years old. I have been
in practice as a counselor or psychotherapist since 1979, and I am registered
as a practitioner with the British Association for Counselling and Psycho-
therapy. After 10 years of full-time work as a practitioner, I pursued master's
and doctoral studies in counseling from 1990 to 1995.1 have worked full time
as an academic since 1995.1 was made a Fellow of the British Association for
Counselling and Psychotherapy in 2002.
I am currently senior lecturer in Counselling Studies at the University
of Manchester (England), where I am director of Counselling Courses. I am
also director of the Professional Doctorate in Counselling. I am a core mem-
ber of the team for the Masters in Counselling Studies program and the Post
Graduate Certificate in Counselling Supervision. In addition, I am Special
Advisor on Research to the British Association for Counselling and Psycho-
therapy, and served from 1996 to 2001 on their Research and Evaluation
Committee, with additional service as Chair. I am also an active member of
the Society for Psychotherapy Research (International).
My therapeutic orientation is humanistic integrative (West, 2000a),
and in the last 5 years I have sought for my small private practice clients who
see spirituality as part of the solution to their problems. I felt it necessary to
stipulate this as I wished to work in a more explicitly spiritual though not
necessarily religious way. This gives me and my clients greater freedom in
how we can work together therapeutically. Much of the therapy practiced in
Britain is secular, and several therapists are antithetical to their clients ex-
ploring issues related to their spirituality (West, 2000b). It meant, for ex-
ample, that insight that came to me from what I regarded as a spiritual source
could be easily put to use; that my clients and I could talk explicitly in spiri-
tual and religious terms when appropriate. It also meant that my clients were
given explicit permission to include their spiritual lives in the therapeutic
process, and that the therapeutic process itself could be understood in spiri-
tual terms.
Nearly all schools of counseling and psychotherapy in England insist
on regular, often individual, supervision of therapeutic practice throughout
one's career as a practitioner. The spiritual aspect of my work was, and re-

202 WILLIAM WEST

mains, a key element to be explored in supervision, as will become apparent
later in this chapter. The inclusion of spirituality in therapy remains contn>
versial within England and can be a contentious yet key focus of therapeutic
supervision (West, ZOOOc). However, the supervisors for my therapy work
during the past 5 years have all been accepting of, and experienced in, work-
ing with their clients' and supervisees' spirituality.
My clients welcome the spiritual approach, though I suspect those who
do not value it will not have sought me out or been referred to me. However,
one client who was keen to work with me, and who did not especially explic-
itly engage in his therapy work with me around spirituality, said at the end of
his therapy with me that he valued the fact that I was spiritually and reli-
giously orientated. This seemed to imply that my orientation nevertheless
did have some influence on and meaning for him, despite my not making it
explicit in therapy.
My clients mostly seem to be Buddhist or New Age in their orientation
rather than Christian, which I find curious. I will not work with members of
my own Quaker congregation but am willing to work with people from other
Quaker meetings in my area. I often see people for spiritual direction and on
occasion run retreats (West, 2001), though this is a separate matter from my
therapeutic practice.

SETTING

I work alone in private practice seeing three or four clients a week in

my home city of Manchester, a large city in the northwest of England. I
invite my clients to set the fees involved according to their means, which has
resulted in fees varying from £1 ($1.50) to £40 ($55) per hour. This seems
spiritually appropriate, although I am aware that it does also have therapeu-
tic significances, which are explored in supervision. Clients see me weekly or
fortnightly for one hour, or occasionally twice weekly. My clients' therapy
may last for a few sessions or for many months. Usually the therapy ends by
mutual agreement when the therapeutic process appears complete.

CLIENT DEMOGRAPHIC DETAILS

The client, Matthew (his name and some personal details have been
changed), was in his early 30s and of mixed race origins but was raised within
a White working class family. Although raised within a fairly devout Chris-
tian (Church of England) family, Matthew had become a Sufi in his adult
life and had regular contact with his Sufi teacher or master. His spiritual life
was of great importance to him, and he would quote from Sufi poets, such as
Rumi, during his therapy sessions. However, it was many months into his

A SUFI CONVERT 203

therapy with me when he chose to reveal his religious orientation. He was
working as a psychiatric nurse at the time of his therapy with me.

Presenting Problems and Concerns

Matthew's immediate presenting issue was that of tension with a woman

manager that was affecting his performance at work. He also reported that he
was "out of touch with his feelings" and had some sense of "not taking his
place in the world." He said that he did not feel grown up, and was not
"coming into his power." He also expressed regret that he was not married or
in a committed long-term sexual relationship.

CLIENT HISTORY

Matthew spent his first 6 weeks of life being looked after by Christian
nuns in an orphanage until he was adopted. Matthew described himself as
somewhat rebellious as an adolescent and in early adulthood, and as an un-
derachiever at school. In his early 20s he had worked as a freelance journalist
on a local paper developing a reputation for articles that had an angry and
political edge to them. He resumed his studies in his mid-20s and chose nurs-
ing; he then realized that he had found his vocation.
However, it soon seemed very clear to me that although Matthew was
making an apparent success of his working life, he felt that he was not realiz-
ing his full potential at work and in his life as a whole. He felt particularly
aware of the fact that he was neither married nor in a committed relationship
yet had a deep connection to his adopted Christian family in which being
married and having children were expected. Matthew was living in Manches-
ter on his own, but he made regular weekend visits to his parents' home some
miles away, where a Sunday family meal usually occurred. Although such
family life fit the Christian subculture in which he was raised and to which
he felt he belonged, it also emphasized how young he still seemed. Questions
often arose about whether or when he was going to meet a nice Christian girl
and settle down.

ASSESSMENT AND DIAGNOSIS

My approach to assessment (West, 200Gb) is to revisit it as an ongoing

process rather than devoting an inordinate amount of time to it in the first
session or two. Indeed, the assessment process begins with the telephone
call, which is my usual way of contacting a prospective client. During the
phone call I decide whether it is worthwhile for the prospective client and
me to meet. Occasionally I will screen out a client over the phone, usually

204 WILLIAM WEST

offering a more appropriate referral. If we both choose to meet to explore the
possibility of working together therapeutically, then the key assessment ques-
tion I pose to myself is whether I can work with this client. I also always
make a screening diagnosis of whether there are mental health issues for the
prospective client that mean that one-to-one sessions once or even twice a
week will not be sufficient or effective treatment for their problems, or that
their problems are beyond my skills to help. My work for a mental health
charity in West London in the early 1970s gave me training in, and a deep
understanding and experience of, the varieties of mental health problems
that people have and how to recognize them.
The next question in this basic assessment is whether the client and I
can establish an effective therapeutic alliance so that there is a good chance
he or she can make progress through consulting me. Related to that question
is whether the client recognizes that he or she has a problem that is treatable
by psychotherapy. I have on occasion been consulted by prospective clients,
at the instigation of their families or friends, who have not accepted that
they have a problem, which makes therapeutic work impossible.
With Matthew there seemed a basic developmental issue of why he was
not progressing into adulthood and starting a family, which seemed to form
the basis of his therapy with me. This involved an exploration of his thoughts
and feelings about his experience and understanding of his adoption, his early
childhood, and also his difficult and sometimes rebellious adolescence. I felt
at times like a mentor, older brother, or parent. At other times 1 felt more
like a fellow traveler on the spiritual and therapeutic journey.
Matthew sometimes seemed to take up my suggestions too readily, some-
thing that I explored in supervision: Was I becoming too much of an expert
for him? It seemed clear that, in fact, he was taking up that which was of use
to him, making it his own, and developing it further for himself in his own
unique way.

TREATMENT PROCESS AND OUTCOMES

Rather than cover Matthew's therapy with me in some detail, which, to

do it justice, would take a whole book, I have decided to select some parts of
the case narrative that especially reflect the spiritual interventions used.
However, it must be recognized that much of the work could be seen and
understood in fairly conventional therapeutic terms, but for Matthew and
me this was a therapeutic encounter that was infused with spirituality and
reflected the spiritual paths and spiritual journey we both saw ourselves as
being on. From this perspective, the whole of life is both sacred and spiritual.
I have, after consultation with Matthew, chosen not to focus on most
aspects of his family and his work life within this case study. It seemed espe-
cially and ethically important to gain Matthew's explicit permission to draw

A SUFI CONVERT 205

on his case material in a way that felt appropriate to him. Even when some of
the details are changed, clients can still feel uncomfortable with publication
of their experiences. (I have explored issues relating to ethics in therapy and
therapy research elsewhere; West, 2002b.)
However, it does need to be acknowledged how important the thera-
peutic work was around Matthew's adoption. Previous therapeutic work with
adopted clients had alerted me to how less firmly rooted or grounded they
might feel. It felt as if the work around Matthew's adoption was a necessary
prelude to him being able to move on developmentally in his life. It also
raised profound spiritual questions, some of which were explored in the ses-
sion I alluded to previously.
Inevitably the early sessions were spent in hearing something of his
story, why he had come for counseling, and in an exploration of some imme-
diate issues at work. To give a flavor of these early sessions, I include some
extracts from my case notes at the time:

One session: At work in the multidisciplinary team it had been easier for
him this last week, but he felt that his spiritual side was still not fully
acceptable, however he had challenged a woman who he felt was trying
to shame him. He read me a poem he had written, which I was very
moved by. Apparently I am the only person he can talk to about his
spirituality outside of the weekly meditation group he belongs to. His
work with me is getting more explicitly spiritual.
Next session: He said that he feels he is now more authentic, more his
true self, and he offered a powerful image of him spiritually climbing a
ladder to heaven, but having other bits to his self that were maybe left
behind.
I feel that he is still telling me so little, but he is talking about things
he tells no one else, and I value his sharing them with me, and I hope
that I convey this to him. I praised him for the poem from our last session
and said how it stayed with me all week, but it was very hard for him to
accept this praise. He told me a moving Sufi story, which I compared to
the death of Jesus.
One week later: He said he was not ready to face the truth about his
adoption and what it meant to him. Clearly, despite his feeling of not
being ready, he is beginning the therapeutic and spiritual journey, but it
feels painful and difficult.
Next session: Perhaps this is a real turning point, he was angry with
God in the session, and I feel that this could just help to begin to heal
issues about his adoption.

There were also several key moments some months into his therapy. In
one session, I was moved to share with him that his spirituality had a feeling
or flavor of the Middle East or Istanbul, a sense of a place where East meets
West. This reflected my feeling, which I had not expressed, that his spiritual-
ity was in some way different from Christianity. (In retrospect, it also could

206 WILLIAM WEST

have reflected his mixed race origins.) He was pleased by what I said and
shared the fact that he was a Sufi. Looking back on his therapy, there was a
pattern of Matthew choosing when to share key aspects of himself with me.
A similar withholding occurred later in relation to him telling me about a
key sexual, possibly abusive, relationship from his past, which I am unable to
discuss further here not having Matthew's permission to do so.
It is interesting to reflect that one way of understanding Quakers is to
see them as essentially a mystical group (Jones, 1921); indeed the Quaker
focus on experiencing God, on the value of silently waiting (Gillman, 1988),
underlines this viewpoint. Likewise, Sufis are also considered as representing
the mystical tradition within Islam. This I think made it more possible for
Matthew and me to share the frequent silences that appeared to have a huge
therapeutic value for him during our sessions. I think this shared mystical
focus on experiencing the Divine and on waiting for Divine guidance gave us
a common spiritual or theological base with which to work. I was conse-
quently less challenged spiritually by Matthew than some of my other spiri-
tually minded clients who held a religious outlook different than my own. It
was as if with Matthew we simply shared the spiritual nature of our encoun-
ter rather than trying to make shared theological sense of it—the focus was
on experiencing rather than on theorizing or theologizing.
One session soon after this Matthew said that he was afraid of the "spiri-
tual intimacy" that was occurring between us. I was very struck by this phrase.
By exploring what this meant, Matthew referred to the silences that arose in
our sessions that had a healing effect on him, the synchronous way words and
images that overlapped came to both of us, and the feelings of
interconnectedness that arose especially in the silences. It seemed important
to me to check out with him what role he was experiencing me in, as I was
wary of in any way becoming his spiritual director and what that could mean.
He replied that I was his counselor, that he had a spiritual teacher but that
because his spirituality was important to him, he wanted to be able to ex-
plore it in his therapy with me. I was relieved to hear this.
A few sessions later I had an experience in the silence with him of
dropping into a very deep place that I can, and do, reach on occasion in
meditation or spiritual contemplation. I felt that I was on the edge of going
so deep that I would lose all ordinary consciousness. I knew that it was not
appropriate for me to go any deeper in the middle of a counseling session, but
I was reluctant to bring myself out of being on the edge of this very deep and
very spiritual space. I was thus able to relate to him from that deep space. It
seemed very important. I assumed that my going there had meaning; it was
not just an accident. It felt important to stay there in that deep space and not
to break contact or consciousness. I did find a way of speaking to him from
that deep space without losing it.
I felt that I was on an edge, I could either go deeper into the space or
come back to a more ordinary way of relating. It was almost as if I was on the

A SUFI CONVERT 207

edge of falling or dropping down inside myself, which felt physically located.
In that moment I did not quite know what this meant. It was, I think, part of
that spiritual intimacy that he had referred to earlier, and part of that was not
always knowing exactly what was going on but trusting in the spiritual pro-
cess that was unfolding. Some of it, I think, was saying to him that this is OK,
that it was OK for him to be in a similar deep and spiritual space. At some
level it felt like a kind of mentoring, being in silence with him from a deep
space, not having to come out of it, staying with that space and with him at
the same time. There was something different about being there with him in
that session and an extraordinary feeling of "holding" that deep space, not
having to come out of it, and not going so deep that I lost that connection. It
felt risky but very important.
Although Matthew had explored his difficulties at work throughout his
therapy with me, especially working within a large multidisciplinary,
multicultural team, the full story did not emerge for many months. He had
been blamed and had subsequently felt both ashamed and angry for a mistake
that had occurred at work. The mistake was for something that was not truly
his fault. It seemed especially important that this whole area of his experi-
ence could be safely brought out into the light of day within his therapy with
me. Clearly the whole incident had proven damaging to him and his rela-
tionships with colleagues. The challenge to him was to find a place from
within which he could forgive and self-forgive. This all seemed part of a
maturing process that also included him successfully applying for promotion
to deputy in the nursing department he worked in.

THERAPIST COMMENTARY

Some of Matthew's therapy could be conceptualized in nonspiritual terms

as being about a developmental need on his part, a need to heal the trauma of
his adoption soon after birth, to deal with his difficulties at work, his need to
find a sexual partner, and so on. However, this misses the truth that Mat-
thew saw himself as being on a spiritual path, that he chose to have therapy
with me because of my spiritual approach to therapy, and that there was for
both of us some explicitly spiritual experiences and spiritual content in the
therapeutic encounter.
It is hard to imagine the spiritual moments in Matthew's therapy with
me occurring without our shared acceptance of the spiritual dimension to
life. No doubt a skilled secular therapist would have benefited Matthew, but
would such a therapist have welcomed Matthew's spiritual explorations? It is
known that such acceptance is not always forthcoming (Richards & Bergin,
1997; Rowan, 1993; West, ZOOOb). A negative or nonwelcoming attitude
to spirituality would have likely caused Matthew to withdraw. It is impor-
tant to notice how long it took for him to make some key disclosures about

208 WILLIAM WEST

his spirituality and sexual history to me. Without a positive attitude to
spirituality, Matthew's therapy would have likely remained superficial and
of a short duration.
It is apparent that Matthew changed in several key ways during his
therapy with me—there were improvements in his self-esteem, his progress
at work, and his ability to form intimate relationships (not covered in this
case study). For a spiritually minded person like Matthew, these changes would
be inseparable from his spirituality.
It could prove helpful to consider the spiritual aspects of my therapeu-
tic work with Matthew in light of the list of possible spiritual intervention in
therapy put forward by Richards and Bergin (1997). Their list is as follows:

Praying for clients, encouraging clients to pray, discussing theological

concepts, making references to scriptures, using spiritual relaxation and
imagery techniques, encouraging forgiveness, helping clients live con-
gruently with their spiritual values, self-disclosing spiritual beliefs or ex-
periences, consulting with religious leaders, and using religious biblio-
therapy. (p. 128)

I consider these items in turn:

1. Praying for clients. I did not specifically pray for Matthew, as

I never felt that he was especially in need of prayer during or
after his therapy sessions with me. I did on several occasions
pray during a session that I would be of best use to him at
moments when things seemed especially stuck or difficult.
2. Encouraging clients to pray. This did not seem at all appro-
priate. Matthew had his own active spiritual life that I knew
included meditation and other spiritual practices that I was
not fully aware of. I also have only somewhat limited knowl-
edge of Islam and of Sufism.
3. Discussing theological concepts. This did occur on occasion,
very often at Matthew's prompting.
4- Making references to scriptures. This occurred fairly often at
Matthew's prompting and occasionally at mine.
5. Using spiritual relaxation and imagery techniques. In the oc-
casions described previously, spiritual relaxation could be said
to be implicitly happening.
6. Encouraging forgiveness. This occurred in the sense that Mat-
thew needed to forgive members of his work team for their
unwarranted attack on him over the alleged "mistake" dis-
cussed earlier and let go of his subsequent anger toward them.
It also occurred, in a more defused sense, through my encour-
aging Matthew to self-forgive for not achieving and not be-
coming the full-fledged person that he was capable of being.

A SUFI CONVERT 209

 7. Helping clients live congruently with their spiritual values.
This was implicitly and sometimes explicitly a key feature of
Matthew's therapeutic work with me.
8. Self-disclosing spiritual beliefs or experiences. This was an
important aspect of trust-building, especially in the early stages
of our work together.
9. Consulting with religious leaders. This did not seem appro-
priate or necessary.
10. Using religious bibliotherapy. This did not arise in the course
of therapy.
In my discussion elsewhere of Richards and Bergin's (1997) spiritual
interventions (West, 2000b), I added one extra element—the rather broadly
based "use of spiritual intuition or inspiration," which I felt was a key feature
of Matthew's therapy with me. There is a growing body of literature and
research that covers spiritual moments in psychotherapy (e.g., Mearns &
Thome, 1988; Richards & Bergin, 1997; Rogers, 1980; Rowan, 1993; Thome,
1991; West, ZOOOb). Rogers (1980) in particular spoke of his experience of
what he called presence:
I find that when I am closer to my inner, intuitive self, when I am some-
how in touch with the unknown in me, when perhaps I am in a slightly
altered state of consciousness in the relationship, then whatever I do
seems to be full of healing. Then simply my presence is releasing and
helpful.... I may behave in strange and impulsive ways in the relation-
ship, ways which I cannot justify rationally, which have nothing to do
with my thought processes.... At these moments it seems that my inner
spirit has reached out and touched the spirit of the other. . . . Profound
growth and healing energies are present, (p. 129)
Was this experience described by Rogers a version of the "spiritual inti-
macy" that Matthew feared? Does it not also encompass the deep spiritual
and meditative space that 1 found myself in with Matthew in the session
described above? I think both are true.
Writing within the client-centered tradition, Thorne (1991) also spoke
of special spiritual moments in therapy similar to Rogers's presence, which he
called tenderness. Significantly, Thorne stated that he no longer had to "leave
my eternal soul outside the door" of the counseling room and that he could
now "capitalize on many hours spent in prayer and worship" (Meams &
Thorne, 1988, p. 37). It seems to me that my openness about wanting to
work explicitly around spirituality with my clients had a similar healing ef-
fect on my own splitting off of some aspects of my spiritual nature from my
therapist self.
To perhaps extend this further, one could consider the work of the Jew-
ish philosopher Martin Buber (1923/1970), who has influenced many hu-
manistic and transpersonal therapists, especially within modern gestalt

210 WILLIAM WEST

therapy. Buber contrasted the potential to treat one another either as an
object or It, and thus forming in an I-IT relationship, or to treat another as
subject or Thou in an I—Thou relationship in which God or spirituality is to
be found in the meeting, or between the people. It is a controversial question
of how much the therapeutic encounter can be truly I—Thou, given the power
imbalance in the relationship between client and therapist. This was dis-
cussed in a famous public dialogue between Rogers and Buber, and I have
explored this issue in some depth elsewhere (West, ZOOOb). One could see
the spiritual moments in Matthew's therapy with me as something akin to
Buber's I-Thou relationship.
Through working with Matthew, I learned a lot about working with my
clients' spirituality. I also learned a lot about my own spirituality. It was a
challenging and rewarding experience to share his spiritual unfolding. As
Rogers (1980) said about his idea of presence, "At these moments it seems
that my inner spirit has reached out and touched the inner spirit of the other"
(p. 129). It was, and is, a rare privilege to share that aspect of my nature so
frequently in the human encounter that is the therapeutic relationship.

REFERENCES

Buber, M. (1970). I and thou. Edinburgh, England: Clark. (Original work published
1923)
Dandelion, B. P. (1996). A sociological analysis of the theology of Quakers. Lampeter,
England: Edwin Mellen.
Gillman, H. (1988). A light that is shining. London: Quaker Home Service.
Jones, R. (1921). The later periods of Quakerism. London: MacMillan.
Mearns, D., &Thome, B. (1988). Person-centred counselling in action. London: Sage.
Richards, P. S., & Bergin, A. (1997). A spiritual strategy for counseling and psycho-
therapy. Washington, DC: American Psychological Association.
Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.
Rowan, J. (1993). The transpersonal: Psychotherapy and counselling. London: Routledge.
Thome, B. (1991). Person-centered, therapeutic and spiritual dimensions. London: Whurr.
West, W. S. (2000a). Eclecticism and integration in humanistic therapy. In R. Woolfe
& S. Palmer (Eds.), Integrating and eclectic counselling and psychotherapy (pp. 218-
232). London: Sage.
West, W. S. (2000B). Psychotherapy and spirituality: Crossing the line between therapy
and religion. London: Sage.
West, W. S. (2000c). Supervision difficulties and dilemmas for counsellors and psy-
chotherapists around healing and spirituality. In C. Feltham & B. Lawton (Eds.),
Taking supervision forward: Dilemmas, insights and trends (pp. 113-125). London:
Sage.

A SUFI CONVERT 211

West, W. S. (2001, August). Retreats. Newsletter of the Association for Pastoral and
Spiritual Care and Counselling, 6-7.
West, W. S. (2002a). Being present to our clients' spirituality. The Journal of Critical
Psychology, Counselling and Psychotherapy, 2(2), 86-93.
West, W. S. (2002b). Some ethical dilemmas in counselling and counselling re-
search. British journal of Guidance and Counselling, 30(3), 261-268.

212 WILL/AM WEST

 A MORMON RATIONAL EMOTIVE
13
BEHAVIOR THERAPIST ATTEMPTS
QUR'ANIC RATIONAL EMOTIVE
BEHAVIOR THERAPY
STEVAN LARS NIELSEN

DESCRIPTION OF THERAPIST

Professional and Religious Background

I received a doctorate in clinical psychology from the University of

Washington (UW), practiced for 7 years in the U.S. Army, and have prac-
ticed for the last 14 years at the Counseling and Career Center at Brigham
Young University (BYU), where I am a clinical professor. I teach and super-
vise for the counseling center's internship and BYU's clinical psychology
program. I am an associate fellow of the Albert Ellis Institute for Rational
Emotive Behavior Therapy (REBT) and a certified REBT supervisor. I have
provided about 24,000 psychotherapy sessions to about 2,800 clients during
my career.
I was born and raised in Salt Lake City, UT, headquarters of the Church
of Jesus Christ of Latter-day Saints. My ancestors were among the Church's

213
earliest members. One of my great'great-grandfathers was a friend of Joseph
Smith, the first Mormon prophet. He joined the exodus from Illinois to es-
cape the persecutions that cost Joseph Smith his life. With his family he
helped explore and settle the Great Basin when it was a wilderness outside
the United States. Despite this heritage, my father and two older brothers
hated the Church and I grew up an agnostic hippie. Partly from curiosity and
partly in rebellion against my family, I attended BYU where religion is an
unabashed element of classroom instruction and Mormonism part of day-to-
day university culture. At BYU my religious experiments led me to devout
belief.

Religion, Psychology, and REBT

At BYU I took a personality course from and then worked as a research

and teaching assistant for Allen Bergin. Allen's recounting of his religious
conversion helped bring greater clarity to my thinking about religion and
science. After working with Allen I decided to study clinical psychology. I
worried initially that my beliefs would meet with hostility in graduate school,
but my UW professors and most of the students were respectful of all kinds of
diversity, including religious diversity. Clinical psychology at UW was overtly
behavioral and aggressively scientific, but it was also encouraging of student
investigation of various psychological topics and therapeutic orientations:
My first supervisor, Leslie Rabkin, was a psychoanalytically oriented thera-
pist. My dissertation chair, Irwin Sarason, encouraged, guided, and supported
my curiosity about psychodynamic concepts, including experimental exami-
nation of selective attention as an analogue of unconscious processing (Nielsen
& Sarason, 1981).
As an intern I experimented with and was won over by REBT's elegant
goal of helping clients adopt more functional philosophies of life. With REBT
organizing the psychotherapy I practice, I began to adopt a rational-emotive-
religious philosophy of life. I remember feeling surprised that Ellis's atheism
was irrelevant to my thinking about REBT, but I now see that his hostility
toward religion was less severe and troubling than what I had experienced at
home.

1 Met Albert Ellis on a Dare

When I began practicing at the BYU counseling center, I saw that REBT
worked well with my many devout clients. There was no contradiction be-
tween scripture and REBT—indeed, scripture facilitated REBT. Allen Bergin
suggested I debate Ellis about this—he dared me, really. I wrote Ellis suggest-
ing that we discuss integration of religion with REBT and he agreed (Ellis,
1994a; Nielsen, 1994; Nielsen & Ellis, 1994). We disagreed about religious
verities—no surprise—but agreed that although he is an atheist, REBT is

2 ]4 STEVAN LARS NIELSEN

neutral toward religion. We also agreed that philosophical tenets in most
major religions mix well with REBT and probably can facilitate treatment of
religious clients. Subsequent collaborations (Ellis, 2000; Johnson & Nielsen,
1998; Johnson, Ridley, & Nielsen, 2000; Nielsen, Johnson, & Ridley, 2000;
Robb, Schneiman, & Nielsen, 2001) led to development of an empirically
supported (Johnson, DeVries, Ridley, Pettorini, & Peterson, 1994; Johnson
& Ridley, 1992), religion-integrative version of REBT. A book-length treat-
ment manual (Nielsen, Johnson, & Ellis, 2001) describes this approach. This
chapter describes using the Qur'an with REBT to treat a Muslim woman.

SETTING FOR THE CASE

BYU's counseling center is one of the largest in the nation; we provided
approximately 23,000 individual and group psychotherapy sessions to about
3,000 of BYU's 30,000 students in 2001. Most BYU students are devout Mor-
mons who commit to attend worship services and religious instruction; to ab-
stain from sexual intimacy outside marriage; and to abstain from coffee, tea,
tobacco, alcohol, and drugs. Non-Mormon students commit to follow these
rules as a condition of enrollment, but they are not required to attend worship
services. Although most of the clients are devout, consistent with professional
and ethical standards the counseling center requires neither religious belief
nor adherence to university standards as conditions of treatment.

CLIENT DEMOGRAPHIC CHARACTERISTICS

Aisha, a 24-year-old single woman, had just begun her second semester
of doctoral studies in biochemistry when she sought treatment. She was born
in a New York City hospital while her father was assigned to the home
country's United Nations mission. Two younger sisters were born in the home
country, which, while officially secular, is predominantly Muslim. Aisha at-
tended private schools in the home nation and in three international cities.
She earned an undergraduate degree in organic chemistry at the home
country's national university. She spoke four languages fluently, the predomi-
nant home country language, Arabic, French, and English.
Aisha and her family followed Sunna, the code of ethical and religious
behavior derived from Muhammad's sayings and deeds; they heeded the five
daily calls to prayer, attended worship at mosque, gave to the poor, abstained
from pork and alcohol, and fasted daily during the monthlong celebration of
Ramadan. Aisha, her sisters, and mother wore scarves to cover their hair
during worship, but not in public. Her parents had completed the Hajj, the
pilgrimage to Mecca required at least once in a lifetime of healthy, finan-
cially able Muslims. Aisha had, on arriving at BYU, ascertained the Qiblah,
the direction of shortest distance to the Kaaba in Mecca toward which Mus-
lims should pray. In Provo, UT, the Qiblah is 28.8°, North by Northeast.

QUR'ANIC RATIONAL EMOTIVE BEHAVIOR THERAPY 215

Aisha prayed five times every day, though not always at prescribed times
because of a lack of privacy.

PRESENTING PROBLEMS AND CONCERNS

At intake Aisha completed the Counseling Concerns Survey (Drum &
Baron, 1998), an alphabetical list of 42 problems college students sometimes
face, providing an index of her level of distress and focal topics for the intake
interview. Aisha described "Extreme" or "Quite A Bit" of distress on 9 of the
42 problems: academics, depression, discrimination, homesickness, making
friends, perfectionism, sexual assault, stress, and uncertainty about her future.
I asked first about sexual assault. Aisha wept and said, "That happened
before I came here. I'm not ready to talk about it. Is that all right?" I assured
her this was all right and asked whether she would prefer to meet with a
woman. She said she preferred not to switch.
I next asked about discrimination. During her first semester, shortly
after the attack on the USS Cole in Yemen, one of Aisha's professors—Pro-
fessor Doe—had taken her aside and asked why Muslims want to kill Ameri-
cans. She was shocked by the question and "froze up" briefly before replying
that "fanatics do such things, not true believers." She received an "A-" grade
in the course, though she believed she deserved an "A." Aisha's distress about
academics, her perfectionism, and her uncertainty about the future were linked
to fear that Doe's prejudices could ruin her grades.
Aisha tearfully explained that her other answers came from distress about
finding a husband. She would not date non-Muslims and Muslim men at
BYU were "too misogynistic." She had decided to assert her right to U.S.
citizenship because of sexism at home. Her mother had encouraged this, but
advised her not to tell her father or sisters. It might anger her father and
make her sisters envious. There were growing numbers of professional women
in the home nation and most women in the middle and upper classes re-
jected wearing scarves in public, but new fundamentalist movements had
created tensions about this. Aisha believed women in the home country would
face significant new difficulties in the future and she was sure that she would
have more professional opportunities and find more like-minded Muslim men
in the United States.

CLIENT HISTORY
Although not wealthy, Aisha's family enjoyed privileges because of her
father's diplomatic work. Aisha had a close relationship with her mother, but
she felt distant from her father, who was both austere and quite busy with his
duties in the home country's diplomatic corps. The sisters attended private
schools paid for by the government when posted outside the home country.
Her parents had, with difficulty, paid for private schools in the home coun-

216 STEVAN LARS NIELSEN

try. All three sisters had excelled academically, entitling them to free educa-
tion at the national university.
A year earlier Aisha had failed in an attempt to gain admission to a U.S.
medical school, probably because of a noncompetitive medical school admis-
sions test score. Graduate study in biochemistry was a second choice, and BYU
was a second tier biochemistry program by her estimation. Her parents had
wanted her to attend BYU because of its conservative reputation. Aisha hoped
that studying for the medical school admissions test and participating in scien-
tific research could help her win admission to a U.S. medical school.
At the end of our sixth session Aisha was ready to discuss the sexual
assault, but said she could only write, not talk about it. In an e-mail she wrote
of coming to New York and moving in with two young women she knew
from an international high school. She intended to work while managing her
medical school applications. Her friends had sexual relationships with boy-
friends, which appalled her, but she said nothing. One of the roommates had
two Muslim friends, young men who were students, who visited the apart-
ment. Aisha was uninterested in them, believing their home country more
sexist than her own. One of these men called from the security door of the
apartment building on a Friday evening when both roommates were away for
the weekend. Aisha "buzzed" him in without stopping to think that she was
alone. He asked about her roommates, struck up a conversation about being
Muslim in the United States, then left. Aisha found him interesting, intelli-
gent, and detected none of the sexism she had anticipated. She did not hesi-
tate to let him in the following evening. He sat next to her as they spoke, and
then suddenly kissed her. She had never kissed a man before and overt dis-
plays of affection are considered inappropriate in the home country. She also
found the kiss exciting and kissed him back. He began to fondle her breasts.
She tried to push him away, but he persisted. She tried again to stop him and
he slapped her, restrained her, and raped her. As he left he told her she had,
after all, let him in and kissed him back.
The next day, Sunday, Aisha called home, complained that she felt
homesick, and asked for a plane ticket home. Monday morning she told her
roommates, who had returned late Sunday night, that her father was seri-
ously ill. She quit her job and flew home that evening. Aisha had no further
contact with the roommates or with the man who had raped her. This was, a
year later, the first time she had told anyone of the rape. She was uninter-
ested in contacting police.

ASSESSMENT AND DIAGNOSIS

Psychiatric Diagnoses

Aisha described symptoms consistent with Posttraumatic Stress Disor-

der according to the Diagnostic and Statistical Manual of Mental Disorders (4th

Ql/R'ANIC RATIONAL EMOTIVE BEHAVIOR THERAPY 217

ed., text rev., DSM-IV-TR, American Psychiatric Association [APA], 2000)
Axis I, code 309.31, including fear during the rape, later flashbacks, night-
mares, and sudden physiological arousal. Women in the home country were
considered responsible for rape if they had allowed themselves to be in "com-
promising circumstances." Subsequently, consistent with a major depressive
episode of mild to moderate severity (Axis I, code 296.21; DSM-IV-TR,
APA, 2000), she had lost interest in many formerly enjoyed activities, suf-
fered at times from insomnia, from hypersomnia at other times, felt persis-
tent guilt, and a sense of worthlessness. She often wanted to die, but had no
intent to kill herself. Aisha was critical of herself and anticipated that others
would also be critical of her. Fear of criticism led her to avoid most socializ-
ing. This was worse after the rape, suggesting that an avoidant personality
style had been present before the rape and was now intensified. Her response
to treatment suggested dependent tendencies. The attack on the USS Cole
and professor Doe's comments had been moderately stressful (DSM-IV-TR,
Axis IV). Despite these problems, Aisha performed well in rigorous course
work, suggesting a Global Assessment of Functioning score of about 60 (DSM-
IV-TR, Axis V).

Psychometric Assessment

Counseling center clients are encouraged to complete the 45-item Out-

come Questionnaire (OQ 45; Lambert et al., 1996) before each session. The
OQ 45 summarizes client report of near-term emotional, interpersonal, and
role functioning; higher scores reveal report of worse functioning. I encour-
aged but did not insist that Aisha complete OQ 45s. Figure 13.1 depicts
OQ 45s, annotated with session numbers and standardization indexes.

TREATMENT PROCESS AND OUTCOMES

The First Session

REBT's A-B-C model (Ellis, 1994b) proposes that it is not Activating

events (A's) by themselves, but A's plus irrational Beliefs (B's) about A's
which yield self-defeating emotional and behavioral Consequences (C's).
REBT theory holds that three main kinds of irrationally evaluative beliefs
(lEBs) cause self-defeating reactions: human rating, demanding, and
catastrophizing. All three lEBs were obvious during the intake session:
(a) Aisha downed herself about grades, (b) demanded near perfect grades,
and (c) catastrophized about poor grades. The clarity with which Aisha ex-
pressed her lEBs allowed us to begin during the intake:

218 STEVAN LARS NIELSEN

 130-
125-
120-
Jacobson-Truax reliable change index
115-
110- 1}
105-
100-
95-
0) 90-

O 85"
O 80-
CO 75_ Average for clients at

g-J
"co ; counseling centers

o 45
40- selected university students
........
o 35--
30-
25-
20-
15-
10-
5-
0,
1-27-01 I 2-24-01 | 3-24-01 I 4-21-01 I 5-18-01 I 6-15-01 I 7-13-01 I 8-10-01 I
2-10-01 3-10-01 4-7-01 5-5-01 6-1-01 6-29-01 7-27-01 8-24-01
Date

Figure 13.1. Aisha's scores on the 45-ltem Outcome Questionnaire (OQ 45;
Lambert et al., 1996) annotated with the session numbers when OQ 45s were
completed. Dotted lines depict average scores among nonclient university students,
clients at counseling centers, and psychiatric inpatients. A solid line depicts the
statistical midpoint between mean scores in clinical and in nonclinical samples
(63.4 points); this midpoint is suggested as a minimum criterion for judging a
client's score to indicate clinically significant recovery (Jacobson & Truax, 1991). A
bracketed vertical bar depicts the reliability boundary for a difference between any
two OQ 45 scores (± 14 points) given the OQ 45's psychometric properties;
Jacobson and Truax (1991) call this reliability range the reliable change index.

SLN: But you earned an A— in the class despite his discriminatory

statement—I agree with you, by the way, that his statement was
discriminatory. It's too bad other students didn't hear him, since
he violated antidiscrimination policies. Was grading objective?
Aisha: Yes and no. If he had given me the credit I earned, I would have
gotten an A. He said I left information out of a proof. When I
look at that grade, I feel like a failure!
SLN: But failure is not a feeling. You're telling yourself that an A-
makes you a failure and the emotion comes from believing that
you are a failure. Let's try something: Close your eyes, look at
your grade, now tell me again how your feel, but don't use the
word failure.
Aisha: But I feel like a failure!

QUR'ANIC RATIONAL EMOTIVE BEHAVIOR THERAPY 219

 SLN: Okay. But what are some other feeling words that could de-
scribe how you feel?
Az'sha: I feel like a loser, like I'm bad.
Aisha's self-rating and the shame it caused were fused. Her belief that
she was a loser and the emotional consequence of that belief were one thing.
I tried to help her analyze her experience:
SLN: Let's see if we can agree about something here: You believe that
you are a failure and you feel ashamed. You believe that you are
a failure if you fail a class or get an A—.
Aisha: I know that doesn't make much sense, but that's what I feel.
SLN: Oh, it makes human rating sense. If anyone believes—really be-
lieves—that they're worth less, they'll feel depressed. You are
rating all of you based on your performance.
Aisha: What else would 1 do?
SLN: It may seem to make sense, but the implications don't hold up.
For example, squeeze this handgrip dynamometer (for neuro-
psychological testing]. Now I'll squeeze it. My hand is more than
twice as strong. So I'm twice as valuable as you?
Aisha: No [she laughed], only twice as strong.
SLN: The dynamometer is scientifically calibrated, but not for mea-
suring humanness. If we can't make a valid instrument for mea-
suring humanity, we can't evaluate human worth. It's not A,
the Adversity of earning a lower grade than you want—go ahead
and want what you want, by the way—but B, the Belief that you
are less because of a lower grade creates C, the emotional Con-
sequence of feeling ashamed or depressed.

Deepening and Generalizing

Aisha tentatively agreed with the A-B-C model and with trying to give
up human rating. We discussed the university's discrimination complaint
process, but decided the risks outweighed the possible slight benefits. As she
worked on her self-rating she experienced gradual relief (see Sessions 2 through
6 in Figure 13.1). She e-mailed her account of the rape to me on the day
before her seventh session. As she sat down in my office for Session 7 she hid
her face, burst into tears, and said, "How can you stand to look at me? I feel so
dirty! So guilty!"
Guilt is another important example of experiential fusion. REBT theory
treats guilt not as an emotion, but as a complex blend of beliefs, emotions,
and behavior (Nielsen et al., 2001). Aisha's Activating event was both recall
of the rape and the inferential idea, "I am guilty of doing something dirty."
Her A was both memory and inference that she was guilty. A was also blended

220 STEVAN LARS NIELSEN

with the evaluative Belief (B), "I, therefore, am dirty." B was then blended
with the joint emotional and behavioral Consequence (the C) of shame.
B in the A-B-C model is more complex and deep than an internal de-
clarative statement. REBT's goals are more holistic than changing internal
self-talk. In both his first (1958) and in his most recent (2002) treatises about
REBT, Ellis called experience inseparably holistic:
Emotion, like thinking and sensori-motor processes, we may define as an
exceptionally complex state of human reaction which is integrally re-
lated to all the other perception and response processes. It is not one
thing, but a ... holistic integration of several seemingly diverse, yet
actually closely related, phenomena. (1958, p. 35, italics in original)

In 2002 he wrote:
Instead, then, of saying, 'Jones thinks about his puzzle,' we may more
accurately say, 'Jones perceives-moves-feels-thinks about his puzzle.' Be-
cause Jones' activity ... may be largely focused upon solving it, and only
incidentally on seeing, manipulating, and emoting about it, we may per-
haps emphasize only his thinking, (p. 9, italics in original)
The discrete words thought, perception, behavior, and feeling can seem to
separate facets of experience from one another. Disturbance is, more realisti-
cally, a holistic perception-inference-evaluative-belief-shame-avoidance ex-
perience like Aisha's "dirty," face-hiding, shame.
Language does, however, provide symbols useful in analyzing experi-
ence. The A-B-C model and the words REBTers cue in on as signs of irratio-
nal belief (should, awful, and so forth) are symbolic tools. Just as a musical
score is not, itself, music, neither are words irrational beliefs. But just as mu-
sic scores facilitate music theory, musical performance, practicing music,
musical publication, pedagogy, and so on, symbolic representations of irra-
tional beliefs can facilitate therapy. Human experience also mixes multiple,
shifting levels of conscious and unconscious experience. Individuals are prob-
ably unconscious of most of our irrational believing (Ellis, 1994b). But again,
just as reading music can raise our musical consciousness, so can highlighting
the language of irrational beliefs raise our consciousness about the role and
function of irrational beliefs in distress. Aisha's word "dirty" was a clear sym-
bol of her shame. Understanding the symbols in her self-rating provided Aisha
with useful tools for manipulating her beliefs.
Aisha had stopped rating herself about academics by Session 6, but her
self-acceptance was insufficient when pitted against her self-damning about
the rape. Her self-acceptance was conditional on viewing herself as clean or
pure. More persuasive belief change was needed.
Qur'anic REBT
REBTers use a wide variety of cognitive, behavioral, and emotive inter-
ventions to dispute lEBs, and create deep and broad changes in believing. A

QUR'ANIC RATIONAL EMOTIVE BEHAVIOR THERAPY 22 I

variety of strategies and styles have been delineated (Beal, Kopec, &
DiGiuseppe, 1996). The notion of a humanometer was a humorous attempt
to point out the illogic of rating humans without a scientific rating system. I
hoped the Qur'an could provide theologically authoritative material for dis-
puting Aisha's human rating. If Aisha could stop damning herself about the
rape, she would, I believed, move closer and closer to achieving uncondi-
tional acceptance of humans—but not unconditional acceptance of all hu-
man behavior—as a new philosophy of life.
God's view of humans increasingly seems benevolent to me. In the
Mormon scripture called the Pearl of Great Price God is recorded telling
Moses, "This is my work and my glory—to bring to pass the immortality and
eternal life of man" (Moses 1:39). According to the Book of Mormon, only
God may judge or rate humans: "The keeper of the gate [of judgment] is the
Holy One of Israel; and he employeth no servant there" (2 Nephi 9:41). I
thought I had read similar benevolent, fair-minded passages in the Qur'an,
and hoped Aisha could find and use them:
SLN: Then Allah is the same God in whom I believe. But Muhammad
was His only prophet?
Aisha: No. Abraham, Moses, Jesus, and others—all prophets.
Muhammad was His last prophet.
SLN: Not you?
Aisha: Of course not! [She laughed.]
SLN: I just wanted to make sure. What did God tell Muhammad about
who judges souls?
Aisha: He does.
SLN: Muhammad?
Aisha: No, no. God.
SLN: Not you!
Aisha: No! [She laughed.]
SLN: That's what you're doing. [She looked baffled.] Judging your-
self, when it's God's job.
Aisha: I'm not sure what you mean.
SLN: Did you get a phone call from God telling you that He's busy, so
please judge yourself? You tell me that not even Muhammad
gets to judge people. But you call yourself dirty. I guess you have
a special calling to stand in for God. Yes?
Aisfia: No. [She laughed a bit.]
SLN: Let's try a little experiment. Try saying this: It's God's job to
judge me. Not my job.

222 STEVAN LARS NIELSEN

 Aisha: It's God's job to judge me. Not my job?
SLN: Could you be less enthusiastic?
Aisha: [She laughed.] God judges people, no one else!
SLN: Did that feel any more believable?
Aisha: Yes.
SLN: Would you say it in [the home country language]? Say it as if
you really believe it? [She did.] In French? [She did.] In Arabic?
[She did.] Does that feel different?
Aisha: I felt less upset when I kept saying it.
SLN: Now I want you to shout i t . . . [she shook her head]... in your
head. Do you know what I mean by shouting in your head? [She
nodded.] Did that feel any different?
Aisha: I felt less upset.
These steps were attempts to add persuasiveness and pervasiveness to
her disputations. It makes no sense for Aisha to judge herself when God
commands otherwise, so I hoped pitting her against Muhammad would be
humorously evocative and more persuasively contradictory of self-rating. I
hoped that speaking more forcefully would be more evocative and persua-
sive. I hoped that speaking in different languages would make her self-talk
more pervasively persuasive.
Believing that homework is the best way to create pervasive change, I
asked if she prayed for guidance and she said yes. I asked her if a Muslim
could, in good conscience, pray about self-rating and the other issues we had
been discussing. Yes. Could she pray to see if we were on the right track? Yes.
Could she look for verses in the Qur'an that discuss judgment? Yes. She re-
turned to the next session with, "We [Allah] shall set up scales of justice for
the day of Judgment, so that not a soul will be dealt with unjustly in the
least" (Surat 3:47). This verse reassured her. Prayer had reassured her. Her
OQ 45 scores at Session 10 suggested that her distress was declining (see
Session 10 in Figure 13.1).
I asked Aisha if Muslims believe in repentance and forgiveness. She
said they do. I asked about repentance rituals, like Christianity's baptism.
She told me that repentance is a personal matter. I told her, "Even though I
think you've done nothing wrong, let's take the strictest possible position and
say it was a sin to be alone with that guy and that you are responsible. Re-
member, I don't believe it! But if it is true, what does the Qur'an say about
forgiveness?" Aisha returned with this comforting verse, "If you love God,
follow me, and God will love you, and forgive you all your sins; God is All-
forgiving, All-compassionate" (Surat 3.31).
I attempted to challenge Aisha's self-rating in a more emotionally evoca-
tive manner by juxtaposing her situation with the fantasy of one of her sisters

QUR'ANIC RATIONAL EMOTIVE BEHAVIOR THERAPY 223

being in the same situation. I asked her to imagine that one of her sisters had
been raped in New York by the same man. How would she evaluate them?
"Kindly," she said. How would God evaluate them? "The same, I think."
What would she, Aisha, think if someone, on learning that one of her sisters
had been raped, considered that sister to be filthy? "I would think he is an
idiot!" she said.
"Then why apply an idiotic standard to yourself?" I asked. This was
risky, but fit the tenor of the moment and she laughed at the difference—the
dissonance—between how she would judge her sister mildly, but judge her-
self harshly. She felt less upset as she reminded herself about this. I decided
to try a still more forceful dissonance disputation: "Suppose you learned your
mother and father had sex before they were married. Would you shun her?"
No, she would still respect her. Her mother would be no less self-assured,
assertive, or kind. By Session 15 her OQ 45 dropped to 64, just one point
above the recovery criterion (see Figure 13.1).
Aisha found that she enjoyed basic biochemistry research, but this cre-
ated new anxiety as she tried to decide between continuing in her doctoral
program or again trying to get into medical school (Session 17). Which was
right, she worried? She laughed when I asked which surat of the Qur'an com-
manded one to get a PhD or an MD. Then I asked, "Does the Qur'an declare
that we must go to paradise?" She answered that God gives us agency. She
laughed when I said, "If you don't have to go to paradise, you sure as Hell
wouldn't have to get a PhD or an MD—either one!" As a homework assign-
ment she wrote something like, "The Qur'an doesn't say I must anything," in
Arabic on her hand and rehearsed this phrase to herself frequently. She re-
turned to Session 18 with "O ye who believe! You have charge over your own
souls" (Surat 5.105) and "No compulsion is there in religion" (Surat 2.256).
Aisha began to feel encouraged. She was delighted that she did not
need to take any more classes from Professor Doe. Her advisor, Professor
Jones, had adopted several of her suggestions for one of his projects and had
also provided her with resources to conduct preliminary tests for a study she
had suggested. Aisha had begun spending free time with a classmate named
Maria and a postdoctoral fellow named Jan. Maria had converted to Mor-
monism while a graduate student in a South American country. Jan, an avowed
atheist, was from Scandinavia.
Four interrelated events threw Aisha into turmoil that Spring: She had
decided to apply to medical school, but feared this would upset Jones (Ses-
sion 22); she discovered that Jan had placed his name ahead of hers on a
technical report on which all three had worked, but which Aisha had de-
signed and analyzed (Session 23); she discovered that Jan and Maria were
having an affair (Session 26); finally, Jan invited, then pressured Aisha to
have an affair with him (Session 30). Aisha was uninterested in Jan, but
missed Maria, who was not working in the lab during that term. It was espe-
cially distressing when Jan began flirting with her (Session 29). He told Aisha

224 STEVAN LARS NIELSEN

that he and Maria were sexual partners and asked if she would like to join
them (Session 30). She told Jan to leave her alone, but he kept asking. He
had begun calling late at night trying to persuade her, which horrified her
(Session 31, see Figure 13.1). I downloaded a copy of BYU's sexual harass-
ment policy and assured her that BYU had no tolerance for such behavior.
Aisha was paralyzed by fear of what Jan, Maria, and Jones might think and by
fear about possible consequences for Maria if she made a formal complaint.
Before our next session I went to the Qur'an looking for something that
might help her stand up for herself. 1 found an index heading which directed
me to this verse, "And the believers, men and women, are protecting friends,
one of another; they enjoin the right and forbid the wrong, and they estab-
lish worship and pay the poor-due, and they obey God and His messenger"
(Surat 9.71). I read this to Aisha during Session 32 and asked if this spoke to
her in any way. Aisha said it indicated that it would be best for everyone,
Maria and Jan, if Jan stopped.
The next night Aisha tape-recorded a new harassing call from Jan—
this is legal in Utah. She then wrote three letters: First a letter to the director
of BYU's Equal Employment Opportunity office, which investigates and ad-
judicates harassment complaints, in which she identified herself and Jan and
stated that Jan had made two unwanted romantic overtures to her. She wrote
that she had declined the first overture and had asked Jan to desist, that after
the second overture she had repeated her request that he desist, and that she
had asked that he limit his contact with her to professional interactions at
school. She delivered copies of this letter to Jones—he was also Jan's supervi-
sor, to the chemistry chair, and to the physical sciences dean. She sent a copy
of the letter to Jan by certified mail delivered at the laboratory. She included
with the letter a note to Jan advising him that any further nonprofessional
contacts or any retaliation would be met with an immediate complaint, plus
full disclosure of all his previous statements, plus a transcript of the harassing
call he had made the night before. The call had been filled with crude sexual
references to Maria, which Jan thought might entice Aisha to meet him.
Aisha also sent a copy of the letter to Maria with a note warning her that she
could have disciplinary problems if she continued to spend time with Jan.
Aisha had worried most about how Jones would react. She felt quite
anxious when he asked her to come to his office the afternoon after she had
delivered her letters. To her surprise, Jones apologized for not having de-
tected Jan's behavior. He informed her that he, the chair, and the dean had
met with Jan, warning him that he was now in a probationary state and that
termination would be immediate should any new complaints arise. Aisha felt
encouraged by his reaction and exhilarated that she had been able to stand
up for herself.
Her OQ 45 scores showed a remarkable degree of improvement over the
next 2 weeks (Sessions 34 and 35). I wondered whether these changes might
be something like a flight to health, but I felt optimistic when Aisha said she

QUR'AMC RATIONAL EMOTIVE BEHAVIOR THERAPY 225

had come to believe she was no less deserving of respect than others. Her
letter writing epitomized the kind of synergistic effects belief change mixed
with behavior change can create: Self-acceptance had facilitated assertive
behavior which then further strengthened Aisha's self-acceptance. We fo-
cused on assertiveness during Session 36, practicing specific maneuvers she
might use when in situations where she would not have been assertive in the
past. When she next saw Jan in the laboratory she was able to fight the im-
pulse to look away by reminding herself that she was no more or less deserv-
ing of respect than anyone else and by looking between his eyes in order to
appear to be making eye contact.
In a very interesting bit of philosophizing, Aisha told me that she was
not angry with Jan. She made the interesting comment that his highly sexu-
alized, atheistic background was more "out of culture" with BYU than her
Muslim background.
Between Sessions 36 and 37 Aisha scheduled an appointment with Jones
to tell him she wanted to apply to medical school. He surprised her, telling
her she would be missed, but would make a fine physician if she chose that
route. He knew of biochemists in joint MD/PhD programs where he might
have some influence and offered to contact some of them.
We met one more time before the beginning of the next school year
(Session 38), and Aisha said she would contact me if she felt she needed to
meet again. Aisha told me she was not abandoning her romantic goals, though
she was adopting a slow, cautious approach. Her research was enjoyable and
time consuming, and she had become close friends with a group of women
she had met playing tennis. With the little time she had left she was trying to
get to know Muslim men at Internet chat sites; she said she had developed
several lines of conversation that she used to detect misogyny.
Aisha called me on the afternoon of September 11, 2001 to express her
outrage at the attacks on the World Trade Center and the Pentagon. I asked
if she wanted to meet, but she did not think it necessary. Professor Jones and
her tennis friends had asked her to spend time with them in case she became
a target for retaliation. She announced to a class she was teaching that she
was proud to be an American citizen and dismayed that vicious fanatics would
subvert God's laws. She has phoned me seven more times over the past 15
months to tell me she is doing well. She is close to finishing her doctorate in
biochemistry at BYU.

THERAPIST COMMENTARY

Rationality and Religious Neutrality in REBT

Although REBTers are alert to violations of consensually agreed-on

reality—bizarre ideas, for example—this is not the problematic irrationality

226 STEVAN LARS NIELSEN

of primary interest in REBT. REBT focuses, rather, on absolutistic evalua-
tions. Human rating, demanding, and catastrophizing can be conceptualized
as absolute evaluations. In the case of human rating a human being's essen-
tial or absolute humanness is most often evaluated as unacceptable. During
demanding and catastrophizing some event in the world is evaluated as being
unacceptable. Aisha's shame epitomized this kind of arbitrary absolutism:
She evaluated not just a few of her behaviors as flawed or possibly unwise,
but because she let the man who eventually raped her into her apartment
and because she kissed him, Aisha evaluated all of her, her essence, as dirty.
She was unacceptable. Humans, their behavior, and the world in general are
too complex for such global evaluations to be reasonable.
Cultural conceptions of morality in Aisha's home country led Aisha to
see herself as culpable, whereas most Americans would see the man as cul-
pable for rape—very different worldviews, to be sure. Religious doctrines may,
similarly, dictate very different worldviews. But whether Aisha and I agreed
about culpability for rape, whether we agreed about most religious doctrines,
we could still reasonably work on helping her achieve self-acceptance. With-
out agreeing or disagreeing about her culpability, we could always work to
show her that she was more than her behavior on the night she was raped.
It is possible, of course, that some religious traditions will rate humans,
will make absolute demands, or will view some form of human adversity as
catastrophic. This would complicate doing REBT with adherents of such re-
ligions and would likely preclude use of such religions' scriptures or theolo-
gies to support REBT. However, the Qur'an does not, the Bible does not, the
Book of Mormon does not, the Baghavad-Gita does not, the fundamental
scriptures and theologies of most religious traditions do not, at their core,
seem to rate humans, impose demands counteracting human freedom of
choice, or consider human adversity catastrophic. Quite the contrary, most
scripture provides philosophical material for disputing human rating, demand-
ing, and catastrophizing.

My Theistic Stance

Religious clients may fear that psychotherapists will disrespect their

beliefs. It probably helped Aisha to see the Qur'an in my office, sitting next
to copies of the Bible, Book of Mormon, Doctrine and Covenants, and Pearl
of Great Price. She probably felt confidence that I would respect her beliefs
when we opened my copy of the Qur'an and she saw that I had marked pas-
sages that interested me. I need not have been theistic to have read scripture,
of course. I am what Richards and Bergin (1997) call a theistic therapist, but
an atheistic therapist might have had a deeper, more expert understanding of
Islam than I. Would the outcome have been different had I been an atheist?
In the one controlled test comparing atheist and Christian therapists treat-

QUR'AMC RATIONAL EMOTIVE BEHAVIOR THERAPY 227

ing Christian clients, atheists who used religious material to supplement cog-
nitive behavior therapy helped their clients at least as much as the Christian
therapists (Propst, Ostrom, Watkins, Dean, & Mashburn, 1992).
Johnson, Ellis, and I contend in our book (Nielsen et al., 2001) that it
is quite possible for an atheist therapist to accommodate a religious client's
doctrinal beliefs during the practice of REBT, because most of the religious
beliefs will be irrelevant to the evaluative beliefs needing disputation. There
are no reasons except the limitations imposed by time that therapists who
are atheists or who come from religious tradition differing from the religions
of their clients cannot learn religious material at sufficient levels to allow
integration of such information with REBT. Robb (1985), who is an atheist,
is probably more familiar with the Bible than most Christians, and is quite
adept at using verses from the Bible to demonstrate rational-emotive phi-
losophies for living to his Christian clients. Part of Robb's skill is conveying
respect for his clients' beliefs, even though he does not share their beliefs.
Communicating respect for religious beliefs may be the most important fea-
ture of forming a working alliance with a religious client. Of course, clients
have a powerful role in generating the trusting alliance, as well. I have had
religious clients reject my treatment before they have met me because of
preconceptions about how REBT would deal with their religious beliefs.
Would it have worked as well as it did had I been an atheist? There are
subtleties in forming and maintaining the therapeutic alliance that I believe
require all therapists to be artisans. For example, a therapist stating that there
was nothing wrong with Aisha's roommates having sex before marriage, so
long as it was safe sex, might have offended Aisha. Would an atheist be more
likely to make such a statement than a theist? It would depend on the thera-
pist. I think Aisha considered our two levels of religiosity identical in their
degree and the forms and focus of our religious beliefs quite parallel. I think
she trusted that we really believed in and prayed to the same God. She trusted
my religiosity would work with hers.

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of

mental disorders (4th ed., text rev.). Washington, DC: American Psychiatric
Association.
Beal, D., Kopec, A. M., & DiGiuseppe, R. (1996). Disputing clients' irrational be-
liefs. Journal of Rational Emotive and Cognitive Behavior Therapy, 14, 215—229.
Drum, D. J., & Baron, A. (1998). Highlights of the research consortium outcomes project.
Retrieved November 23, 2002, from University of Texas, Counseling and Men-
tal Health Center Web site: http://www.utexas.edu/student/cmhc/research/
rcpres98.pdf

228 STEVAN LARS NIELSEN

Ellis, A. (1958). Rational psychotherapy. Journal of General Psychology, 59, 35-49.
Ellis, A. (1994a). My response to "Don't throw the therapeutic baby out with the
holy water": Helpful and hurtful elements of religion. Journal of Psychology and
Christianity, 13, 323-326.
Ellis, A. (1994b). Reason and emotion in psychotherapy, revised and updated. New York:
Birch Lane Press.
Ellis, A. (2000). Can Rational Emotive Behavior Therapy (REBT) be effectively
used with people who have devout beliefs in God and religion? Professional Psy-
chology: Research and Practice, 31, 29-33.
Ellis, A. (2002). Overcoming resistance: A rational emotive behavior therapy integrated
approach (2nd ed.). New York: Springer.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to
defining meaningful change in psychotherapy research. Journal of Consulting
and Clinical Psychology, 59, 12-19.
Johnson, W. B., DeVries, R., Ridley, C. R., Pettorini, D., & Peterson, D. (1994). The
comparative efficacy of Christian and secular rational-emotive therapy with
Christian clients. Journal of Psychology and Theology, 22, 130-140.
Johnson, W. B., & Nielsen, S. L. (1998). Rational emotive assessment with relig-
ious clients. Journal of Rational Emotive and Cognitive Behavioral Therapy, 16,
101-123.
Johnson, W. B., & Ridley, C. R. (1992). Brief Christian and non-Christian rational-
emotive therapy with depressed Christian clients: An exploratory study. Coun-
seling and Values, 36, 220-229.
Johnson, W. B., Ridley, C. R., &. Nielsen, S. L. (2000). Religiously sensitive rational
emotive behavior therapy: Elegant solutions and ethical risks. Professional Psy-
chology: Research and Practice, 31, 14-20.
Lambert, M. J., Hansen, N. B., Umphress, V., Lunnen, K., Okiishi, J., Burlingame,
G. M., etal. (1996). Administration and scoringmanual for the OQ45.2. Stevenson,
MD: American Professional Credentialing Services.
Nielsen, S. L. (1994). Rational-emotive behavior therapy and religion: Don't throw
the therapeutic baby out with the holy water. Journal of Psychology and Chris-
tianity, 13, 312-322.
Nielsen, S. L., &. Ellis, A. (1994). A discussion with Albert Ellis: Reason, emotion
and religion. Journal of Psychology and Christianity, 13, 327-341.
Nielsen, S. L., Johnson, W. B., &. Ellis, A. (2001). Counseling and psychotherapy with
religious persons: A Rational Emotive Behavior Therapy approach. Mahwah, NJ:
Erlbaum.
Nielsen, S. L., Johnson, W. B., & Ridley, C. R. (2000). Religiously sensitive rational
emotive behavior therapy: Theory, techniques, and brief excerpts from a case.
Professional Ps;ycholog)i: Research and Practice, 31, 21-28.
Nielsen, S. L., & Sarason, I. G. (1981). Emotion, personality, and selective atten-
tion. Journal of Personality and Social Psychology, 41, 945-960.
Propst, L. R., Ostrom, R., Watkins, P., Dean, T., & Mashburn, D. (1992). Compara-
tive efficacy of religious and nonreligious cognitive-behavioral therapy for the

QUR'AMC RATIONAL EMOTIVE BEHAVIOR THERAPY 229

 treatment of clinical depression in religious individuals, journal of Consulting
and Clinical Psychology, 60, 94-103.
Richards, P. S., & Bergin, A. E. (1997). A spiritual strategy for counseling and psycho-
therapy. Washington, DC: American Psychological Association.
Robb, H. (1985). How to stop driving yourself crazy withhelpfrom the Bible. New York:
Albert Ellis Institute.
Robb, H., Schneiman, R., & Nielsen, S. L. (2001, June). REBT and clients with reli-
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CO.

230 STEVAN LARS NIELSEN

 A PSYCHOBIOLOGICAL LINK TO
14
SPIRITUAL HEALTH
ZARI HEDAYAT-DIBA

This chapter attempts to describe how my spiritual and religious back-

ground unconsciously guided me in the course of a therapeutic encounter
with a patient who was particularly resistant to the language of psychology or
what she called "psychobabble." To form a therapeutic alliance, I needed to
rely on something more than what I had learned in graduate school. 1 had to
have faith; faith in therapy as a spiritual process and faith in the wholeness of
the mind, body, and spirit as a unit.
However, more important, I hope this chapter demonstrates that spiri-
tuality, like other aspects of personal growth, can best unfold in a relational
context that is mutually influenced. This chapter does not describe a unidi-
rectional relationship in which the therapist is the observer and the patient
the observed, with the former guiding the latter toward "health," but rather
as one in which both people are touched and in some ways changed.

DESCRIPTION OF THERAPIST
Personal Background

I am a woman of Persian descent, currently in my 40s, practicing as a

marriage and family therapist in California since 1986. For my doctorate

231
degree in clinical psychology, I wrote my dissertation on the "Selfobject Func-
tions of the Koran," a portion of which was published in the International
journal for the Psychology of Religion (Hedayat-Diba, 1997).
My dissertation was inspired by a desire to connect with some of my
Iranian/Muslim roots. I was raised in a non-practicing family, and spent most
of my childhood in Europe where 1 attended catholic schools. I came to Cali-
fornia to study psychology in 1978.
Although Islam was not a conscious part of my family life, it was none-
theless present through my nanny who was a devout Muslim, following all of
the religious rituals, which led to intrigue and curiosity in me. It was not
until I studied the topic of Islam for my dissertation that I realized how much
of my life had actually been imbued by it, making me aware of the extent to
which one's culture, and in this case, one's religious culture is incorporated
in the unconscious and silently lives there as all other unconscious matters,
until something stirs it to the surface.
Despite the lack of religious activities, the idea of God and a sense of
spirituality had been present in me since childhood. Three dreams stand out
in my mind, in which the idea of God was clearly present. The following is
one such dream I had at age 17. In the dream, I am walking on a beautiful
path, by a stream, in a beautiful green field blooming with colorful spring
flowers. The feeling is one of peacefulness, along with a sense of awe for the
overwhelming beauty and gratitude for being able to witness it. I then see an
old man sitting under a big oak tree, crying. I go to him and say, "What is the
matter. Why are you crying?" The old man looks up at me and says, "Why do
you disturb me? I am talking to God." To this, I was left speechless and puzzled.
The dream ends there.
This dream has never faded in clarity or vividness. As a therapist, it has
served me well on the occasions when someone's tears felt so compelling
that I would want to reach forth and intervene. Instead, I would hear the old
man's words reminding me that God is listening and that I can, at best, just
be present but unobtrusive.

Theoretical Orientation

My theoretical orientation is psychoanalytically informed. For the pur-

pose of this chapter, I use and describe Kohut's theory of self psychology and
Jung's theory of individuation, which have influenced my work with Mrs. A,
both clinically and in a more spiritual realm. These theories bear resem-
blance with some of the Islamic ideas about the human condition; especially
those described in Sufism, which is often known as the mystical Islam.

Carl G. Jung
Carl Jung's concepts of the individual and collective unconscious, along
with his emphasis on dreams and their functions in the pattern of psychic

232 ZAR; HEDAYAT-DIBA

growth have been of great interest and have inspired some of my spiritual
attitudes toward therapy. Jung's description of the individuation process es-
pecially has been an invaluable signpost when a patient's growth seemed to
be stalling or even appeared to be more destructive than constructive.
Jung (1921) described the individuation process as:

The process by which individual beings are being formed and differenti-
ated; in particular, it is the development of the psychological individual
as a being distinct from the general, collective psychology. Individua-
tion, therefore, is a process of differentiation having for its goal the de-
velopment of the individual personality, (p. 757)

Jung's concept of individuation holds into account who the person re-
ally is, aside from what she wants to be and who society wants her to be. The
individuation process is the psychological growth that is one's birthright,
and which happens unconsciously and naturally without the necessity of willful
effort. It is in essence an unconscious process propelling the true self toward
wholeness. However, Western culture, social roles and responsibilities, along
with many of life's necessities make it increasingly difficult for modern indi-
viduals to follow or even keep track of one's internal landscape. Neurosis and
symptoms ensue when one's innermost need to find wholeness from within is
thwarted by external forces, because as pointed out by Hollis (1993), "as long
as we remain primarily identified with the outer, objective world, we will be
estranged from our subjective reality" (p. 94). Thus, the symptoms can be
viewed as blessings in disguise, a calling of attention back to the inner self,
where one can find all the tools necessary toward spiritual growth, because
"what we must know will come from within" (Hollis, 1993, p. 94). It is remi-
niscent of Jesus' utterance "if you bring forth what is within you, what you
bring forth will save you. If you do not bring forth what is within you, what
you do not bring forth will destroy you" (in Hollis, 1993, p. 96).
Such destruction or "such symptoms announce the need for substan-
tive change in a person's life. Suffering quickens consciousness, and from
new consciousness new life may follow" (Hollis, 1993, p. 95). This is the
point that Jung made so well. That even in the midst of what may seem
irrational, one can find symbols that are psychologically meaningful to that
individual and guide them back to their innermost self, albeit through a lot
of psychic pain.
The individuation process is not finite with a determined goal. It is an
ongoing journey. Jung (1963) referred to it as "a religious capacity" and be-
lieved that nearly all religious systems on this planet contain images that
represent various stages of the process.

Heinz Kohut
Post-Freudian psychoanalysts continued to build their theoretical con-
structs on the basis of the tripartite psychic structure originally proposed by

A PSYCHOB/OLOGICAL LINK TO SPIRITUAL HEALTH 233

Freud, namely the id, ego, and superego, with little attention to the idea of
the self. In the mid 1960s, Heinz Kohut, who was trained as a classical ana-
lyst, found a need to reframe the long-standing psychoanalytic paradigm of
neurosis and symptom formation as arising from conflicts attributed to id
impulses against which the ego erects defense mechanisms. Instead, Kohut
(1971) proposed a new model, moving toward a theory of the self and its
development throughout the life span. Pathology was now viewed not as
arising from conflicts but rather from deficits in one's sense of self. His theory
came to be known as self psychology. He defined the self as a "center of
initiative and recipient of impressions" (Kohut, 1977, p. 99). The self is not
synonymous with one's identity or self-image, an observable entity, but rather
as an experience. The self is the center of one's psychological universe. It is
not cognitively penetrable or observable from the outside; another can reach
it only via introspection and empathy. For this reason, the notion of
"intersubjectivity" and of "mutuality" hold crucial significance in the clini-
cal work. Currently, intersubjectivity is defined as designating "the basic pro-
cess of psychotherapy. The term emphasizes the idea that in the therapeutic
situation two individuals co-create the relationship they live and talk about"
(Natterson & Friedman, 1995, p. 1). In the case presented here, the two
spiritualities of the patient and therapist came to have a reciprocal influence
on each other.
From his clinical work, Kohut (1977) came to see that his patients'
development had been most damaged in the area of the formation of self-
esteem, often because of caretakers' lack of attunement to the child; and in
therapy, it was the working through and resolution of their frustrated needs
for understanding, appreciation, and empathy that led to maturation.
He believed that certain kinds of responses from the environment are
essential to the development of a cohesive self, and that these reflect the
existence of three kinds of underlying psychological needs. These are (a) the
need to be mirrored (to feel validated, supported, and valued); (b) the need
to belong and feel a part of something (to have a sense of sameness with
someone, a group, or a community); and (c) the need to look up to an ideal-
ized other, in whose strength one can find either comfort or inspiration, or
both.
Furthermore, one does not become independent from those basic hu-
man needs; rather those needs mature from archaic forms that are specific to
early development to increasingly symbolic ones later in life. As Kohut (1984)
explained:
Throughout his life a person will experience himself as a cohesive har-
monious firm unit in time and space, connected with his past and point-
ing meaningfully into a creative-productive future, only as long as, at
each stage in his life, he experiences certain representatives of his hu-
man surroundings as joyfully responding to him, as available to him as

234 ZARIHEDAYAT-DIBA
 sources of idealized strength and calmness, as being silently present but
in essence like him, and, at any rate, able to grasp his inner life more or
less accurately so that their responses are attuned to his needs and allow
him to grasp their inner life when his is in need of such sustenance.
(P- 52)
Although Kohut's theoretical formulations and language were more
"scientific" than Jung's, and were not imbued with the spiritual tone of the
latter, he too, believed that the self has a central raison d'etre, and that hu-
man growth was inevitably tied to the uncovering of one's destiny and the
striving toward its fulfillment.
As with other psychoanalytic methods, the client/therapist relation-
ship is viewed as central to healing, with the therapist often providing self-
object experiences needed for the patient to resume their developmental
growth. For Kohut, the establishment of empathic attunement is the main
therapeutic tool. And empathy is achieved through a process of introspec-
tion, a turning inward to understand the patient's subjective experience.

Sufism
Sufism is a branch of Islam. Its doctrines are derived from the Koran
and Islamic revelations. It is often referred to as the inner dimension of Is-
lam; the mysticism or esoterism of Islam (Glasse, 1989, p. 375). The central
issue in Sufism—similar to psychoanalysis—is the development of awareness
to higher levels of consciousness, leading to a process of transformation to-
wards the inner self, which is believed to have unlimited potential. The
premise is that the individual is in search of his or her higher self; or as aptly
put by Arasteh (1980) humans are a "psycho-religious being in search of our
origin and in pursuit of our ultimate destiny" (p. 3). This destiny is to be
found inward.
In Sufism, while on this spiritual self-realization journey, a teacher is
necessary. The Sufi teacher is the transitional object between man and his
true self. He is a guide in the individuation process. As explained by Dorst
(1991), "In Sufism it is said: the teacher is without name. He or she doesn't
work through teaching but through being. The teacher is an energetic cur-
rent. The student, who submerges himself into it, is influenced by these ener-
getic forces and his process is speeded up" (p. 21). Perhaps the main charac-
teristic of the Sufi student is longing; a longing that has been translated as
the search for God, for understanding, for love, or any other nameless yearn-
ings. This longing is perhaps best represented and best known to the West-
erner through the poetry of Rumi (1207-1273), one of the greatest mystics of
Islam.
The Sufi tradition is also a group tradition. The group is organized around
a teacher, but it is determined by commitment of group members to the same
goals. In addition to the ritual prayers of Islam, meditation exercises are com-

A PSYCHOBIOLOGICAL LINK TO SPIRITUAL HEALTH 235

mon practices for individuals and groups alike. These are God-centered medi-
tations, such as repeating His name in remembrance, or using Him as the
object of contemplation or even of active imagination (Spiegelman, 1991, p.
106). The purpose of meditation is to expand both consciousness of an inner
spiritual self and consciousness of God. Finally, dreams are considered im-
portant vehicles of guidance and transformation along the spiritual path.

SETTING

The setting was a private practice office in Los Angeles, California.

The patient was in weekly, individual psychotherapy.

CLIENT DEMOGRAPHIC CHARACTERISTICS

At the time of our first meeting, Mrs. A was a 32-year-old Caucasian

woman from Australia, married to a French man of the same age. She holds
two college degrees in education and psychology. She used to work as a school-
teacher in Europe, where she lived with her husband for several years before
moving to Los Angeles, where both of them began to work for a film produc-
tion company.
Her religious background is Anglican, but her family was not religious,
did not go to church, nor encouraged theistic views. However, Mrs. A at-
tended Catholic schools where she went to church on a daily basis. Her real
sense of spirituality or of a higher power came from experiences with her
grandmother who always admired nature and saw God in all of nature's beauty.

CLIENT HISTORY

Mrs. A was the third of four children. She has a sister 5 years older, a
brother 4 years older, and another sister 4 years younger than herself. Follow-
ing Mrs. A's birth, her mother nearly bled to death and was advised not to
have another child, but her younger sister was nonetheless planned.
Her father was an engineer and her mother an artist who worked mostly
from home. Mrs. A also had a nanny who helped look after the children.
They lived on a big property in Australia, with horses, tennis courts, a
pool, and all the amenities of a luxurious lifestyle. She described her child-
hood as "charmed and privileged" and her parents as respectful and encour-
aging but also critical and very strict. She described herself as the "ugly duck-
ling" because her two sisters were very pretty, whereas she was athletic and
tomboyish. She was involved in many sports, with special interest in gym-
nastics and dance from an early age. She recalled with gratitude her mother

236 ZARl HEDAYAT-DIBA

driving her everywhere so Mrs. A could make it to her practices and sport
events. In that sense her mother was encouraging and supportive, and Mrs.
A probably was gratified with some degree of mirroring and appreciation
through her athletic achievements. She was dedicated to her gymnastic train-
ing, as she was an Olympic hopeful, and for many years she endured sacri-
fices, including numerous separations from her home and family. In addi-
tion, she would frequently come home from gymnastics bruised or injured,
but would brave through the pain for the love of the sport. Eventually, a
serious back injury from a fall on the balance beam brought her Olympic
dreams to a sudden end. She was on bed rest for almost a whole year.
In matters of parenting and discipline, the cultural norm in those days
permitted the use of physical punishment. Thus, she and her siblings were
spanked regularly, sometimes severely so. She claims her parents—especially
her father—had calmed down considerably by the time they had her—the
third child—and believes that her two older siblings got the worst of it. She
realizes that according to current American standard, those experiences would
today be considered child abuse, but she still downplays the emotional dev-
astation that must have accompanied those physical punishments. One spe-
cific incident stands out in her memory. Her mother had been away for a few
days. She returned in the evening, around bedtime. Mrs. A was excited to see
her mother and wanted to stay up a bit longer to be with her. Father wanted
her to go to bed. As then 6-year-old Mrs. A was not listening, he took her to
her room and started "laying into her." That is the only time she remembers
her mother actually stepping in, telling the father something like "darling,
that's enough now." During her father's outbursts of rage, she would "sepa-
rate her mind from her body," like she had learned to do in gymnastics and
because of that she doesn't feel that her spirit has been damaged.
Mrs. A is a very grateful woman who does not easily complain. It took a
while before she could comfortably speak of how critical her father was and
how dismissing and unavailable her mother was. Her father especially was
impossible to please. He was mercilessly critical and intolerant with the chil-
dren as well as with his wife. He was very demanding, yet nothing anybody
could do ever pleased him. When he would have an outburst of anger with its
accompanying spanking, Mrs. A would typically go in her room and "break
up inside." She would be devastated and cry alone until she felt better, or
distracted herself with some athletic activity. She would not go to mother for
comforting because "they wouldn't pamper us," she explained; the motto was
"pull yourself together."
She remembered being loved, nurtured, and comforted by her maternal
grandmother. Her family spent all their Christmas vacations at the
grandmother's house by the sea, away from home. As a young child she cher-
ished those times with her grandmother, to whom she had a strong connec-
tion. She described her as the "epitome of love and acceptance." If she felt
sad or upset, being with her grandmother was comforting. To this day, Mrs.

A PSYCHOBIOLOG/CAL LINK TO SPIRITUAL HEALTH 237

A attributes her belief in God to her grandmother's capacity to love nature
and to see God in it. She would always admire nature as a miracle—this
reminded me of how in awe of nature I was in my dream. Mrs. A. thus learned
from her that miracles are possible and can be found all around us. Therefore,
since early childhood, she remembered having a "spiritual sense." Then, some-
thing happened to challenge her belief in God. Her sister who had suffered
from scoliosis needed surgery, but a heart condition made surgery risky. She
was taken to a healer who performed a ceremony after which the sister seemed
"miraculously" better. "It's as though she had grown a couple of inches," re-
called Mrs. A. This had a tremendous effect on her. She had witnessed God's
healing power. She and a high school friend now began to read the Bible
every night. She became eager to explore religion. But then, her sister ended
up needing surgery nonetheless. This led to a spiritual crisis. She remembers
thinking that God had not really healed her sister and was not really watch-
ing over her because she still needed an operation on her back. The sister
survived the operation and the loss of faith was soon forgotten when Mrs. A.
began college. She recalled feeling very good and happy during her first year
of college. Studying came easily to her. She had a boyfriend for the first time
and started exploring her sexuality.
Following college she decided to travel abroad. She first came to the
United States and then traveled through Europe, where she met her hus-
band. They came back to Los Angeles together before resuming traveling
through Southeast Asia, where they were acquainted with several adven-
tures including exploring monasteries, and discovering meditation and Bud-
dhist practices.
On their return to the United States, they started working for a produc-
tion company. Mrs. A was a dedicated and efficient project manager, work-
ing many hours and traveling a great deal. She was capable of handling much
pressure. At times, it seemed like nothing was too much for her. All was
seemingly going well when she unexpectedly found herself pregnant. This
would be her first pregnancy. She was then 32 years old.

PRESENTING PROBLEM

When Mrs. A became aware of her pregnancy, she was on a very de-
manding schedule and because she was in good health, she postponed going
to the doctor until she was about 3 months pregnant. At that time, she was
told that the fetus was not growing and she needed to have a dilation and
curettage procedure (D & C). The amniotic sac had grown in a normal fash-
ion, but the fetus had not. She was devastated. She had the D & C performed
in the following days. When she returned home from the hospital she found
herself in a lot of pain and woke the next day in a pool of blood. She called
the hospital and was told to come in right away. She had developed a blood

238 ZARIHEDAYAT-DIBA
clot between the uterus and cervix area. The doctor said they needed to
perform a quick and simple vaginal intervention. Presumably they were go-
ing to puncture the blood clot, but in the process, apparently punctured her
uterus by mistake, which led to hemorrhaging. She was losing so much blood
they thought she might die and were considering performing a hysterectomy
when one of the surgeons successfully cauterized the uterus to stop the bleed-
ing. She was told she probably would not be able to get pregnant for quite
some time—this was reminiscent of her mother's experiences following her
pregnancy with Mrs. A.
Three months later, Mrs. A. was pregnant again. This time, she went to
the doctor very early on and was followed very carefully because her preg-
nancy was considered high risk. She was still so grieved by the previous loss
that she was not letting herself get emotionally attached to the new fetus, for
fear she might lose this one as well. She remained detached, continuing to
work and live as if she was not pregnant so as to avoid feeling the grief of the
previous loss and protecting herself from having to experience that grief again.
Because pregnancy and the postpartum period is an area of special in-
terest to me, Mrs. A was referred to me by her gynecologist. Mrs. A presented
with a mix of anxiety and optimism. The anxiety was that she might again
lose a fetus, and thus she feared getting attached to it. There was also anxiety
about medical procedures and interventions as well as the physicians them-
selves. She had been traumatized by medical errors and mishaps and did not
feel safe at all in the hands of doctors—and that, I thought included me,
although I am not a physician. In spite of her anxiety, she was optimistic that
things would turn out for the better. I could not quite tell if her optimism was
a form of denial or if it was a spiritual attitude of having faith.

ASSESSMENT AND DIAGNOSIS

Mrs. A was suffering from post-traumatic stress disorder due to the cata-
strophic medical experiences during which she risked losing her life. I also
felt that the current trauma was compounded by numerous smaller, but none-
theless significant childhood traumas that had not been resolved. As pointed
out by Shapiro (2001), when trauma occurs, the brain's capacity to process
the information it is receiving becomes ineffective and the perceptions that
were there at the time of the event become locked in the nervous system. In
other words, the events of the trauma are remembered by the body, are felt in
the body, but remain inaccessible to the mind and to language—the medium
of psychotherapy. It was as though her body was trying to say something, to
tell a story, or to remember something and to free itself.
I felt that she had much to grieve for, but had not yet given herself
permission to do so. It was imperative that she be able to experience the
fullness of her emotions and grieve for not having felt seen in the gleam of

A PSYCHOBIOLOG/CAL LINK TO SPIRITUAL HEALTH 239

her parents' eyes, not having been heard, not having been known for her true
self. She had to undo the pseudoautonomy, imposed in the name of self-
reliance at too young an age, which made her circumvent her overwhelming
needs for the mother's nurturing. Her denial was self-preservative as it was
also protective of her parents. To acknowledge what she had missed would
be betraying her parents as well as the image she maintained of a "charmed
and privileged childhood." To do so also probably meant, "creating undue
drama."
She also needed to forgive: Forgive herself for not making the Olympic
team. Forgive herself for all that in her child's mind she had internalized as
"her fault." Forgive the father whose criticisms of her were no doubt trans-
formed in self-reproach and self-blame that was perpetuating the initial in-
sult. Finally, I thought she needed to forgive herself for her mother nearly
bleeding to death following her birth. Did she have to almost bleed to death
herself after the D & C as a way to do that? Had she been punished enough
yet?

TREATMENT PROCESS

Initially, Mrs. A gave the impression that she came to see me on the
basis of her physician's recommendations. She was doing the "right thing" by
following the doctor's orders. Yet, there was more to it than that, as she was
aware that she was not bonding with the fetus and was concerned about that.
She was ambivalent about psychotherapy because she feared I would
define her in terms of a diagnostic category that would be dehumanizing.
This in fact was her experience with the doctor who had told her that she
would not be able to get pregnant again in a while, confining her to the
difficult-to-get-pregnant category. In fact she became pregnant readily. The
doctor had said the blood clot would be taken care of with a 5-minute vagi-
nal intervention, and she ended up with an incision in her belly, a near-miss
hysterectomy, and hemorrhaging to the point of needing a blood transfusion.
How could she trust me when the doctors had been wrong all along? In the
transference I was just an extension of those doctors.
In addition, she felt that relying on someone else would be more "drama
than necessary. It would complicate the issue more than necessary." This, I
would realize later, resonated with the experience of the little girl who would
"just go in her room and break up inside" to come back out only when she
had pulled herself together. To do otherwise would be "dramatic."
Pseudoautonomy was valued, respected, and in fact, demanded. To go to
someone for comfort or reassurance, to rely on another person, to trust the
restorative function of a relationship was not a familiar experience.
I was a little intimidated by her lack of trust, yet I felt a desire to work
with her. I did not argue with her doubts, nor try to convince her otherwise.

240 ZARIHEDAYAT-DIBA
Now, I was the one feeling confined and limited, pinned to my chair unable
to be much of a therapist. This feeling—confined and limited—matched her
description of therapy as she imagined it would feel to her. In feeling it my-
self, I could now have an appreciation for that experience. It was uncomfort-
able, yet I felt a connection to her and knew that we could work well to-
gether. I just let her know that I understood and remained mostly silent. I
also encouraged her, as I often do with all patients, to remember her dreams.
My main clinical concern was for her to be able to let herself feel and
get attached to the baby inside her womb so that eventually she could ex-
plore her fantasies about the baby inside her mind. The "motherhood con-
stellation" (Stern, 1995), that is her psychological birth as a mother, was
what I was hoping to address. But her physical body had been so traumatized
by the previous pregnancy experience that I was not sure if she would be
available to explore motherhood yet. And because she had been told to pre-
pare herself for not becoming a mother for a long time, she was naturally
unprepared to face the impending reality of motherhood now. I feared that if
I proceeded as I would with most patients, I would run the risk of "confining"
her into a clinical model of intervention that would confirm her anxiety
about therapy and send her running away. I realized how much I wanted to
protect her from that disappointment and betrayal; how much 1 wanted to
protect her the way her mother had not.
During our weekly sessions, I continued to feel pinned to my chair,
unable to say much of anything at all. I took that as my clue to just sit back
and let the process unfold. For some reason, I had faith in this woman. There
was something very powerful about her—which I did not think of as patho-
logical. I had faith in her process. I had faith she needed to be here and I had
a strong sense that I should let go of all expectation, just let myself be as
empty of intellectual content as possible, and let the student/client teach
me—a Sufi stance.
Because my countertransference reactions often led me to think about
Jung and Sufism, I decided to inquire more about her spiritual beliefs. She
revealed that her childhood disappointment in God that she had experi-
enced around her sister's health problems had now resurfaced with the loss of
the pregnancy and the physical traumas that ensued. I felt strongly that for
her physical well-being as well as her psychological well-being, Mrs. A needed
to find a way to reconcile with God. I thus did an informal "spiritual assess-
ment" (Richards & Bergin, 1997). I asked her whether prior to the preg-
nancy, she actually believed in a Creator or God. She confirmed "absolutely."
I asked how she imagined this Creator, what was her image of Him? She said
that to her "God is energy. It's a God force that is eternal and all encompass-
ing, embracing everything in every realm of life." The depth of her response
and the clarity with which she spoke these words struck me. I asked her if this
God was punishing or loving, or had any such qualities commonly attributed
to Him? She did not think God was punishing. "I think we punish ourselves.

A PS YCHOBIOLOGICAL LINK TO SPIRITUAL HEALTH 241

And our purpose in life is to discover the God within us: to discover through
Him the source of power, inspiration and healing that is in us," she said. I was
once more reminded of Sufism and its eternal quest for the Divine within.
This line of inquiry seemed to free us both from the therapeutic con-
fines that her fears had imposed on us. I no longer felt pinned to my chair,
and she seemed very at ease talking about her beliefs. Then, she asked me if
I believed in God. I told her a little bit about Sufism and the similarity of its
tenets with the ones she had described. Then, I said I thought there were two
kinds of Gods. The God that in our child's mind we see in our all-powerful
parents—who often end up disappointing us—and the God that she experi-
enced through her grandmother, best made visible in the miracles of nature.
I told her I believed in both. She was able to take that in and I took that as
my clue that she was ready for a more detailed interpretation. I wondered out
loud if maybe it was not her parents she was really mad at. I suggested that
maybe God became confused with the all-powerful parents who abused their
authority. Just like God became confused with the all-powerful doctors who
made so many mistakes. But the God of her grandmother, I suggested, was
still with her and their relationship intact.
It is in this way that slowly she opened up and began to trust me. One
day, she revealed that I had become like a "security blanket," her weekly
connection to the baby, and she looked forward to coming in. By the fourth
month of pregnancy, she felt attached to the baby, experiencing its reality
both in her belly and in her mind, with fantasies of how life will be with a
baby. She was now contemplating stopping work and nesting. This was a
major shift for her because her identity and self-esteem was so far largely tied
to her productiveness and success at work.
Mrs. A did slow down considerably and gave birth to a healthy baby
girl. To her surprise she was very happy to stay home with the baby. She
would go to the beach every day and take long walks. She continued therapy.
This was a happy and healthy time.
One day, I asked her if she had forgiven God. She confessed it was
impossible to have a baby and be angry with God. Nowhere is His creation
more manifest than in the miracle of babies. She revealed that in fact, her
spiritual sense was still with her, and probably had never really left her, but
had been overshadowed by disappointment, fear, and anger. Unbeknownst to
either one of us, she would need that spiritual sense very soon, when a new series
of medical mishaps led to a near-death experience.
When her baby was one year old, Mrs. A started experiencing sharp
pains in the lower abdominal area. One night, the pain became so severe she
was taken to the hospital where she had an ultrasound, which revealed what
the doctors suspected was a tumor, the size of an orange, in the large intestine
area. They had to operate immediately. They removed 3 inches of her large
intestine, her appendix, and 10 inches of her small intestine and the illiosacral
valve, which is responsible for removing the moisture from the stool.

242 2ARIHEDAYAT-DIBA
 She was in the hospital for 10 days. The tumor was not malignant. It
was a growth created by an overactive immune system. The doctors diag-
nosed the condition as Crohn's disease. Three weeks after her surgery she
had to go in for a colonoscopy. She was watching on the TV monitor and
could see blood gushing out with every biopsy pinch. It did not seem right to
her. After the procedure she drove herself home. Hours later, she started
feeling a lot of pain. She was taken to the hospital again, where they discov-
ered her colon had been punctured during the procedure—reminiscent of
her uterus having been punctured earlier. They had to operate to try to find
the hole and seal it. They could not find the hole. They tried to give her
intravenous antibiotics but her veins would collapse with every attempt. She
would look at a picture of her baby every time they tried, because the thought
of her kept her going. But still, the IV never got in. By the third day, the
doctors said there was nothing more they could do and told her husband to
bring the baby in to say goodbye. He did bring the baby and then had some-
one take the baby away while he stayed with Mrs. A. He held her hand,
leaned his head on their joined hands and they fell asleep. According to the
nurses, neither one of them could be roused for 45 minutes. She woke up first
and knew at that moment that she would live. When she later asked him
what had happened, he said he was trying "to pour all of his life energy into
her." It seemed he succeeded, because 10 minutes later, her veins opened up
and the IV was successfully inserted. Two days later, she decided to discharge
herself from the hospital against the doctors' advice. She felt she needed to
save herself from the hospital and the doctors. The next day, a celebrity
friend of hers sent a limousine to pick her up and take her directly to a Chi
Gong master who would perform bodywork. She had never heard of Chi
Gong before. This Chinese man put her on a bed and started a healing ses-
sion, where he would chant or pray over her. She did not feel anything or any
change. However that night she had the following dream:

I see a Black man and a friend of mine from college. My friend used to
have a very bad knee. I watch this man do something energetically, with-
out ever touching my friend. Then she started walking without any pain
at all. Then he said, "come with me" and took me behind a glass door.
There was a swimming pool, and a boy—I thought his son—was swim-
ming in it. He pointed to the boy and said, "Do what he's doing." I pro-
tested: "But I'm not in water." He said, "Move like if you were in water."
Then the little boy got out of the pool and said to his dad, "I know what
is wrong with her." The dad took the boy inside, had a talk with him,
then said to me, "You can go now." The next part of the dream was that
I was at a place in Santa Monica that I could recognize. In my dream, it
was called the BUS.

The next morning, she was compelled to go to that place in Santa

Monica. She drove herself to the place she knew from the dream. She arrived

A PSYCHOBIOLOG/CAL LINK TO SPIRITUAL HEALTH 243

at the studio where the man in her dream was teaching a Tai Chi class.
People were doing "strange" movements. She joined them as best she could.
During a move called "Golden eagle spreads wings to embrace child," she
started sobbing uncontrollably.
After class, the teacher said to her, "I know you are very ill. If you work
with virtue, I will teach you how to heal yourself." He was on his way to
another class at another location. She went with him. From then on, they
worked together on a daily and continuous basis. She started getting stronger
and stronger until she was well again.

THERAPIST COMMENTARY
Both religion and psychology are guilty of a common mistake: They
have excluded the body from spiritual and psychological growth and devel-
opment. In religion, it is abstinence from physical desires that leads to spiri-
tual purity and the attainment of a higher self; in psychology, therapists sim-
ply have continued Descartes's error of placing the mind outside the body
(Damasio, 1994), well despite the fact that Freud (1923/1961) had initially
suggested that "the ego is first and foremost a body ego" (p. 26). Cognition
and affect are interrelated and both have a physical corollary.
As pointed out by Lillas (2000), "psychoanalytic work has focused on
interpreting bodily processes as metaphors for psychic processes that need to
be made conscious, with the primary emphasis on the mental domain ... but
some types of information can be accessed only through the body because
words provide inaccurate representations" (p. 21). Children are a testimony
to this: When their feelings are hurt, they will describe a physical pain.
My experience with Mrs. A made me realize this fully and my work has
changed because of it. I no longer accuse the body of doing the mind's work or
suspect the patient of displacing their feelings into their physical symptoms. I
now in fact ask patients where they feel their pain, depression, anxiety, crav-
ing, or joy in their body, because we can fully know an emotion, including a
spiritual one, only after we sense it in the body. Because as beautifully said by
Moore (1998), after all, the body is the soul perceived by the senses.
That is how Mrs. A came to be so flooded with emotion during some of
the Tai Chi movements. She could feel the feelings of grief as sensations in
her body. The movements in Tai Chi became the words she did not have.
Once she could be the recipient of the feelings, she could in turn talk about
them too.
As Mrs. A learned a new language by putting words to the feelings in
her body, I learned through my work with her that the body is a central
pathway in the individuation process, in the journey toward wholeness and
in some cases even toward God.
Tai Chi is known as a martial art; but it really is a spiritual discipline,
one that emphasizes breathing, relaxation, and meditation. It is a movement-

244 ZARIHEDAYAT-DIBA
based meditation technique, during which "the whole body must be relaxed,
loose and open, so that the ch'i, the vital energy, can pass through without
blockage. This is the principle of Tai Chi as a health exercise, as well as a
system of self-defense" (Lowenthal, 1991, p. 6). The movement of "Golden
eagle spreads wings to embrace child" is one in which one stretches the whole
body slightly arched back with arms extended toward the heavens; then one
gathers oneself moving straight down toward the earth, bending the knees,
head bowed forward, chin tucked into the chest, crossing arms across the
heart, as if embracing a child. It is a movement that feels like a "letting go"
and then a "coming back to self." In Mrs. A's words, "while you gather unto-
ward your own heart, there is a feeling of unconditional love and tenderness
as if nurturing the child within or a loved one. Then you slowly come back to
standing, exhaling and releasing the breath, allowing a feeling of loss or sad-
ness for a moment, but with the next inhale, you gather that love once again,
opening the heart."
It was in doing that movement that Mrs. A's feelings of grief and for-
giveness finally emerged and were freed from her body so she could now
embrace the child that had never been truly embraced in the way she had
needed; and in doing so, she could embrace her inner self.
The Tai Chi master became the teacher and father she could look up
to, in whose strength and calmness she could find refuge, and in whose eyes
she could finally see a reflection of her true self: vulnerable yet capable of
virtue and in possession of a creative inner healing capacity.
One may ask why that did not happen in therapy? 1 believe the therapy
was a stepping stone, and in the transference, I was the grandmother in whose
safety she could bond with her fetus as well as reconnect with her own spiri-
tuality. I was the grandmother who had known the beauty of God through
nature—as manifested by my own dream. In addition, I think I provided
some of the "twinship selfobject functions" she longed for. We both had
children, both were athletic, and we both studied psychology. But perhaps
most important, we both shared a similar spiritual proclivity that helped cre-
ate a sense of sameness that was comforting and reassuring to her, despite our
actual cultural and religious differences.
My theistic views—unconscious as they may have been—guided me
toward a spiritual approach, making it possible for Mrs. A to access her own
internal faith. In her words, "both the therapy and the body work helped
restore my connection to my life force and eternal energy, finding my way
back to the God within and to my own buried true self, not judged or dam-
aged by people or forces outside of myself."

REFERENCES
Arasteh, A. R. (1980). Growth to selfhood: The Sufi contribution. London: Roudedge
& Kegan Paul.

A PSYCHOBIOLOGICAL LINK TO SPIRITUAL HEALTH 245

Damasio, A. R. (1994). Descarte's error: Emotion, reason, and the human brain. New
York: Grosser/Putnam.
Dorst, B. (1991). The master, the student and the Sufi-group: Sufi-relationships to-
day. In M. Spiegelman, P. V. Inayat Khan, & T. Fernandez (Eds.), Sufism, Islam
and Jungian psychology (pp. 19-28). Scottsdale, AZ: New Falcon Publications.
Freud, S. (1961). The ego and the id. In J. Strachey (Ed. & Trans.), The standard
edition of the complete psychological works of Sigmund Freud (Vol. 19, pp. 3-66).
London: Hogarth Press. (Original work published 1923)
Glasse, C. (1989). The concise encyclopedia of Islam. San Francisco: Harper &. Row.
Hedayat-Diba, Z. (1997). The selfobject functions of the Koran. International Journal
for the Psychology of Religion, 7(4), 211-236.
Hollis, J. (1993). The middle passage: From misery to meaning, Toronto, Ontario, Canada:
Inner City Books.
Jung, C. G. (1921). Psychological types. In R. F. C. Hull, H. Read, M. Fordham, &
G. Adler (Trans. & Eds.), The collected works (Vol. 8). London: Routledge &.
Kegan Paul.
Jung, C. G. (1963). Psychology and religion: West and East. In R. F. C. Hull, H.
Read, M. Fordham, & G. Adler (Trans. & Eds.), The collected works (Vol. 11).
London: Routledge & Kegan Paul.
Kohut, H. (1971). The analysis of the self. New York: International University Press.
Kohut, H. (1977). The restoration of the self. New York: International University Press.
Kohut, H. (1984). How does analysis cure? Chicago: University of Chicago Press.
Lillas, C. (2000). Applying neurobiological principles to psychoanalysis. Psychologist-
Psychoanalyst: Official Publication of Division 39 of the American Psychological As-
sociation, 20(3), pp. 21-28.
Lowenthal, W. (1991). There are no secrets: Professor Cheng Man-ch'ing and his Tai
Chi Chuan. Berkeley, CA: North Atlantic Books.
Moore, T. (1998). The soul of sex (audiocassette). New York: Harpor Audio.
Richards, P. S., & Bergin, A. E. (1997). A spiritual strategy for counseling and psycho-
therapy. Washington, DC: American Psychological Association.
Shapiro, F. (2001, March). Healing trauma: Attachment, trauma, the brain, and the
mind. Paper presented at the Lifespan Learning Institute Conference, San Di-
ego, CA.
Spiegelman, M. (1991). Active imagination in Ibn' Arabi and C. G. Jung. In M.
Spiegelman, P. V. Inayat Khan, & T. Fernandez (Eds.), Sufism, Islam andjun-
gian psychology (pp. 104-118). Scottsdale, AZ: New Falcon Publications.
Stern, D., (1995). The motherhood constellation. New York: Basic Books.

246 ZARI HEDAYAT-DIBA

 RATIONAL EMOTIVE BEHAVIOR
15
THERAPY FOR DISTURBANCE
ABOUT SEXUAL ORIENTATION
W. BRAD JOHNSON

DESCRIPTION OF THERAPIST

I am a 39-year-old White man. A licensed clinical psychologist, I re-

ceived my doctorate from the Graduate School of Psychology and my master's
degree from the School of Theology at Fuller Theological Seminary. I prac-
ticed full time for 4 years as a U.S. Navy psychologist, then continued my
clinical career while serving as a faculty member in a doctoral training pro-
gram—first in part-time private practice and then as a consulting psycholo-
gist in a clinic for low-income children and adolescents. For the past couple
of years, my responsibilities have been exclusively academic and supervisory.
I consider myself Christian in a broad and ecumenical sense and no
longer identify with any single protestant denomination, though my back-
ground is conservative and evangelical. I do not endorse some of the tenets
or doctrinal views common of most evangelical denominations. I have no
interest in literalism, dogma, or religious performance, but 1 have a great deal
of interest in the person of Jesus and modeling Christlike humanity for those
I engage professionally.

247
 During my second year in graduate school, I became intrigued with
the writings of Albert Ellis and his unique psychotherapeutic approach—
rational emotive behavior therapy (REBT). I was immediately impressed by
two aspects of Ellis's work. First, I was impressed with his willingness to boldly
dispense with all but the most essential truths and elegant solutions when
helping clients. Second, I was impressed by the strongly negative views about
Ellis among my peers and teachers—most were offended by Ellis's Epicurean
personal behavior, his atheistic philosophy, and his overt rejection of most
religious belief as largely pathogenic.
During the remainder of graduate school and my early career as a psy-
chologist, I explored the application of REBT to religious clients and their
unique concerns (Johnson & Nielsen, 1998; Johnson, Ridley, & Nielsen,
2000; Nielsen, Johnson, (Si Ridley, 2000; Nielsen, Johnson, & Ellis, 2001).
Contrary to prevailing opinion among religious psychologists, I found that
REBT had much to offer religious clients; like other human beings, religious
clients often make themselves miserable by rating themselves and others or
making irrational (and mostly unbiblical) demands of themselves and vari-
ous situations. In fact, I found that religious persons sometimes create irratio-
nal disturbances with help from their religion or their own idiosyncratic ren-
dering of doctrine and scripture. Research applying REBT to depressed
religious clients has clearly supported its efficacy as a treatment approach for
religious persons.
Although I have undergone formal training in REBT at the Institute
for REBT in New York, and although I largely use REBT as my treatment
paradigm when helping clients, religious or not, I am not much like Albert
Ellis in the counseling session. Whereas Ellis can come across to clients as
brash, highly vocal, and given to a range of confrontational and humorous
techniques early on in treatment, I am more interested in establishing rap-
port and engaging the client relationally before moving to dispute irrational
beliefs. Although Ellis downplays the significance of warmth on the part of
the therapist (Ellis &. Dryden, 1997), I see it as markedly important—if not
essential—to maximal outcome. So, I might practice a kinder, gentler ap-
proach to REBT, but it is REBT nonetheless.
In my clinical work, integration of faith and practice occurs in several
ways. Most broadly, I work at being Christlike in my relationships with cli-
ents. This means offering clients care and positive regard without condition. It
means avoiding judgment, disdain, or collusion in the client's self-damnation
or the damnation of others. Although always imperfect, I hope to offer de-
pressed, anxious, or angry clients a glimpse of what dwelling in the presence
of the tolerant and loving Christ might be. More specifically, I sometimes
augment traditional REBT techniques with religious content (e.g., a scrip-
ture verse or biblical parable) to reinforce the point or make an intervention
more meaningful to a client. In some cases, I may use religiously sensitive
REBT disputation techniques to counter irrationally demanding or evalua-

248 W. BRAD JOHNSON

tive client beliefs. When client religious beliefs are directly linked to emo-
tional disturbance—clinically salient religion—I am willing to point out in-
consistent or incongruent aspects of their religious framework (e.g., "you say
you are forgiven for your sins, yet you rate yourself as worthless because of
things you have done. How can that be/"), and to challenge and debate the
demanding and evaluative quality in their religious beliefs.

SETTING

The setting was a midsized county community mental center in the

Pacific Northwest. The center offered services specifically to children, ado-
lescents, and families. Adult services were offered elsewhere in the county
system. The range of services provided in this mental health center included
individual counseling sessions, psychological assessments, group therapy for
children and adolescents with both general and specialized clinical concerns
(e.g., sexual abuse issues, eating disorders, and postdivorce concerns), family
therapy, and various programs for addictions.

CLIENT DEMOGRAPHIC CHARACTERISTICS

Gary was a 17-year-old White male student in a private Christian school.

Gary hailed from an upper-middle class family. His father was a successful
attorney and his mother a homemaker. The family was devoutly religious
and identified with a charismatic nondenominational Christian church. The
church was on the fundamental end of the evangelical Christian church spec-
trum. Gary espoused very conservative religious beliefs and would be consid-
ered quite devout in his own Christian commitments and practices. At the
beginning of his senior year, Gary was an excellent student and quite active
in both school and community fine arts programs. Choir, band, and art courses
occupied much of Gary's extracurricular time.

PRESENTING PROBLEMS AND CONCERNS

Gary was referred for counseling by his psychiatrist. The psychiatrist

had been treating Gary for depression for approximately 6 months and had
placed Gary on a selective serotonin reuptake inhibitor (SSRI) antidepres-
sant, which had resulted in moderate reduction in Gary's depressive symp-
toms. The primary reason for referral was depression with a duration of at
least one year prior to referral to me. Gary's symptoms included dysphoric
mood, sleep disruption, fatigue, hopeless ideation, episodic thoughts of sui-
cide (although he had never formulated a plan for suicide or made any sui-

DISTURBANCE ABOUT SEXUAL ORIENTATION 249

cide gesture), feelings of shame, thoughts of worthlessness, and episodic with-
drawal from family and friends. Although all of these symptoms had lessened
in severity by the time Gary was referred, his psychiatrist and family noted
that Gary continued to evidence milder symptoms of low mood, social with-
drawal, and a cognitive tendency toward self-deprecation. Gary's father
brought him to the community mental health center, rather than to a psy-
chologist in private practice specifically because the psychiatrist had included
me among a list of psychologists who were Christian.

CLIENT HISTORY
Gary was the second of three children born to loving and committed
Christian parents. He had achieved normal developmental milestones, scored
above average on standardized achievement tests, and performed extremely
well in school. Although he was not particularly athletic, Gary's interests
were primarily musical and artistic. His brother James had been both an aca-
demic and athletic standout in the same Christian school and, to the plea-
sure of his parents, had gone off to a competitive Christian college. His younger
sister Amy was 2 years behind Gary, and by all accounts, Gary had solid
relationships with both siblings. The family was quite involved in the church
and Gary's father was an elder. Gary was active in choir and youth group and
nearly all of the family's friends were also members of their church. Gary had
a few friends both in church and in school, and nearly all shared his conser-
vative and charismatic religious views.
There was a family genetic diathesis for depression. Several members of
Gary's extended family had mood disorder symptoms, including his maternal
grandmother who had been treated long-term with antidepressant medica-
tion. When Gary first evidenced signs of depression at age 16, his parents
had initially taken him to their pastor, who saw Gary for several sessions of
pastoral counseling. When Gary's symptoms worsened and he acknowledged
some suicidal ideation, he had been taken to a psychiatrist who had initiated
a trial of SSRI medication. Although antidepressants helped diminish many
of Gary's more severe depressive symptoms, his parents noted that he contin-
ued to seem "down" and "withdrawn" from the family at times. Gary's psy-
chiatrist recommended a period of cognitive-behavioral psychotherapy as a
supplement to psychotropic intervention.

ASSESSMENT AND DIAGNOSIS

Mood Disorder

Prior to Gary's first appointment, I was able to review copies of his

psychiatrist's case notes. The only clinical diagnosis was major depression,

250 W. BRAD JOHNSON

moderate, single episode. When he had begun treatment 6 months prior at
age 16, Gary had been markedly depressed with episodic thoughts of suicide,
and daily symptoms of sleep disruption, hopelessness, decreased appetite, feel-
ings of shame and guilt, and general mood dysphoria. At that time, Gary's
intake score on the Beck Depression Inventory (BDI) was 34, indicating rather
severe clinical depression. Almost immediately, Gary was started on a trial of
Paxil and the dose had been modified twice until maximally therapeutic for
Gary. In the months following this intake, case notes documented a signifi-
cant decline in depressive symptoms. By Gary's report, sessions with his psy-
chiatrist consisted mainly of a brief discussion of his depressive symptoms,
medication side effects, and encouragement for Gary to become increasingly
involved in school and social activities. Gary's most recent BDI scores had
fluctuated between 12 and 18.
During my own assessment with Gary, I saw him as mildly to moder-
ately depressed, and felt that the existing clinical diagnosis was quite accu-
rate. In addition to a rather detailed client history form, Gary completed the
BDI and scored 16—indicating mild depression. The only other clinical tool
utilized at intake with Gary was a simple Sentence Completion Question-
naire. Responses to this measure were notable for themes of pessimism—if
not hopelessness—and ambivalence in relationships.
Gary was a medium-sized soft-spoken White adolescent with some fa-
cial acne. During the intake session he indicated an understanding of why
his psychiatrist had recommended therapy, and how talking therapy would
differ from his appointments with his physician. Gary showed good insight
and his intellectual level was clinically assessed to be well above average. He
also showed glimmers of humor—a particularly good prognostic sign for re-
sponse to cognitive psychotherapy. When asked about his own understand-
ing of his depression, Gary said, "well, I'm afraid I have bad genes for depres-
sion. My grandmother had it, and I guess other people in my family too."
Gary attributed most of his treatment gain to the SSRI medication, yet also
seemed to understand the potential efficacy of exploring his thoughts and
behaviors.

Sexual Orientation

During our fourth session together, Gary disclosed considerable distress

about his sexual orientation—an orientation that I would eventually come
to understand as primarily homosexual. Although homosexuality is not a
disorder (Haldeman, 2002), and although it is certainly not an issue for clini-
cal diagnosis, I include a discussion of sexual orientation in this section on
assessment because Gary's concerns about sexual orientation were deeply
connected to his emotional tumult and depressed mood. Because homosexu-
ality was so central to this case, I include a very brief description of my own
understanding of sexual orientation, as well as a brief synopsis of Gary's very

DISTURBANCE ABOUT SEXUAL ORIENTATION 251

conservative and religiously orthodox views about homosexuality. It is im-
portant to note that although our assumptions about sexual orientation were
disparate, both were rooted in a Christian worldview.
Serra (2001) defined sexual orientation as "an innate predisposition to
respond with enduring emotional, erotic, affectionate, or romantic attrac-
tion to individuals of a particular sex" (p. 170). Research on the develop-
ment of sexual orientation shows that most homosexuals experience homo-
sexual feelings by early adolescence and that many report same-sex attraction
well before puberty (Hershberger &. D'Augelli, 2000; Money, 1987). Most
models of sexual identity development posit a period of identity confusion or
crisis in which the experience of same-sex attraction can be confusing and
distressing (Yarhouse, 2001). Self-labeling of same-sex sexual orientation
generally occurs around the age of 15 and is often described as "coming out to
oneself (Hershberger & D'Augelli, 2000, p. 227). Still, the nature of one's
sexual expression and other factors such as attribution of same-sex attraction
and religious beliefs can significantly affect the rate of sexual-orientation
consolidation. Although I see sexual orientation as remarkably complex in
origin—typically involving an unknowable mix of genetic, biological, rela-
tional, and contextual factors—I see sexual orientation as largely determined
by early adulthood, and most often, by late adolescence.
Lewis Smedes, a professor of mine in seminary, helped me to conceptu-
alize a Christian framework for sexual orientation. He taught me that Jesus
was a savior, not a moralist (Smedes, 1983). In his own life and ministry,
Jesus showed that traditional rules surrounding the divine commandments
were invalid if they kept people from the humanizing intent of the law. Smedes
suggested that there are really only two fundamental commandments of the
moral life—love and justice. Smedes frequently cites the Old Testament pas-
sage from Micah 6:8 "and what does the Lord require of you but to do justice,
and to love kindness, and to walk humbly with your God?" In my work, I am
most concerned with how to best love lesbian, gay, or bisexual (LGB) per-
sons and actively incorporate them in the Christian community.
Gary's view of sexual orientation, and homosexuality in particular, was
largely congruent with very conservative Christian theological tradition on
the topic. Many organized religions (particularly the three monotheistic reli-
gions) view same-sex identification as incompatible with normative or pre-
scriptive dimensions of religion and many are relatively intolerant of openly
LGB individuals (Davidson, 2000; Swidler, 1993). From a conservative reli-
gious perspective, people who experience homosexual desires and attractions
are not morally bad, unworthy, or sinful; however, people who act on their
homosexual desires and engage in homosexual behavior are committing sin
because homosexual behavior is morally wrong. From this viewpoint, the
most moral way to respond to homosexual desires and attractions is to seek
control, minimize, and when possible, overcome them. Quaker theologian
Richard Foster offers an example of this perspective: "The practice of homo-

252 W. BRAD JOHNSON

sexuality is sin, to be sure. . . . The Christian fellowship cannot give permis-
sion to practice homosexuality to those who feel unable to change their ori-
entation or to embrace celibacy" (Foster, 1985, p. 112).
From the moment in psychotherapy when Gary first began describing
his struggle with sexuality and the possibility of being gay, it was apparent
that Gary held very orthodox and anti-LGB religious beliefs. Gary's primary
fear was that he was gay and therefore exposed to the danger (in terms of
committing a mortal sin) of homosexual behavior. Although it was clear
that Gary and I operated from significantly disparate understandings of both
sexual orientation and how sexual orientation can be understood and ac-
cepted within a religious faith, Gary's specific sexual orientation was never
the focus of our brief period of psychotherapy; we did not work at determin-
ing whether Gary was primarily heterosexual, bisexual, or homosexual. In-
stead, the focus of treatment became Gary's catastrophic and depressogenic
response to the feelings of same-sex attraction and the possibility of being
gay in sexual orientation.

TREATMENT PROCESS AND OUTCOMES

REBT in the Dark: ABCs Without the A

After my intake session with Gary and a brief session with Gary's par-
ents to outline my treatment plan and highlight the importance of Gary's
right to confidentiality, 1 was eager to commence a trial of REBT for Gary's
clinical depression. I have found that REBT is often a particularly elegant
approach to therapy with religious clients because it focuses specifically on
foundational beliefs, emphasizes client responsibility for working hard at
change, and is quite existential and philosophical at the core (Johnson, 2001;
Nielsen, Johnson, & Ellis, 2001). The primary difference between REBT and
other psychotherapies is REBT's emphasis on evaluative beliefs (Ellis &
Dryden, 1997), or the "B" in the ABC model in which "A" is the Activating
event, and "C" is the negative emotional consequence (depression, anxiety,
anger, and shame). In REBT, the therapist quickly works with the client to
discern irrational evaluative beliefs related to emotional upset, help them clearly
understand the connection between these irrational beliefs and their current
disturbance, and then help the client move from irrational, absolutistic, evalu-
ative beliefs toward more rational preferences. Beliefs are considered irrational
if they are logically inconsistent, inconsistent with empirical reality, absolutis-
tic and dogmatic, prone to elicit disturbed emotions, and likely to block the
client's goal attainment. Finally, the primary therapeutic approach in REBT
(although there are many) is disputation or the persistent, forceful, and con-
cise challenging of the client's primary irrational beliefs while simultaneously
showing the client how more rational alternatives will likely lead to less dis-

DISTURBANCE ABOUT SEXUAL ORIENTAT/ON 253

turbed emotional and behavioral outcomes. (I offer clearer examples of various
REBT cognitive interventions later in this chapter.)
Because Gary was intelligent, insightful, and blessed with a sense of
humor, I believed that his lingering depressive symptoms might be quite treat-
able with REBT. To this end, I quickly began a process of rational emotive
assessment with Gary—searching for examples of activating events (As),
irrational beliefs (Bs), and depressive emotional consequences (Cs). Gary
had great difficulty articulating specific events or situations that tended to
foreshadow depressed mood. In fact, Gary could only describe some "prob-
lems with friends" (these problems were described only in the vaguest of
terms) as precipitating some of his depressive episodes. When pressed, he
described feeling like he did not "fit in" with many peers and wishing that he
had a few close friends versus numerous "acquaintances."
It is often the case in REBT that primary emotional problems (depres-
sion) cannot be effectively addressed until secondary emotional disturbances
(shame about depression) are handled (Ellis & Dryden, 1997). In light of Gary's
very conservative religious views, I wondered if he felt guilt or shame or addi-
tional depression related to his diagnosis and treatment for a mood disorder.
Gary appeared initially quite animated by this suggestion and agreed that he
was often self-condemnatory in response to his mood problems and his inabil-
ity to "get over it." I proceeded to teach him to dispute this irrational belief
(demanding) with both standard ("where is it written that you must be per-
fect?") and religiously oriented ("can you remember that biblical passage where
Jesus says that depressed people are less worthy?") disputations.
Although Gary began to understand the REBT process, and perhaps to
benefit slightly from our work on his secondary emotional disturbance
(shame), it became clear by our fourth session together that we had yet to
identify a particularly "hot" irrational belief for Gary. That is, it did not ap-
pear that Gary really believed firmly that being depressed was awful, or that
not fitting in socially led directly to depression-causing irrational beliefs.
Although our rapport appeared to be growing, and although Gary was clearly
present in the sessions, he continued to report substantial depression. With
approximately 20 minutes remaining in the fourth session, I made these ob-
servations to Gary. He concurred with our apparent "stuckness." As I some-
times do when stuck with a client, I returned to the ABC model and asked
Gary if we could talk in more detail about a recent example of an activating
event in which he felt alienated socially (only because he had noted that
most of these events involved friends).

Understanding Gary's Primary Activating Event

At this point, with tremendous trepidation and a look of sober pain,

Gary nearly blurted out "one thing I worry about is what my friends would
think if they thought I was attracted to men." Surprised but quite relieved to

254 W. BRAD JOHNSON

better understand my client, I thanked Gary for sharing this concern and
endorsed it as quite important. In our remaining moments of that session, I
used no specific technique save for the essential elements of unconditional
regard, warmth, and sincere affirmation of Gary's concern as well as his will-
ingness to entrust this to me. Gary appeared simultaneously shaken (perhaps
at his own boldness) and relieved to be discussing this crucial component of
his life and depression.
In three subsequent sessions with Gary, I adopted a client-centered thera-
peutic stance; I attempted to surround him with warmth and acceptance
while he shared some of his long-standing concern about sexual orientation—
including several homoerotic experiences. Hershberger and D'Augelli (2000)
noted that the first disclosure of homoerotic orientation is often the most
difficult and fraught with perceived risk for the client. I could see that Gary
was simultaneously anxious and deeply relieved about these disclosures.
Gary recalled feeling sexually aroused around other boys, his brother,
and when looking at pictures or artwork of men's bodies from about age 13
onward. At the age of 15 he had been humiliated when apprehended by a
department store clerk for stealing small cardboard pictures of young men in
briefs from packages of men's underwear. The clerk did not summon his par-
ents or the police. Gary had "stashes" of bodybuilding and sports magazines
depicting attractive men and frequently masturbated with these. He appeared
forlorn when acknowledging almost no sexual attraction to women that he
could recall. He noted that most of his good friends over the years had been
girls. He had had two homoerotic sexual encounters with other boys, once
when 15 during a weeklong church camp, and once just before turning 17
with a friend from school. Both experiences were single episode and involved
mutual masturbation, and in the second case, oral sex.

SEXUAL ORIENTATION CONCERNS IN PSYCHOTHERAPY:

A SYNOPSIS OF THE CONTROVERSY

Although I have mentioned that my focus in treating Gary was not to

change or affirm a particular sexual orientation, I am aware that Gary will
eventually have to address this issue—either alone or in the context of a
subsequent helping relationship. Unfortunately, few topics have generated
such acrimonious controversy both within the mental health establishment
and between mainstream mental health practitioners and conservatively re-
ligious groups. In this section, I briefly summarize the primary perspectives
on treating persons with concern about sexual orientation with emphasis on
both gay-affirmative and conservative religious points of view. For those with
additional interest in this issue, I recommend an excellent series of recent
articles in Professional Psychology: Research and Practice (Benedict, VandenBos,
&Kenkel, 2002).

DISTURBANCE ABOUT SEXUAL ORIENTATION 255

 A gay-affirmative approach to sexual orientation rests on several as-
sumptions including the following: (a) homosexual orientation is largely ge-
netic and biological in origin, (b) a homosexual or bisexual orientation rep-
resents an enduring or lifelong sexual orientation, (c) homosexual attractions
and preferences are largely unchangeable, (d) ethical and appropriate psy-
chotherapy for these LGB persons involves affirmation of an LGB identity,
reduction in internalized homophobia, and eventual integration into an LGB
lifestyle and community, and (e) attempts to change or "convert" sexual ori-
entation are ethically dubious and often harmful to LGB clients.
In contrast, a conservatively religious view of psychotherapy and sexual
orientation assumes that (a) people have a right to choose their own values
and lifestyle, including those relevant to sexual orientation, (b) many reli-
gious clients may find homosexual behavior to be morally wrong and these
religious views should be respected and affirmed, (c) clients who decide they
do not wish to pursue the gay lifestyle, but would prefer to seek, reduce, mini-
mize, or overcome their homosexual attractions and desires may benefit from
working with a therapist who has training in sexual reorientation therapy.
Research bearing on sexual reorientation or "reparative" therapy for
LGB men and women who wish to change their sexual orientation or reduce
their same-sex attraction is preliminary (Haldeman, 2002; Throckmorton,
2002). A review of the scanty empirical literature indicates that although
some who define themselves as "ex-gay" feel reorientation therapy was useful,
others report the opposite and a minority feel significantly harmed by such
treatment approaches (Throckmorton, 2002). Perhaps not surprisingly, stud-
ies emanating from both conservative religious (Nicolosi, Byrd, & Potts, 2000)
and gay-affirmative (Shidlo & Schroeder, 2002) camps tend to show that cli-
ents are either largely satisfied with reorientation therapy or deeply wounded
by such services, depending on the study's design and who is surveyed.
To their credit, professionals from both sides of the debate now seem to
agree that respect for client diversity (sexual and religious) and autonomy
should be a preeminent clinical concern:
Neither gay-affirmative nor ex-gay interventions should be assumed to
be the preferred approach to recommend to clients presenting with con-
cerns over sexual identity. Generally, gay-affirmative therapy or referral
should be offered to those clients who want to adjust to and affirm a
same-sex sexual orientation. Clients who decide they want to modify
same-sex patterns of sexual arousal could consider ex-gay or reorienta-
tion therapy or should seek referral to ex-gay ministries. (Throckmorton,
2002, p. 246)

My View of Psychotherapy With LGB Persons

I am supportive of the American Psychological Association's (1998)

resolution on appropriate therapeutic responses to sexual orientation con-

256 W. BRAD JOHNSON

cerns in therapy which affirms, among other things, that (a) homosexuality
is not a mental illness, (b) mental health services to this client population
should be free of bias, prejudice, and discrimination, and (c) such services
should be provided by mental health professionals who are trained in this
area.
My fundamental approach to counseling LGB youth (or young adults)
who are questioning and exploring their sexual identity is one of accep-
tance first and foremost (Hershberger & D'Augelli, 2000). To this, I would
add affirmation and admiration. By this I mean conveying that the client
has unconditional value and worth regardless of sexual orientation, and
that their courage—evidenced in disclosing—is admirable. Of course, de-
cisions about sexual orientation—or more accurately acknowledging sexual
orientation—are often more weighty and often perceived as danger-laden
for the client.
I personally do not practice reorientation therapy and would be quite
hesitant to refer an LGB client for such services unless it was quite clear that
they were seeking such services after careful informed consent regarding po-
tentially negative outcomes (Schneider, Brown, & Glassgold, 2002; Shidlo
& Schroeder, 2002). Although my own approach to addressing issues of sexual
orientation issues in psychotherapy is most congruent with a gay-affirmative
model, I agree heartily that gay-affirmative therapists need to take seriously
the experiences of their religious clients, refraining from encouraging an aban-
donment of their spiritual traditions in favor of a more gay-affirmative doc-
trine (Haldeman, 2002).
I am particularly concerned about the experience of gay youth and rec-
ognize that they face a number of substantial stressors not shared by their
heterosexual peers. These include the experience of invisibility or open
rejection (sometimes including violence), development of a negative self-
concept, lack of information and resources to assist them in self-understand-
ing, potential conflict with and rejection by family and friends, and higher
rates of various emotional difficulties including mood disorders and active
suicidality (Davidson, 2000; Hershberger & D'Augelli, 2000).
In some religious subcultures, these hurdles are exacerbated by both
subtle and overt messages that a homosexual orientation implies spiritual
weakness, moral depravity, or intentional sinfulness. Young LGB parishio-
ners may feel compelled to choose between their religious community (per-
haps their only link to the divine) and the LGB community or lifestyle
(Davidson, 2000). Research suggests that adolescents from traditional fami-
lies perceive greater disapproval and rejection when revealing their LGB
orientation (Newman & Muzzonigro, 1993). Paradoxically, a religious com-
munity may be a religious youth's primary source of social support and corpo-
rate identity—making it considerably more difficult for him or her to suc-
cessfully blend religious and sexual identities (Davidson, 2000; Yarhouse,
2001).

DISTURBANCE ABOUT SEXUAL ORIENTATION 257

 In Gary's case, these complex stressors were clearly in play. Gary ini-
tially avoided use of the terms gay or homosexual, and although he spoke
matter-of-factly about being "attracted to men," he preferred to speak in terms
of the hypothetical with respect to his sexual orientation. He also made it
very clear that "if I end up being gay, I would never tell my parents." Gary
also insisted he would never disclose his sexual orientation to members of
the church or even his siblings. In fact, I was somewhat surprised that he had
already formulated a clear plan for heterosexual marriage. Though he wor-
ried such a marriage may be "not very fair" to his wife, he thought he could
manage this with help from God. He also believed that having children was
very important both personally and religiously. Throughout these three to
four sessions of exploration and disclosure, it became clear to me that al-
though Gary's sexual orientation was almost certainly homosexual, he viewed
such an orientation as repellant and immoral. He felt simultaneously eroti-
cized and guilty about his daily homosexual fantasies and masturbation as
well as firm in his resolve to keep his sexuality silent as he lived an overtly
heterosexual life in the community and the church. Gary admitted that con-
cerns about his sexuality had often caused him to feel depressed.

REBT for Gary's Disturbance About Sexual Orientation:

Seeking the Elegant Solution

I believe that efforts to disabuse clients of foundational religious beliefs

are both ethically and clinically inappropriate (Johnson, 2001; Richards &.
Bergin, 1997). At the same time, it is not uncommon for clients to present
with clinically salient religious beliefs and behaviors that are discordant or
incongruent with other elements of the client's religious worldview. When
religion has become clinically salient and the therapist has both familiarity
with and respect for the client's theistic beliefs and practices, it is both pos-
sible and preferable for the therapist to engage in REBT disputation aimed at
both the evaluative and demanding nature of the client's beliefs, as well as at
problematic or discordant beliefs themselves. I have elsewhere referred to
this as specialised disputation with religious clients (Johnson, 2001).
In Gary's case, it was possible for me to approach the client with an
overarching assumption of theistic realism or the notion that God is real and
sustaining humankind's existence (Richards & Bergin, 1997) and to com-
municate some shared Christian commitments. I was also interested in help-
ing Gary to examine the effect his religious beliefs had on his presenting
problem (depression) while being careful to consider Gary's religiousness a
potential asset in treatment. In terms of clinically significant dimensions of
religiosity discussed by Richards and Bergin (1997), it was apparent that Gary
was suffering from clinical distress related to both belief orthodoxy and value-
lifestyle incongruence. Belief orthodoxy involves acceptance of the doctri-
nal beliefs of one's religion even when these are incongruent or produce de-

258 W. BRAD JOHNSON

structive outcomes. Value-lifestyle incongruence typically refers to value- or
belief-discordant behaviors. In Gary's case this included largely covert be-
havior such as homoerotic fantasy and masturbation.
It is essential to point out here that during my treatment of Gary, I
made no attempt to help him clarify or label his sexual orientation, nor did I
make an effort to move him in the direction of either accepting a gay iden-
tity or working to ameliorate his same-sex attraction and sexual behavior.
Rather, because Gary's depression appeared to be most clearly driven by his
strong demanding and evaluative beliefs about the possibility of being gay, it
was most important to begin helping him change these cognitions. In REBT,
the elegant solution (Ellis & Dryden, 1997; Walen, DiGiuseppe, & Dryden,
1992) involves helping a client make a profound philosophic change or fun-
damental attitudinal shift in the way he or she thinks about a problem or an
inference about a problem. The elegant solution assumes that the activating
event is true and will remain so or could easily occur (assuming the worst)
and then encourages the client to change his or her evaluation of this given
reality. In Gary's case, the elegant solution was epitomized by helping him to
make a profound shift from evaluative and demanding beliefs (e.g., "If I am
gay, that would be awful and catastrophic. I must not be gay! I could not
stand or tolerate being gay. If I were gay, it would prove I am worthless and
evil.") to preferential and functional beliefs (e.g., "It would be too bad and a
real problem for me in many ways if I were gay, but with God's love and assis-
tance, I could bear it and find some way to cope with that reality. 1 would be
merely gay, not unworthy or unlovable."). So, the elegant REBT solution is
aimed at helping the client to make a profound shift from extreme demanding
and evaluating (which was clearly depressogenic in Gary's case) to preferring
and observing. It is worth noting that the elegant solution in REBT is also
elegant from a spiritual and religious perspective. For example, Christian spiri-
tuality will rarely support catastrophic or demanding beliefs and there are nu-
merous scriptural challenges and contradictions to such disturbed thinking.
During our eighth session, I asked Gary if we could explore how his
worries about sexuality may be related to his mood problems. Having vented
and disclosed importantly about his struggles with sexual orientation and the
very negative implications of possibly being gay, Gary appeared ready to re-
turn to some focus on the presenting problem. He agreed that the two were
probably connected and we again began to formulate an REBT assessment of
Gary's depression—this time considering various activating events (As) re-
lated to his sexuality.
In our subsequent REBT treatment sessions, Gary quickly identified
several important activating events that typically preceded bouts of more
severe depression. These included interactions with other young men he found
interesting or attractive; questions from peers, siblings, or parents about why
he did not date or show particular romantic interest in some of the girls who
had pursued him; and imagining a lifetime of hiding his sexual orientation or

DISTURBANCE ABOUT SEXUAL ORIENTATION 259

sharing his orientation with family. Gary was quick to pick up the REBT
model of disturbance and showed some obvious amusement at the suggestion
that these events (As) alone were not enough to "cause" his depression, but
that he was indoctrinating himself with certain "crazy" beliefs about these
events to really get depressed.
Although Gary was able to articulate several irrational beliefs (Bs), in
the interest of space I will highlight just three of these—each representative
of the main types of irrational belief (Ellis & Dryden, 1997): (a) awfulizing
(e.g., if I am a gay man, it is awful, terrible, and catastrophic); (b) demanding
(e.g., I absolutely must not disappoint God and my parents by acting on my
sexual desires); and (c) global human rating (e.g., feeling attracted to men
and masturbating while fantasizing about men shows that I am not worthy in
God's eyes).
As we moved to disputation in the next several sessions I began with a
general approach to disputation—focusing primarily on the evaluative and
demanding nature of Gary's beliefs without questioning or creating disso-
nance regarding specific religious beliefs. In REBT disputation, there are sev-
eral strategies available to the therapist. In my work with Gary, I used logi-
cal, empirical, and functional disputations—both because I am comfortable
with these strategies and because Gary seemed to respond favorably. Regard-
ing style of disputation, I tend to use Socratic, self-disclosing, and humorous
approaches when possible. Examples of some of the disputes I used with Gary
follow.
Logical disputes were designed to help Gary see the unreasonable and
arbitrary nature of his irrational beliefs ("help me understand how being gay,
if that ends up being true for you, qualifies as a catastrophe," "How does it
follow that because you wish you wouldn't disappoint your parents, then you
absolutely must not do so under any circumstances?"). Empirical disputa-
tions helped Gary see that the facts of the world did not support his irrational
beliefs ("Where is it written that feeling sexual pleasure around men is one of
life's greatest calamities?" "Everyday I make lots of mistakes as a father,
husband, and teacher. This proves that I am worthless. Right?"). Finally,
functional disputations were used to help Gary see how his irrational be-
liefs both created and sustained self-defeating emotions and behaviors, in
other words, one function of adopting more rational beliefs is suffering less
("I wonder if insisting that your sexuality is awful is helping you to feel less
depressed?" "Help me understand how rating yourself as worthless is mak-
ing you feel").
Because Gary was bright, somewhat philosophically oriented, and en-
gaged in treatment, these general REBT disputations helped Gary to better
understand how his demanding and harshly evaluative thoughts were natu-
rally intensifying his experience of depression. Because Gary did not speak of
himself as gay or homosexual in certain terms, I felt it important to present
these disputations in the hypothetical (e.g., "if it is true that," or "if you end

260 W. BRAD JOHNSON

up discovering that you are gay"). I believe this allowed Gary to experiment
with new ways of believing without feeling so threatened.

Navigating a Minefield: Disputing Religious Beliefs

Although Gary was experiencing some relief, it also became clear that
several of his most salient and depressogenic irrational beliefs were deeply
intertwined with long-held religious doctrine regarding homosexuality. For
instance, Gary frequently engaged in selective abstraction (DiGiuseppe,
Robin, & Dryden, 1990)—becoming disturbed by selectively focusing one
aspect of his religion to the exclusion of the bigger picture or larger meaning
of his faith. Specifically, Gary was prone to see himself as damned and worth-
less for his homosexual urges—often entirely ignoring the grace-filled pur-
pose of the life of Jesus. In addition, Gary tended to (unbiblically) rate his
own perceived sin as measurably worse or more severe than other forms. For
this reason, I also began to incorporate more specialized (Johnson, 2001; Nielsen,
Johnson, & Ellis, 2001) disputations to create dissonance between discordant
beliefs and instill doubt about dubious (often unbiblical) doctrine.
Although I generally contend that practitioners should avoid disputing
religious beliefs, there are times when strong religious views are contrary to
the entire body of a religion and clearly linked to emotional and behavioral
dysfunction and pain. In Gary's case, I felt it imperative to question his strongly
dogmatic and depressing beliefs about the possibility of being gay. I explained
to Gary that although I shared his general Christian view of the world, I
thought it might be useful to explore some of his specific beliefs surrounding
this issue (e.g., "God will reject me if I am gay. If I am gay, it just proves 1 am
sinful and unworthy"). Some examples of these more specialized disputations
for Gary's main irrational beliefs follow.
For Gary's pervasive awfulizing about homoerotic impulses and the pos-
sibility of being gay (both of which he identified as forms of sin), I used the
following disputations ("The Bible says that all of us sin and fall short of the
glory of God [Romans 3:23], that is we all sin all the time. Where is it written
that feeling attracted to men is one of the worst sins? I'm confused; the Bible
says that for those who believe and ask for grace, all sins are forgiven. That
must only apply to everyone EXCEPT you? You know Gary, Jesus didn't seem
to say much about homosexuality. It didn't seem very upsetting to him. What
did seem important were kindness, mercy, and love. I'd like you to read through
the gospel as homework and next week, show me that scripture where Jesus
says homosexual feelings are terrible, awful, or the worst possible sort of sin").
For Gary's self-rating, the following appeared helpful ("If your best friend
had the same kinds of gay feelings that you have, would you tell him he was
a worthless sinner in God's eyes? Something's wrong here, Gary. You're tell-
ing me you believe God created you [as the Bible says], but that the way God

DISTURBANCE ABOUT SEXUAL ORIENTATION 261

created you [your sexual feelings] is wrong. This just doesn't make sense does
it?"). Finally, for Gary's demand that he not be homosexual, and that he live
a heterosexual existence, the following functional dispute seemed particu-
larly helpful for Gary ("I agree that your life might seem a bit easier and less
confusing right now if you were exclusively heterosexual. But, from what
you've told me, that is simply not the case. So, it seems that you can either
keep demanding that you be someone you are not and stay depressed or ac-
cept all facets of who you are today and get busy living").
I moved to Maryland after only 16 sessions with Gary. Although he was
by no means free of depressive symptoms at termination, his two final BDI
scores (I administered the BDI monthly) were 8 and 10.1 believe that our 4
months together helped Gary understand how to apply REBT himself, and
how to be kinder and gentler to himself as a Christian man struggling with
reconciliation of sexual orientation and religious beliefs regarding sexuality.
There has been no follow-up and I am uncertain regarding Gary's status to-
day. During our final session, I gave Gary referrals to two other psycholo-
gists—both of whom I felt certain would help Gary to continue exploring
these issues, and both of whom were competent providers of service to LGB
persons, and persons with strong religious commitments.

THERAPIST COMMENTARY

Although I believe I helped Gary with several REBT disputations, both

general and religiously oriented, and although 1 believe our REBT work helped
him to become less catastrophic, demanding, and self-downing in his think-
ing (and thereby less vulnerable to depression in the long run), it is quite
possible that the most therapeutic thing I did for Gary was listen and accept
him when he first disclosed his homosexuality. On that day, and those im-
mediately after, I witnessed a leviathan lift from Gary's shoulders. Offering
authentic admiration, empathy, and unconditional acceptance felt both
maximally therapeutic and clearly Christian. I believe that Gary expected
me to affirm his damning self-view as vile, morally flawed, and chuck full of
the worst sort of sin. I also believe that in his selective brand of Christianity,
he expected the same of God.
I believe this case highlights the ethical and professional challenges
inherent in treating a religious client when the therapist does not share sa-
lient elements of the client's worldview, and in fact, may see some aspects of
the client's religiousness as connected to his or her disturbance. To fully
address Gary's suffering, it was necessary to carefully challenge elements of
Gary's religious dogma without questioning the veracity of his more funda-
mental faith commitments. Therefore, instead of saying "What makes you
think any supernatural being gives a damn about you?" as my teacher Albert
Ellis might, I prefer to work gently from within the client's own faith sur-

262 W. BRAD JOHNSON

round using more subtle disputes of those aspects of a client's religion that
appear clinically harmful. At the same time, I believe it imperative to honor
the client's religious commitments and preferences. Had my work with Gary
continued, we would certainly have reached a crossroads at which Gary may
have benefited from a referral to a therapist with more competence than I in
helping young LGB persons adapt and adjust fully to a gay lifestyle. Alterna-
tively, had Gary ultimately requested assistance with sexual "reorientation,"
I believe I would have been obligated to provide him with such referrals
(although this would have pained me professionally and I would have done
so only after careful informed consent regarding the potential drawbacks of
these techniques).
In closing, I want to acknowledge that some of my conservatively reli-
gious colleagues will feel that 1 am far too religiously liberal on the topic of
sexual orientation, and may believe that I should have confirmed Gary's view
of homosexuality as sin while perhaps helping him accept an asexual life
("love the sinner but hate the sin"). I understand that others more strongly
committed to gay-affirmative services in all circumstances in which a person
explores sexual orientation in therapy might criticize me for not pushing
Gary to "come out" further, self-identify as exclusively gay, and perhaps be-
gin exploring homosexual relationships more actively. The first option is
simply incongruent with my own therapeutic and faith perspective. The sec-
ond option would have been disrespectful of Gary's strong religious views
and his tentative stage of sexual identity consolidation (Haldeman, 2002;
Yarhouse, 2001). In the end, I hope that seeking the elegant solution helped
to reduce Gary's depression in such a way that he will be better prepared to
address these difficult and meaningful questions when the time comes.

REFERENCES

American Psychological Association. (1998). Resolution on the appropriate thera-

peutic responses to sexual orientation. Proceedings of the American Psycho-
logical Association, Incorporated, for the Legislative year 1997. American Psy-
chologist, 53, 882-935.
Benedict, J. G., VandenBos, G. R., & Kenkel, M. B. (Eds.). (2002). Professional Psy-
chology: Research and Practice, 33(3).
Davidson, M. G. (2000). Religion and spirituality. In R. M. Perez, K. A. DeBord, &
K. ]. Bieschke (Eds.), Handbook of counseling and psychotherapy with lesbian, gay,
and bisexual clients (pp. 409-433). Washington, DC: American Psychological
Association.
DiGiuseppe, R. A., Robin, M. W., & Dryden, W. (1990). On the compatibility of
rational emotive therapy and Judeo-Christian philosophy: A focus on clinical
strategies. Journal of Cognitive Psychotherapy: An International Quarterly, 4,
355-368.

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Ellis, A., & Dryden, W. (1997). The practice of rationed emotive behavior therapy (rev.
ed.). New York: Springer.
Foster, R. (1985). The challenge of the disciplined life: Christian reflections on money, sex,
and power. San Francisco: Harper.
Greene, B., & Herek, G. (Eds.) (1994). Lesbian and gay psychology: Theory, research
and clinical applications. Thousand Oaks, CA: Sage.
Haldeman, D. C. (2002). Gay rights, patient rights: The implications of sexual ori-
entation conversion therapy. Professional Psychology: Research and Practice, 33,
260-264.
Hershberger, S. L, &. D'Augelli, A. R. (2000). Issues in counseling lesbian, gay, and
bisexual adolescents. In R. M. Perez, K. A. DeBord, &. K. J. Bieschke (Eds.),
Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients
(pp. 225-247). Washington, DC: American Psychological Association.
Johnson, W. B. (2001). To dispute or not to dispute: Ethical REBT with religious
clients. Cognitive and Behavioral Practice, 8, 39-47.
Johnson, W. B., & Nielsen, S. L. (1998). Rational emotive assessment with religious
clients. Journal of Rational Emotwe and Cognitive Behavioral Therapy, 16,
101-123.
Johnson, W. B., Ridley, C. R., &. Nielsen, S. L. (2000). Religiously sensitive rational
emotive behavior therapy: Elegant solutions and ethical risks. Professional Psy-
chology: Research and Practice, 31, 14-20.
Money, J. (1987). Sin, sickness, or status? Homosexual gender identity and psycho-
neuroendocrinology. American Psychologist, 42, 384-399.
Newman, B. S., & Muzzonigro, P. G. (1993). The effects of traditional family values
on the coming-out process of gay male adolescents. Adolescence, 28, 213-234-
Nicolosi, J., Byrd, A. D., & Potts, R. W. (2000). Retrospective self-reports of changes
in homosexual orientation: A consumer survey of conversion therapy clients.
Psychological Reports, 86, 1071-1088.
Nielsen, S. L., Johnson, W. B., & Ellis, A. (2001). Counseling and psychotherapy with
religious persons: A rational emotive behavior therapy approach. Mahwah, NJ:
Lawrence Erlbaum.
Nielsen, S. L., Johnson, W. B., & Ridley, C. R. (2000). Religiously sensitive tational
emotive behavior therapy: Theory, techniques, and brief excerpts from a case.
Professional Psychology: Research and Practice, 31, 21-28.
Richards, P. S., & Bergin, A. E. (1997). A spiritual strategy for counseling and psycho-
therapy . Washington, DC: American Psychological Association.
Schneider, M. S., Brown, L. S., &Glassgold, J. M. (2002). Implementing the resolu-
tion on therapeutic responses to sexual orientation: A guide for the perplexed.
Pro/essionaJ Psychology: Research and Practice, 33, 265-276.
Serra, R. (2001). The continuing struggle for civil rights in the gay community. Jour-
nal of Psychology and Christianity, 20, 168-175.
Shidlo, A., &. Schroeder, M. (2002). Changing sexual orientation: A consumer's
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264 W. BRAD JOHNSON

Smedes, L. B. (1983). Mere morality. Grand Rapids, MI: Eerdmans.
Swidler, A. (Ed.) (1993). Homosexuality and world religions. Valley Forge, PA: Trinity
Press International.
Throckmorton, W. (2002). Initial empirical and clinical findings concerning the
change process for ex-gays. Professional Psychology: Research and Practice, 33,
242-248.
Walen, S. R., DiGiuseppe, R., & Dryden, W. (1992). A practitioner's guide to rational-
emotive therapy (2nd ed.). New York: Oxford University Press.
Yarhouse, M. A. (2001). Sexual identity development: The influence of valuative
frameworks on identity synthesis. Psychotherapy, 38, 331—341.

DISTURBANCE ABOUT SEXUAL ORIENTATION 265

 RELIGIOUS CROSS-MATCHES
16
BETWEEN THERAPISTS AND CLIENTS
ROBERT J. LOVINGER AND SOPHIE L. LOVINGER

More than 80% of the American population is either Protestant or

Catholic (Hoge, 1996), and although Jews comprise perhaps 2% of the gen-
eral population, it seems that a considerably higher percentage are repre-
sented in the population of psychotherapists, at least in major metropolitan
areas. Because some 85% of Americans have at least a conventional connec-
tion with religion in some form, much of which falls under the general um-
brella of Christianity, there is a significant likelihood of a cross-match be-
tween the therapist and client on this broad religious variable of affiliation/
background. With the growing realization of the complexities of the thera-
pist-client interaction, it can no longer be assumed that thorough training,
careful supervision, and long experience will prevent the therapist's personal
qualities from slowly permeating the therapy in subtle and perhaps overt
ways.
The therapeutic relationship, especially when conducted in a psycho-
dynamic framework, has no real parallel to any other type of relationship in
adult life. This induces some sense of mystery in the client who may wonder
what the therapist is about and where they are going together. More than
one client has said to us that if she or he knew where we were going they

267
might not have started, but at the conclusion of therapy, she or he was glad
we journeyed together. When a Jewish therapist works with a Christian cli-
ent, there is likely to be even more of a sense of mystery about the therapist.
Unsophisticated clients and children may fall back on what they have heard,
or absent that, may fill in the information gap with a variety of fantasies.
Even knowledgeable and sophisticated adults will blend information and fan-
tasy to develop a composite portrait of their therapists. If the therapist works
outside of a large metropolitan area where anonymity is less easily main-
tained, the situation becomes still more complex. The intertwining issues of
mystery and familiarity, often in the background of the therapies we describe,
nevertheless surfaced occasionally and influenced these treatments in some-
times surprising ways.
Although Judaism and Christianity share a great deal of features, the
differences embedded in their respective cultures are quite significant, the
more so because they are largely implicit (Lovinger, 1984). Some of the more
important ones are as follows:

1. Although obedience to God's will is a familiar theme in both

Christianity and Judaism, Jews have a more disputatious rela-
tionship with God and with each other because their goal is
to determine what is the right thing to do rather than the
right thing to believe. Study and debate lead to the right path
in Jewish thought, so tolerance for minority opinions is much
greater.
2. Justice for the less fortunate and for strangers is a powerful
imperative in Judaism, so Jews in general, and Jewish thera-
pists in particular, are likely to be on the liberal end of the
political spectrum. For Jews, charity is not the beneficent be-
stowing of gracious alms by the giver, but an obligation on
the giver and a right of the receiver whose dignity should not
be impaired by the act of giving.
3. Although there is an ascetic strain in Christianity and Juda-
ism, it is not as emphasized in Jewish practice. Because the
world created by God was good, it is proper that it be enjoyed
in a permissible manner. It is a Talmudic dictum that one
who neglects a legitimate pleasure in this world will be pun-
ished for ingratitude to God in the world next to come.
4- Sin and forgiveness are somewhat differently construed. In
Jewish thought, sin (whether through error or deliberate ac-
tion) is a choice, rather than a choice that overlays an inher-
ent condition as in Christianity. Forgiveness is more of an
imperative in Christian thought and more available, whereas
in Judaism only the injured party can forgive, after an apology
and reparation (if appropriate).

268 LOVJNGER AND LOVINGER

 We present three cases: Alfred, a mature, sophisticated adult man near-
ing 50 when he initiated therapy; Danny, an adolescent boy who began therapy
while still in grade school; and Jody, a child just beginning school. In these
cases, religious themes surfaced from time to time, coloring some sessions
and serving as a counterpoint to whatever issues were present at that point in
treatment.

DESCRIPTION OF THERAPISTS

When these three therapies began, we held full-time faculty appoint-

ments in the psychology department of a regional, midwestern university
located in a small town and taught classes in the graduate program in clinical
psychology as well as some undergraduate classes. We were known in both
"town" and "gown" settings. Growing up in New York City, where we re-
ceived our public school, college, and graduate educations, left us marked by
accent and attitude as outsiders in our midwestern town even though rela-
tionships with "townies" were always amicable. Still, the faster pace and ob-
scurity that characterized New York life, coupled with the expectation of
psychoanalytic anonymity in our work, indirectly jarred our sensibilities at
times. We came to accept the occasional encounters with clients in local
stores with relative equanimity, but we always experienced ourselves as "strang-
ers in a strange land," locking doors and cars when it was not necessary and
being perpetually but pleasantly surprised when a proffered check was ac-
cepted in a store without identification.
In our thinking, we were broadly psychoanalytic, evolving at the time
of these therapies from a mainly ego psychology stance toward an object
relations perspective, further flavored by concepts from self psychology. We
were also influenced by the work of Harry Stack Sullivan, but we did not
regard ourselves as eclectic. Rather, it might be better to say we saw ourselves
as adaptive, modifying our methods and conceptualizations over time and in
accord with our perceptions of the needs of the client. Robert Lovinger at-
tended to the adult case and Sophie Lovinger attended to the two child cases.

SETTING

At work there were the usual political abrasions in a university depart-

ment. We had also served the university outside the department and we were
fairly well known. Our department had several married couples, a relatively
unusual policy when so-called antinepotism rules were common in many
universities. Our differences and our capacity to say what we thought, some-
times more bluntly than was absolutely necessary, gave us some further promi-
nence that eventually affected the work with Alfred in indirect fashion. The

RELIGIOUS CROSS-MATCHES 269

sometimes-irrepressible humor in the form of puns that Alfred's therapist
expressed also probably influenced that therapy.
When we moved to this midwestern town, we joined the local syna-
gogue and became involved in the Sunday school as a way to ensure that our
young children (boys ages 5 years and 9 years) would realize that we took our
Judaism and their Jewish education seriously. We went to services quite regu-
larly, observed many of the Sabbath rituals, and observed Passover and other
holidays. The boys helped their mother (Sophie Lovinger) with much of the
preparation for Passover because sometimes more than 30 people attended
the Passover Seders we held in our home. Their father (Robert Lovinger)
studied with a man who led Sabbath services to help prepare both boys for
their bar mitzvahs. Although not Orthodox in practice, we were moderately
observant and fully committed Jews in a synagogue affiliated with the con-
servative movement (Miller & Lovinger, 2000).

THE CASE OF ALFRED

Client Demographic Characteristics

Alfred was near 50 years old when he first consulted me (Robert

Lovinger), deeply unhappy in his marriage, and emotionally and sexually
frustrated. He held a tenured faculty position in philosophy specializing in
the philosophical and theological underpinnings of religions, and also a mid-
level administrative position in the university. Handsome, quiet, and with a
gentle but earnest demeanor, I had known him slightly when I had presented
an early draft of a couple of chapters in a book I was writing to a colloquium
that included his faculty colleagues. His wife, Rachel, also knew me slightly
from mutual service on the board of a local community agency.

Presenting Problems

Although sexual frustration was presented as an initial issue and re-

mained present for a considerable period of time, Alfred's anger related to
deeper feelings of insecurity, inadequacy, and an angry, hurt response to slights,
disparagement, or rejection. In the first session, his initial uncertainty of
whether his problem was important enough to need therapy yielded to my
assurance that I had never had a request for therapy from someone who did
not have ample reason to start. Because the question of continuance of his
marriage was an implicit issue in the first session, and he was perturbed by
sexual responses he felt to attractive women he met, his deeply felt religious
background (mainline Protestant) aggravated an already sensitive conscience.
Values were a larger issue. In my notes I wrote that he "feels I have a clear cut
set of moral values and fears being told to go do whatever he wants. I ac-

270 LOVJNGER AND LOVINGER

knowledged having values but also said I didn't put them on people and he
felt he didn't want that either." The wish in this obvious contradiction be-
tween recognizing my moral values and his fear of being told to do whatever
he wants did not register with me at the time. Perhaps mindful of Jesus' state-
ment about lusting in his heart, he felt that he had already committed nearly
a mortal sin. Although Alfred was aware that I was Jewish, that issue did not
emerge openly again for many sessions.

Assessment and Diagnosis

We agreed to meet once a week on a face-to-face basis. My initial diag-

nostic impression of Alfred, reinforced as therapy continued, was of a classi-
cal neurotic structure marked by good self-control, an overactive conscience,
strong ego functions, effective work habits, and substantial accomplishments.
His investment in his children and his marriage was what would be expected
in this personality constellation, as was his ability to see others as people
whose existence was beyond that to serve his needs. Although powerful pre-
Oedipal issues dating to his first year of life eventually emerged in therapy,
my view of his basic personality organization remained essentially unchanged.
Early in therapy, his education, academic specialization in philosophy, and
overall sophistication allowed him to dismiss some of my interpretations as
coming from a textbook, although he eventually came to see that they did
indeed fit him well. Because the importance of very early issues was not
immediately apparent, I was probably premature in some of my Oedipal
interpretations.

Client History

As we explored Alfred's current situation, he soon told Rachel of his

entrance into therapy and she expressed her own thought of going into therapy
to deal with her long-standing depression. This depression and her emotional
and sexual withdrawal were coincident with the birth of their first child.
This discussion opened several themes. They perceived their respective par-
ents as critical and demanding, people who neither Alfred nor Rachel felt
they could quite please. This apparently made each of them very suscep-
tible to real or apparent slights or rejections, followed by a tendency to-
ward withdrawal, depressive affect, and self-blame. Whenever I made in-
quiries in therapy, Alfred quite readily heard this as criticism. Before we
reached the 20th session, we agreed to meet twice a week, and sometime
afterward he agreed to try the couch. I suggested that this would help be-
cause he could not see my face and be overly influenced by my perceived or
actual facial expressions.
The complex nature of his early experiences of closeness to his mother,
interrupted by his father's return from service overseas, became a dominant

RELIGIOUS CROSS-MATCHES 271

theme. Over the course of therapy the early image of his mother's warmth
gave way to a greater realization of her emotional coolness compounded by a
classical Oedipal struggle with his father to whom he also turned for support
and affection. His father seemed present but not emotionally expressive, even
at times of severe grief. Raised with a typical midwestern stance of "boys
don't cry," asking for help was a matter of shame and embarrassment for
Alfred. Similarly, making clear his needs and wishes to Rachel (and eventu-
ally to me) was difficult. His religious upbringing was Calvinist, which seems
to have reinforced his self-critical tendencies, although at the time of his
therapy he had a more Lutheran stance that he summarized as "everyone
sins, so do your best."

Treatment Process

We directly explored conflicting loyalties between several pairs of people

and I directly raised my being Jewish. Admitting to being exposed to the
usual prejudices that he probably absorbed to some degree, he also confessed
to a quiet admiration and respect. Criticism cut him deeply yet he admired
my presenting an early draft of some book chapters (eventually, Lovinger,
1984) to a faculty colloquium and my listening openly and nondefensively to
the frank criticism I received. Of course, in a subsequent session typical ste-
reotypes of Jews emerged, and ambivalent feelings and perceptions emerged
in subsequent sessions as well.
Alfred's relationship with his wife showed some improvement rather
quickly and then he had to face his own reluctance to respond fully to this
change, motivated by unacceptable desires for revenge and even deeper dif-
ficulties in emotional responsiveness. About 100 sessions into the more than
250 that comprised Alfred's therapy, we came to his "secret," that he could
not love the other person enough to be what he or she needed and this was
his core defect. This was eventually understood to derive from a little boy's
inability to "cure" his mother's depression over her husband's missing-in-
action status. This emotional equation of his failure was likely reinforced by
the Calvinistic nature of his early religious indoctrination.
Religious themes emerged over the course of therapy. In an early ses-
sion, he reported having read a selection in church about David's replace-
ment of Saul. David was described as handsome and ruddy, which also fit his
son. A group of associations referred to killing Goliath, the murder of Uriah,
and his being his mother and grandmother's favorite when his father was
missing in action. I made the obvious Oedipal link. Anger, defiance, and
submission to male authority issues developed and were recurrent issues
through much of Alfred's therapy. A couple of months later, a dream about a
work associate somewhat his senior named Joseph was connected to Joseph
and his brothers. Paralleling the biblical story, I interpreted this as express-
ing his desire to be assertive as well as his fear of displacement.

272 LOVINGER AND LOVINGER

 Around the 40th session, his reluctance to disclose in therapy came
into focus, as he feared humiliation related to an experience of conversion in
graduate school, where he accepted Jesus as his personal savior. Acceptance
of conversion would lead to some unnamed terrifying recognition. In the
following session, he related his dream of being in the army and dealing with
a rebellion. Cornered in a building, all his ammunition was exhausted, and
he was hiding in a room. He heard noises outside that he feared were rebels
trying to break in, but instead a tall, super-powerful savior entered. He appre-
ciated the rescue but resented the implication that he was inadequate. By
this point, Alfred was beginning to do his own interpretive work in therapy,
and he identified the "savior" as both his father and me. Conversion would
make him "a new man," but he did not deserve it. The concept of the savior
originated in the Old Testament as the mashiach or "anointed one" and was
carried forward into the New Testament, and the "new man" appeared in the
letters of St. Paul, with which he was well acquainted. Alfred's conflict be-
tween wanting help and fearing the loss of independence, wanting to iden-
tify with his father (and me) but fearing something terrible, became more
sharply delineated. The conflict between his loyalty to his family and his
Protestant background and his attraction to me as a Jew who heard and ac-
cepted him surfaced several times. Late in November of that year when 1
announced a plan to raise my per session fee, he agreed willingly. Later in the
session, he disclosed stereotypes of Jews as pushy and aggressive and reported
a dream of being in New York City in which a cab driver takes financial
advantage of a friend.
As he became more experienced and sophisticated about a dynamic
approach to psychotherapy, his expression of some difficult issues became
more subtle. After about one year of therapy, he was better able to communi-
cate not only with his wife but also with his parents. Nevertheless, in one
session he reported that the improvement with his parents was moving at a
"galatial" (sic) pace. I inquired about Galatians, and he recalled that in Jesus
all are free: men and women, Greek and Jew, bond and free. Although I
interpreted this in terms of other themes that seemed more significant, in
retrospect this may have expressed a wish for a closer affiliation with me that
would have been easier had I converted to Christianity.
The complex nature of Alfred's difficulties with relationships was
opened to deeper scrutiny after the first year of therapy had passed. The
first year of his marriage to Rachel was felt to be very satisfactory, as was
the first year with a previous girlfriend. Suspecting this pattern hid the
imprint of an earlier life experience, I found that there was a year between
his birth and the report of his father's MIA status. When I delineated this
pattern, it had a considerable effect on Alfred's view of himself and left
him feeling like a puppet. I suggested that he has the pieces now and we
were working to understand them. He left feeling more hopeful about his
relationship to Rachel.

RELIGIOUS CROSS-MATCHES 273

 Some degree of humor began to appear. Alfred teased me about my ma-
cho, four-wheel off-road vehicle and then talked about wanting to change some
troublesome behaviors. I replied that I thought Christians emphasized changes
in the heart and we both laughed. At another time when the campus was
plagued by serious electrical outages, he asked me if I was out of power in the
Psychology Center, where I was director. I replied, "No ... but we don't have
any electricity." Again, we both laughed. As we continued to work, there were
steady improvements in his relationships, especially with his wife. The embed-
ded criticisms he carried with him decreased but did not end. Religious con-
cerns, as a vehicle for his self-disparagement, waned, and the important figures
and experiences behind those feelings came into sharper focus.
Alfred's self-critical attitudes were a recurrent theme. Nearly halfway
through our therapy he challenged me, asking if there was anything that I
criticized him for, in my mind. I thought that clients' perceptions of their
therapists are a complex mixture of their projections and accurate percep-
tions and that mystifying clients is rarely if ever useful, especially when a
solid therapeutic alliance has been established. I affirmed that the way he
had handled an administrative matter in his job that he reported about some
time previously felt shoddy to me. He felt relieved and four sessions later he
reported the unbidden thought "You're really a pretty good person after all."
It seemed there was an increased sense of self-worth after hearing a legiti-
mate criticism from me, which dispelled a vague sense of dread, especially
about being exposed.
One of the most explicit instances of the appearance and use of reli-
gious materials occurred about 10 sessions later. Alfred reported, with some
discomfort, a Bible study session at church. The pastor discussed chapter 7
from Acts, which involved the stoning of Stephen. Stephen was a Helle-
nized Jew who talked to a Jewish mob about freedom from the law and he is
stoned. Alfred expressed a poignant sense of the beginning divergence of two
valid traditions and commented that the pastor's position was the standard
Christian one of freedom from the Law. Alfred had the uncomfortable thought
that he might have this idea to please me. As we explored this further, I
thought that the actual content of this chapter in Acts might be important
to know and I took the Anchor Bible edition of Acts (Fitzmyer, 1982) from
a shelf and scanned the chapter. My clinical notes show

Stephen reviews Jewish history from Abraham to Moses to the prophets

and accuses Jews of murdering the Righteous One. He is stoned and Saul
approved (Paul). He felt he identified with Stephen but I suggested that
I was Stephen saying unpleasant truths and he [Alfred] did not want to
change. He agreed that was also true.

A further theme, not interpreted, may be Alfred's sense of the essential

gap between us as a function of Jewish-Christian history, of which he was
cognizant.

274 LOVINGER AND LOVINGER

 Subsequent sessions were emotionally flat, and in retrospect, I think I
missed an important theme. It would be an error to characterize his lack of
productivity as resistance although it had that character; rather it represented
my failure to be adequately attuned to his mood and implicit message. Just a
few sessions later, I had an opportunity to repair this breach. The session
began with the flat tone that had recently developed. He began with some
dreams that led to his conflict in which he wished for something from me but
to take it would change him. "Like grace?" I inquired and that fit. Alfred
talked about how grace is given freely yet (citing a theologian) people want
grace without accepting the obligations of living a grace-filled life. I con-
trasted the contradiction of freely given grace, contingent on obligation, which
surprised Alfred. Although I had not directly dealt with the rupture in em-
pathic understanding of a few sessions before, this seemed to have repaired it
as at the end of the session he remarked that he could not believe that I could
listen to him for so long and patiently. In the session after the Christmas
holiday, he was more upbeat as his relationship with Rachel continued to
improve but he felt that change was something he had to do himself. In view
of the repetitive religious themes being expressed, I asked about his theology
and he described three views of God: as a benign helper that does not take
away his initiative; a distant, barely available or helpful God; or a Calvinistic
God making demands one cannot meet. Drawing the parallel between the
second view and therapy, I noted there was no view of God—or me as a
collaborative partner, and this surprised Alfred.
Two sessions later, Alfred focused more intensely on not getting his
needs met in therapy but he did not allow himself to get these needs met. As
we explored his fear of shame and ridicule, plus his anger at the expected
deprivation, he was able to sense the child within that he had to protect or
he would dissolve, as if without a skeleton. I replied that he had to develop a
too-early maturity to compensate for his mother's deficits and called this a
brilliant solution. Alfred felt this was devastatingly accurate, but I remarked
on his lack of compassion for himself. This appeared to delineate a major
characterological dimension.

Outcomes

Religiously related themes continued to appear in session, sometimes

in dreams, sometimes in church-related activities, and sometimes in profes-
sional activities. About 6 months after the sessions just described, Alfred's
efforts to find a higher level administrative position finally paid off and he
was offered a deanship at a small but prestigious college in Oregon. This had
many advantages, including being somewhat closer to both their families.
Both he and Rachel were very pleased, although it meant they would sever
many of the good relationships they had developed while at the university.
Two sessions later he reported the wish, with Rachel's approval, to help fi-

KELIGIOUS CROSS-MATCHES 275

nancially someone at their church take a course but he did not want anyone
to know because he would feel mortified. He did not want to disclose this to
me nor did he have many associations. I now think that, at one time, his
philosophical training put him in contact with the teachings of Maimonides,
the preeminent medieval Jewish philosopher. It was Maimonides who de-
scribed the concept of the ladder of charity and one of the higher levels is to
help someone without being asked and without identifying the giver. Al-
though this was never established, given the paucity of his associations, it
seemed plausible and suggested that he may have made a considerable un-
conscious identification with my values.
The differences in background, upbringing, and religious affiliation sur-
faced from time to time. I think that the Jewish roots of my attitude that life
is to be lived and enjoyed in the here-and-now, indirectly influenced therapy
as 1 attempted to modify Alfred's negative self-image but also to get him to
own his personal contributions to the issues that beset his life. Having the
dean's position offered to him represented a way to start over and to draw
closer to his wife, as their mutual support in a new environment would be
very helpful to each other.

DANNY

Client Characteristics

I began seeing Danny when he was 9 years old. He had been in treat-
ment for about 2 years before he was transferred to me.

Presenting Problems

Danny was an angry youngster with serious learning problems and diffi-
culties with impulsivity. For about 2 years in once-a-week treatment we worked
on the anxiety he chronically experienced. Any mention of his internal states
made him quite angry with me, for as is typical with middle childhood chil-
dren, they experience interpretations and explanations as accusations of be-
ing a less than adequate child. As a result, Danny kept away from discussing
anything he considered a secret. I did not even know that he struggled with
the issues of having a Catholic mother and Protestant father with whom he
went to church, each to their own, but not as a family. During a session with
his mother and myself he lashed out at me with a swinging punch as he was
leaving the room. His mother was mortified but we continued to discuss this
event and other issues. She wanted him to continue in treatment with me
and he wanted to leave. I supported this child's need to leave. She finally
accepted this. 1 did not hear from the family for about a year. I received a call
form Danny's mother telling me that Danny asked to come back to talk to

2/6 LOVINGER AND LOVINGER

me. Once I had ascertained that this request came from the child, I agreed to
see him for one session. I took Danny to my office, which surprised him as he
expected to go back into the playroom. For the session we talked about how
angry he was the last time I had seen him and what had made him so angry.
He mentioned that I had talked about all those wiggly feelings he had inside
which made him very upset, not only because he had those feelings but also
because I had not labeled them as anxiety and because I was right about
them. He also felt I had been saying that he was not a good kid and that he
was very different from everyone else 1 knew. Some things were clarified
during this session, and he reiterated his wish to come back.

Assessment and Diagnosis

Danny's having hit me at the end of our last session a year previously
was a repetitive, emotional, and moral theme for him for a long time. He
began to address the anger that was part and parcel of most areas of function-
ing for him. The anger was not the problem as he felt he could come in and
see me and talk about his angry feelings and punch on the punching bag to
get rid of the feelings. Rather it was the fantasies he generated, which were
about doing away with the person involved. This was very difficult for him
because he thought it was morally wrong to think such things. My theistic
views came into play around this issue, because for me thinking is not the
same as doing as it was in his religious views from his mother. We worked on
sorting out the difference between the two concepts. As he slowly under-
stood that his fantasies were the result of his confusing the thought with the
deed, he could allow himself the pleasure of his fantasies without the fear he
would express the content of them. At about the same time he began playing
his father's drums, and using the drum I had in the playroom as well. This
further aided the resolution of his dilemma as he could express his feelings
through the rhythms he played out on the drum.
For both of us, diagnosis means an understanding of what are the major
factors operating in the dynamics and character structure of the child or adult
we are working with. This understanding changes over time as the patient
changes. Danny seemed to have a basically neurotic structure. Although in
the first phase of therapy his anxiety led to some aggressive acting out, he was
able to recognize this was wrong, that he responded to internal pressures, and
that he needed help in dealing with his problems rather than just blaming
others.

Client History and Treatment Process

During this period in treatment, Danny began to periodically raise moral

and ethical issues. For example, he came into session, and told me about his
biracial friend who had asked a girl to go to the movies with him. The mother

RELIGIOUS CROSS-MATCHES 277

said she could not go with this youngster, but Danny knew she had gone to
the movies with other boys. Danny wondered whether the girl's mother re-
fused permission because his friend came from those people who were "slaves
once?" Danny and I got into a long discussion about prejudice and the moral-
ity of it and how angry it made him for his friend and then what he could do
about it. He also moved to talking about his sense of difference from oth-
ers—mostly in negative terms. Danny also expressed much anger toward his
parents, especially his mother whom he experienced as not hearing him or
even understanding him. Weeks of sessions followed as he struggled with his
difference from others and his parents seeming insensitivity to him. School
was an added factor, given his hearing loss in one ear and his difficulties with
the learning process. Slowly he sorted out his feelings about what he could
and could not say in response to the assault he experiences from others. He
also began to process how he is like and different from others and where he
belongs. The flow of the sessions enabled him to look at these issues more
directly than he had previously, but in the process his anxiety was aroused.
As a result he moved toward me and then distanced himself in the relation-
ship, almost as though he were looking for a comfortable place for himself in
relation to me. Shortly thereafter, Danny began raising the issue of our reli-
gious differences and what being Jewish meant.
Starting with issues of celebrating holidays—which ones he celebrated
and which ones I celebrated—he began to look at the differences between
us. Although this was not a week-by-week discussion, he would raise the
religious issue as he struggled with both of his parents. At one point he came
into a session and told me about having watched all the presidential debates.
He had come to the conclusion that Clinton was correct in all his positions,
and that if he could vote, he would vote for Clinton, in spite of the fact that
both parents were staunch Republicans. In a sense then, he was using our
religious differences to work through issues of separation and differentiation.
I also think that my religious difference underscored how differently I re-
sponded to him: different from his parents and teachers. Danny began to
wonder about what made for the differences.
One of the first religious differences he questioned was why Jews did
not believe in Jesus and did it mean they did not believe in God. I could find
no easy way to deal with these questions in a more traditionally therapeutic
manner and so I dealt with it in a straightforward cognitive manner. Al-
though I explained that Jews certainly believed in God, they just did not
believe in Jesus, this was a very hard concept for him to process. We came
back to these questions repeatedly during the remaining course of treatment.
Although he could verbally express my response to him on this issue, it was
clear he could not understand it fully. At other times, when he was angry
with me, or needed more distance in our relationship he would angrily attack
through statements regarding the lack of belief in God by the Jews. At other
points during sessions he would present me with scenarios questioning how I

278 LOVfNGER AND LOVJNGER

would respond if the Nazis would come back and do a variety of atrocious
things to the Jews. He would become outraged if I did not immediately fight
back. He did not tolerate processing a response or trying to figure out the best
way of handling the situation.

Outcomes

Danny used the religious differences between us in the service of under-

standing and working through his sense of difference from family, friends,
and peers. Although this was the predominant issue in later stages of treat-
ment, he was also curious as to how someone so different from himself could
understand him better than his family with whom he lived. This was a real
existential issue for this young man. The use of religious differences, at this
point in Danny's life, was in the service of resolving personal issues, and not
for religious reasons. In contrast, I briefly present the case of a 7-year-old who
also expressed religious themes in the service of emotional issues.

JODY

Client Characteristics

Jody, a 7-year-old, the second of two children, was adopted at birth.

She had a naturally born sister some 8 years older who was reported to be
functioning well.

Presenting Problem

The parents reported noncompliance with parental requests and de-

mands. Maternal requests were either ignored or done at a very slow pace.
Jody was reported to be functioning satisfactorily at school.

Assessment and Diagnosis

For reasons that will become clear, Jody was understood to have an
attachment disorder. She and her mother seemed to have very different tem-
peramental styles, expressed in their mutual pace of activity and response.
Jody appeared very angry with her mother, who was experienced as unre-
sponsive to Jody's needs for a slower pace and greater patience.

Client History and Treatment Process

Some months after therapy had begun she came into the playroom,
took all the furniture and people out of the dollhouse and jumbled every-

RELIGIOUS CROSS-MATCHES 279

thing together in front of the dollhouse. She then rummaged through the
mess she had created and found an adult female doll, a cradle, and a baby.
She then rummaged through my collection of animals and chose a ferocious-
looking tiger. She placed this entire collection in front of the mess in front of
the dollhouse. She had trouble deciding where to place the female doll that
she labeled as the mother and finally decided on placing her around the
corner of the house at the left side, out of sight. The baby was placed in the
cradle at the front of the house toward the right side. The tiger was placed off
in the distance but visible from the front of the house. She was then ready to
play out her theme. Mother was around the corner hanging up the wash, the
baby Jesus was in his cradle and the tiger was slowly coming toward the house
to get the baby Jesus. As the tiger neared the house, it began to slink along so
it could not be seen or captured. It reached the cradle, snatched the baby
Jesus, ate him up, and ran away. Feeling remorse, the tiger came back to the
house, threw the baby Jesus up, left him on the ground, and ran away. Mother
then came from around the house to take care of the baby Jesus. This theme
was repeated many times in the ensuing weeks.
When I discussed this scenario with the parents in a parent conference,
Jody's father commented that Jody's theology left a lot to be desired. He
clearly saw it as a problem with understanding the religious significance of
the birth of Jesus. I, on the other hand, saw an emotional conundrum the
child was expressing through the use of the religious issues. We will return to
the meaning of this vignette shortly.
After the Christmas holidays, this theme was not repeated. Instead,
Jody began playing with a set of anatomically correct baby dolls. She moth-
ered them throughout the sessions. Some time later during a session, she
played out getting a babysitter to take care of these twins she had as she and
her husband wanted to go out. The sitter came; mother gave her instructions
about the care of the baby and mother left. The sitter did some of the moth-
ering Jody had enacted, but then the sitter took the clothes off the baby, put
the babies in a roasting pan and roasted them in the oven. When the parents
returned, the sitter told the parents the babies were good and were now asleep.
The sitter served the parents dinner . . . roasted baby.
These two play enactments carry a similar theme although one is
couched in religious terms and the other is not. They both express this
youngster's issues with adoption and her relationship with her mother. The
play enactment begins with this youngster creating a mess in front of the
dollhouse. It seems plausible to hypothesize that the mess represents the in-
ternal mess and confusion Jody experiences both within her home and within
her head when she thinks about this. There is an assumption here that the
play of a child is a reflection of the thought processes within a child's head.
As they cannot deal with thinking processes internally, playing them out
where children can visualize their thoughts is the next best thing. Eventually
children do learn to think in their heads, but they need to have achieved

280 LOVINGER AND LOVINGER

concrete thinking, in Piagetian terms, before they can do this. One must
remember that the acquisition of this skill is a slowly developing achieve-
ment. Jody started her play with a sense of confusion that she slowly works
through as the play develops. She does have a mother in the sequence, but
the mother is placed outside the action.
At a psychoanalytic conference in Michigan, Umberto Nagera, chief of
the adolescent service at the University of Michigan Hospital, discussed the
complex issues adoptive children deal with regarding their adoption. They
have two mothers to contend with, the reality of the adoptive mother and
the fantasy of the birth mother.
It is never clear which mother is being described either verbally or in
play. They may even be confused in the child's own thoughts about them.
More likely, the birth mother becomes the idealized mother while the adop-
tive mother can become the less than adequate mother of reality. This is one
of the dilemmas in understanding Jody's depiction of her mother. In any
case, both mothers in this play were unavailable. Not only was mother not
around but the baby was left all alone; no one was caring for it. I would
hypothesize that the story of there being no room at the inn, and the birth of
Jesus in the stable was translated by this child as being alone. This also fits
with her feelings that there was no room in her family, in her relationship
with her mother for her or her slower style of functioning.
With no one to care for the baby Jesus, he was vulnerable to all kinds of
"bad" things happening. At first the baby Jesus was stolen. Being stolen is
one of the explanations young adoptive children develop to explain why
their birth mother gave them up for adoption. Unable to grasp or understand
how a mommy could give them away, they assume that they were stolen from
their "good, birth mommies" by their "bad" adoptive mothers. For Jody this
conceptualization did some important things: (a) it preserved herself as a
"good baby" through her identification with the baby Jesus; (b) it established
her adoptive mother as the "bad" one; (c) it affirmed her lack of identifica-
tion with her adoptive family; and (d) it allowed herself to be identified with
the fantasized "good/perfect" family.
In spite of the identification with the perfect baby Jesus, this approach
did not save her from being devoured. No matter how many times this child
played out the original scenario, she could neither alter the ending nor ben-
efit from her identification with goodness. Thus, when the holiday season
ended and some months had passed, she came back to the same theme and
expressed her feelings in a very brutal, uncaring, unsympathetic manner. I do
think her brutal expression of the theme represents her experience of her
mother's treatment of her as well as her increasing loss of sense of self. In her
original play, the tiger first ate, but then threw up the baby Jesus unharmed.
In the second play sequence the babies were roasted and served up to the
parents. There was no saving of the babies. Interpretively one could suggest
that this child is sending a message to her birth mother, such as, look what

RELIGIOUS CROSS-MATCHES 281

you have done while at the same time expressing how hopeless things seem
to her and that because things can be no different for her, she is paying every-
body back.

Outcomes

Attachment disorders are quite difficult to treat and Jody's parents did
not wait for therapy to take effect, removing her at the end of the school
year. Although here too, there was a difference between the therapist and
the patient in religious affiliation, Jody was developmentally much younger
than Danny and thus this factor did not emerge in therapy in any detectable
fashion. In Judaism, although the Bible records stories of the childhood of
major figures, these childhood narratives do not have the same place in the
religious education or imagination of Jewish children. I think I found Jody's
graphic use of the baby dolls startling and off-putting. Whether this counter-
transference reaction had any effect on therapy I do not know, although I
could not detect any.

THERAPISTS' COMMENTS

When children have a usable religious base to express their internal

conflicts, these religious ideas as well as other learnings become drawn into
the unconscious workings of their dilemmas. For both of these youngsters
religion was brought into the session as an aid in the resolution of individual
conflicts each was dealing with. However, when religion, or any other expe-
rience does not help in the resolution of the issue, the child will go on to try
out other means of solution. This was obvious in the material presented on
Jody. For Jody, the Jesus story was a convenient vehicle to express an issue
that was deeply important to her—adoption and what that meant.
Jody's use of religious stories could have been used in treatment with
anyone. It was not specific to the therapeutic relationship she developed
with me. In fact, these religious overtones quickly disappeared from our dia-
logue when the problems she was struggling with did not readily resolve. She
then went on to other ways of struggling with her concerns about being
adopted.
Danny's use of religious differences between us was a vehicle to explore
his sense of difference from others, but also his sameness, which would allow
for further differentiation. Danny struggled with differentiation of himself
from his family throughout the therapy. My representing a different "other"
from all the "others" he came in contact with was very important to the
treatment. One must remember that his questioning of the religious differ-
ences between the two of us did not occur until later in therapy when a solid
relationship had been developed, and he could trust me to maintain the rela-

282 LOVINGER AND LOVINGER

tionship with him even though he was challenging and testing me. Thus, my
difference gave him the needed courage to face and accept his own differ-
ences, not only from me but also from his peers, his teachers, and his family.
I do think that the older the child is, the nearer she or he is likely to be
to formal operations, hence the ability to think about experience not yet
encountered is an important underpinning for the use of religious experience
and understanding in the resolution of difficulties. The adolescent is only
just beginning to be able to do this, whereas the younger child does not yet
have this capacity.
Although many adults have at least some capacity to think symboli-
cally, this is not always maintained when the person regresses deeply in the
course of intense therapy, or suffers from a developmental arrest (Stolorow &
Lachman, 1980) at the point they enter therapy. However, this was not the
case with Danny or Alfred, both of whom had neurotic personality structures
that could tolerate considerable emotional stress. By virtue of his intelli-
gence, sophistication, educational background, therapeutic issues, and per-
sonal religious orientation, Alfred would have brought religious issues into
any therapy where it was not actively discouraged. Because we lived in a
relatively small community where we as therapists were relatively well
known, and in particular where Alfred knew of his therapist's background
and professional interests, religious issues were likely to be prominent in
therapy—and so they were. The religious component of his personality or-
ganization allowed for a fuller engagement and resolution of his personal
issues in therapy, and his experience of another person who respected and
defended his integrity, even on religious issues, contributed to Alfred's re-
covery. Even when vulnerable in therapy, the therapist made no effort to
"convert" him as Alfred might have expected from a Christian therapist
(whether realistic or not).
It is plausible to assume that if the therapist and patient have similar
backgrounds and similar values, therapy is likely to proceed more smoothly
and produce a better outcome. At least with regard to religious issues, there is
some evidence that such similarities may not necessarily lead to better out-
comes (Propst et al, 1992). In the cases presented in this chapter, the differ-
ences were larger than would be typical with a patient-therapist dyad drawn
from two different Christian denominations. For Danny and Alfred these dif-
ferences, attended to by the therapists and responded to in therapy, may have
helped resolve more fully certain of the issues both of them had and rather
than be an obstacle to the therapy, these differences had a facilitating effect.

REFERENCES

Fitzmyer, ]. A. (Ed.). (1982). The Acts of the Apostles: A new translation with introduc-
tion and commentary. Garden City, NY: Doubleday.

REZJGJOUS CROSS-MATCHES 283

Hoge, D. R. (1996). Religion in America: The demographics of belief and affiliation.
In E. P. Shafranske (Ed.), Religion and the clinical practice of psychology. Washing-
ton, DC: American Psychological Association.
Lovinger, R. J. (1984). Working with religious issues in therapy. New York: Jason Aronson.
Miller, L., & Lovinger, R. J. (2000). Psychotherapy with conservative and reform
Jews. In P. S. Richards & A. E. Bergin (Eds.), Handbook of psychotherapy
andreligious diversity (pp. 259-286). Washington, DC: American Psychological
Association.
Propst, L. R., Ostrom, R., Watkins, P., Dean, T., & Mashburn, D. (1992). Compara-
tive efficacy of religious and nonreligious cognitive-behavioral therapy for the
treatment of clinical depression in religious individuals. Journal of Consulting
and Clinical Psychology, 60, 94-103.
Stolorow, R., & Lachman, F. (1980) The psychoanalysis of developmental arrests. New
York: International Universities Press.

284 LOVINGER AND LOVINGER

 THEISTIC PERSPECTIVES IN
17
PSYCHOTHERAPY: CONCLUSIONS
AND RECOMMENDATIONS
P. SCOTT RICHARDS AND ALLEN E. BERGIN

We hope that you have found the diversity of case reports described in
this book fascinating and helpful. We were impressed by the many similari-
ties among the cases, as well as the differences. We hope they have given you
additional ideas about how you might apply theistic spiritual perspectives in
your own work.
In this chapter we briefly consider how we think theistic spiritual per-
spectives and interventions uniquely influenced the processes and outcomes
of these cases. We then discuss some objections and concerns that have been
raised about integrating theistic perspectives into mainstream psychotherapy.
We conclude by offering some recommendations for those who wish to in-
corporate theistic perspectives into their work.

INFLUENCE OF THEISTIC PERSPECTIVES ON

THEORETICAL FRAMEWORKS
There was considerable diversity in the theoretical frameworks and treat-
ment approaches described in the case reports. In Table 17.1 one can see

287
 TABLE 17.1
Incorporation of Theistic Perspectives Into Therapists' Theoretical
Orientations and Approaches
Theistic
Therapist Integrative theoretical
(Case) combinations assumptions Spiritual interventions used

Slife, Mitchell, Community-theistic God exists. Encouraged client to pray.

& Whoolery traditions Moral framework Encouraged client to read
(Laura) for therapy. spiritual readings.
Spiritual Spiritual journaling.
inspiration for Spiritual discussions.
client. Spiritual exploration in
Faith and group setting occurred.
spirituality Client participated in acts
important for of altruistic service as
healing. part of treatment
Altruism, agency, program.
and holism Client was taught to listen
important to the "Source" (God,
guiding the Spirit) to help guide
assumptions. her life decisions.
Hardman, Cognitive- God exists. Encouraged client to pray.
Berrett, & psychodynamic- Moral framework Encouraged client to read
Richards theistic traditions for therapy. scriptures and other
(Jan) Spiritual spiritual readings.
inspiration for Spiritual journaling.
client. Spiritual discussions.
Faith and spiritual Spiritual exploration group.
experiences Therapist privately prayed
important for for client.
healing.
Miller (Renee I nterpersonal-theistic God exists. Spiritual discussions in
& liana) traditions Moral framework group.
for therapy Discussed and affirmed
(Spirit of Truth). spiritual and moral truths
Spiritual (universals).
inspiration for
client.
Faith and spiritual
experiences
important for
healing.
Krejci (Mary & Humanistic- God exists. Encouraged clients to
John) cognitive-theistic Moral framework forgive.
traditions for therapy Encouraged client to read
(virtues such as scriptures for religious
forgiveness, stories and images
love, about forgiveness.
tolerance). Clients prayed for their
Faith important for spouse and with each
healing. other.
Altruistic service to each
other.

continues

288 RICHARDS AND BERGIN

 TABLE 17.1 (Continued)

Theistic
Therapist Integrative theoretical
(Case) combinations assumptions Spiritual interventions used
Participated in Bible study
with each other.
Spiritual discussions during
therapy.
Dobbins Cognitive- God exists. Encouraged client to pray
(Kathy) psychodynamic- Moral framework for new interpretations of
theistic traditions for therapy. past painful
Spiritual experiences.
inspiration for Encouraged client to read
client. scriptures.
Faith and spiritual Spiritual discussions.
experiences "Putting off the old man"
important for technique to control
healing. drinking.
"Praying through"
technique to emotionally
work through pain from
childhood.
Encouraging self-
forgiveness.
Rabinowitz Psychodynamic- God exists. Encouraged clients to read
(multiple cognitive-theistic Moral framework scriptures and other
cases) traditions for therapy. spiritual readings.
Faith important for Spiritual discussions.
healing. Cognitive restructuring of
dysfunctional religious
beliefs.
Interpreted religious
themes in a
psychodynamic
framework.
Encouraged involvement in
religious community.
Sperry Biopsychosocial: God exists. Encouraged client to pray,
(Gwen) medication- Moral framework focus, and meditate.
psychodynamic- for therapy. Spiritual journaling.
cognitive- Faith and spiritual Spiritual discussions.
psychoeducational experiences Cognitive restructuring of
-social-theistic important for dysfunctional religious
traditions healing. beliefs.
Encouraged client to
participate in religious
community.
Shafranske Psychodynamic- God exists. Spiritual discussions.
(Joan) theistic traditions Moral framework Interpreted religious
for therapy. themes in a
psychodynamic
framework.

continues

CONCLUSIONS AND RECOMMENDATIONS 289

 TABLE 17.1 (Continued)

Theistic
Therapist Integrative theoretical
(Case) combinations assumptions Spiritual interventions used

Cook Multicultural-person God exists. Encouraged client to pray,

(Grace) centered-theistic Spiritual meditate, and engage in
traditions inspiration for spiritual imagery alone
client. and during therapy
Faith and spiritual sessions.
experiences Encouraged client to read
important for scriptures and other
healing. spiritual readings.
Spiritual journaling.
Spiritual discussions.
Therapist privately prayed
for client.
Rayburn Cognitive- God exists. Encouraged client to pray.
(Paul) psychodynamic- Moral framework Spiritual discussions.
theistic traditions for therapy Challenged unhealthy
(e.g., equality religious beliefs with
of men and cognitive therapy
women). techniques.
Spiritual
inspiration for
client.
Faith and spiritual
experiences
important for
healing.
West Humanistic-theistic God exists. Discussed theological
(Matthew) traditions Moral framework concepts.
for therapy. Made references to
Spiritual scripture.
inspiration for Spiritual "silences;" feeling
client. connected spirituality
Faith and spiritual with each other.
experiences Encouraged forgiveness.
important for Helped clients live
healing. congruently with their
spiritual values.
Self-disclosed spiritual
beliefs or experiences.
Nielsen REBT-theistic God exists. Rational disputations of
(Aisha) Moral framework irrational religious
for therapy. beliefs.
Faith and Used scriptures to
scriptural challenge irrational
rationales beliefs.
important for
healing.

continues

290 RICHARDS AND BERGIN

 TABLE 17.1 (Continued)

Theistic
Therapist Integrative theoretical
(Case) combinations assumptions Spiritual interventions used
Hedayat-Diba Psychodynamic- God exists. Discussed spiritual
(Mrs. A) theistic traditions Moral framework experiences and
for therapy. concepts.
Spiritual Self-disclosed spiritual
inspiration for beliefs or experiences.
client.
Faith and spiritual
experiences
important for
healing.
Johnson REBT-theistic God exists. Religious and spiritual
(Gary) traditions Moral framework assessment.
for therapy that Engaged in REBT
emphasizes disputations of client's
tolerance and depressogenic religious
love and beliefs about what it
downplays means if he is "gay."
specific
behavioral
prescriptions
about morality
or sexual
behavior.
Lovinger & Psychodynamic- God exists. Spiritual discussions.
Lovinger theistic traditions Moral framework Interpreted religious
(Alfred, for therapy. themes in a
Danny, psychodynamic
Jody) framework.
Note. REBT = Rational emotive behavior therapy.

that the theoretical traditions that the therapists combined in their integra-
tive approaches are (a) psychodynamic-theistic (N = 4), (b) psychodynamic-
cognitive-theistic (N = 4), (c) rational emotive behavior therapy (REBT) -
theistic (N = 2), (d) cognitive-theistic (N = 1), (e) interpersonal-theistic (N
= 1), (f) multicultural-person-centered-theistic (N = 1), biopsychosocial-
theistic (N = 1), and (g) community-theistic (N = 1).
The therapists also differed in the manner and degree to which they
have incorporated theistic perspectives into their work. Some of them used
theistic perspectives in an implicit, minimal fashion and seemed to rely quite
heavily on traditional mainstream perspectives and interventions (e.g.,
Shafranske and Lovinger and Lovinger). Other therapists integrated theistic
perspectives and interventions into their approach in a much more explicit
and encompassing manner (e.g., Dobbins, Cook, Slife and colleagues, and
Rabinowitz), and others adopted more of a middle-ground approach (e.g.,
Rayburn; Miller; Sperry; and Hardman, Berrett, and Johnson).

CONCLUSIONS AND RECOMMENDATIONS 291

 We think it is problematic to attempt to pass judgment about which
approach is best because we think that the manner and degree to which the-
istic perspectives and interventions may appropriately come to the forefront
during therapy depends on a variety of things. These include clients' pre-
senting problems and issues, religious backgrounds, and current spiritual
orientations. In addition, therapists must feel free to integrate theistic per-
spectives and interventions in the manner and degree to which they feel
comfortable. Therapists' theoretical orientations, religious backgrounds and
beliefs, and level of training and expertise in religious and spiritual issues
may all influence their decision about how fully they wish to integrate the-
istic perspectives.
Although we have described our own theistic psychotherapy orienta-
tion and approach in considerable detail in chapter 1, and in A Spiritual Strategy
for Counseling and Psychotherapy (Richards & Bergin, 1997), we wish to em-
phasize here that we do not think therapists must incorporate all of our ap-
proach to be regarded as theistic psychotherapists. In our view, counselors
and psychotherapists who believe in God in a manner that is generally con-
sistent with the theistic world religions, and whose theistic beliefs influence
their theoretical perspective and therapeutic approach in an appreciable way,
are theistic psychotherapists. If a therapist responds "yes" to all or most of the
following questions, then by our definition it would be appropriate to refer to
her or him as a theistic psychotherapist:
1. Do you believe in God or a Supreme Being?
2. Do you believe that human beings are creations of God?
3. Does your theistic worldview influence your view of human
nature and personality theory?
4- Do your theistic beliefs influence your ideas about human
dysfunction and therapeutic change?
5. Do your theistic beliefs have any impact on the manner in
which you relate, assess, or intervene with your clients?
Most psychotherapists are not accustomed to using the term theistic in
descriptions of their therapeutic orientation, perhaps in part because this has
not previously been offered as an option for mainstream professionals. We
would like to offer it as one now. Although many contemporary psycho-
therapists profess to reject philosophical assumptions such as atheistic-
naturalism, determinism, reductionism, atomism, mechanism, materialism,
ethical hedonism, and ethical relativism, they still often profess theoretical
allegiance to mainstream traditions that are grounded in these assumptions
(Jensen & Bergin, 1988; Richards & Bergin, 1997; Slife, 2003; Slife & Wil-
liams, 1995). On the basis of surveys that have shown that sizable percent-
ages of psychotherapists are members of one of the theistic world religions,
believe in God, and use spiritual interventions in their professional practices

292 RICHARDS AND BERGIN

(Ball & Goodyear, 1991; Bergin & Jensen, 1990; Richards & Potts, 1995;
Shafranske, 2000; Shafranske & Malony, 1990), we hypothesize that many
therapists might appropriately be called theistic psychotherapists. At the least,
perhaps they may wish to include the term theistic in describing their ap-
proach (e.g., I am a theistic-psychodynamic psychotherapist).
Table 17.1 reveals that for many of the therapists who contributed to
this book, the label theistic psychotherapist may be appropriate, for all of
them to one degree or another accept at least some theistic theoretical as-
sumptions and interventions. For example, virtually all of the therapists be-
lieve that God exists and that human beings are the creations of God. These
assumptions sometimes explicitly, but most often implicitly, influence how
they conceptualize and relate to their clients. Most, if not all of them, reject
ethical relativism and to one degree or another use a moral framework to
guide their therapeutic work. Although the therapists undoubtedly differ with
regard to the specific moral values they endorse, all of them seem to gener-
ally adhere to moral values and principles that are grounded in and consis-
tent with those of the theistic religious traditions.
Many of the therapists also either explicitly or implicitly affirmed their
belief that faith and spirituality are important resources for healing. Several
therapists also discussed the role of inspiration and other spiritual experi-
ences in therapy. Some of them personally sought and/or encouraged their
clients to seek spiritual guidance and inspiration in the healing and recovery
process. Table 17.1 also reveals that almost all of the therapists used spiritual
interventions that assume that God exists and intervenes to assist human
beings.
Although counselors and psychotherapists who do not personally be-
lieve in God will undoubtedly not wish to refer to themselves as theistic
psychotherapists, we think that it is possible for therapists from diverse per-
spectives, including those with Eastern, transpersonal, and humanistic spiri-
tual beliefs—and even those who regard themselves as agnostic or atheis-
tic—to accept many aspects of our theistic spiritual strategy. In our view,
therapists are practicing consistent with our theistic psychotherapy approach
if they seek to accept, affirm, and use the healing potential of their clients'
faith in God, personal spirituality, and religious community. As we expressed
elsewhere:
We hope that professionals who find such perspectives [theistic ones]
and recommendations [using various spiritual interventions] objection-
able will not 'throw the baby out with the bath water' and conclude that
there is nothing of value for them in this book. Those who feel nega-
tively about a specific perspective or intervention can certainly disre-
gard it. They may still find considerable value in the overall strategy we
describe, and it should assist them in working more sensitively and effec-
tively with their theistic clients. (Richards &. Bergin, 1997, p. 16)

CONCLUSIONS AND RECOMMENDATIONS 293

 INFLUENCE OF THEISTIC PERSPECTIVES ON
THERAPY PROCESSES AND OUTCOMES

Table 17.2 summarizes the variety of ways that the theistic perspectives
of the clients and therapists influenced the processes and outcomes of psy-
chotherapy in these cases. It was clear in the case reports that theistic per-
spectives had some influence, and sometimes a major influence, on virtually
every aspect of therapy, including presenting problems, therapeutic relation-
ships, therapeutic goals, assessment and diagnosis, therapeutic interventions,
and evaluation of therapy outcomes.
The therapists' theistic beliefs influenced the ways they viewed and
related to their clients. Most of the therapists viewed their clients as cre-
ations of God who were of great spiritual worth and potential. These views
were not usually explicitly discussed in the case reports, but they were com-
municated implicitly and subtly in the accepting, caring, and affirming man-
ner in which the therapists described and related to their clients.
Because of their theistic beliefs, the therapists sought to create a spiri-
tually safe and open relationship with their clients. There were several ways
therapists did this. First, many of the therapists informed their clients that it
was appropriate and even desirable to discuss spiritual issues during therapy
by explicitly mentioning this. Second, all of the therapists showed respect
and interest when their clients brought up spiritual topics during therapy.
Third, some of the therapists inquired about spiritual issues during the assess-
ment phase of therapy and thereby implicitly communicated to their clients
that such topics were open to discussion.
All of the therapists sought to respond respectfully and sensitively to
their clients' religious and spiritual beliefs rather than discounting or
pathologizing them. In some cases, the therapists felt it was necessary to in-
terpret or even raise questions regarding the doctrinal soundness, or mental
health consequences, of clients' religious beliefs, but they always respectfully
affirmed their clinical relevance. In many cases, the therapists recognized
and honored the healing potential of their clients' spiritual beliefs and prac-
tices by using them as a resource during therapy.
The majority of therapists adopted an ecumenical therapeutic stance
with their clients. This was appropriate because most of the therapists worked
with clients whose religious affiliation differed from their own (e.g., Jewish
therapists working with Christian clients, a Roman Catholic therapist work-
ing with a Protestant client, and a Quaker therapist working with a Muslim
[Sufi] client). Several therapists did adopt a denominational therapeutic stance
with clients from their own faith (e.g., Dobbins; Hardman et al.; and
Shafranske). Without exception, the therapists avoided proselyting and did
not seek to convert clients to their own religious tradition.
The therapists' theistic beliefs also influenced them to include consid-
eration of religious and spiritual dimensions of functioning as they assessed

294 RICHARDS AND BERGIN

 TABLE 17.2
Influence of Theistic Perspectives on Therapy Processes and Outcomes
Differences in case
Therapist Influence of Influence of without theistic
(Case) client's faith therapist's faith perspectives
Slife, Mitchell, The client's growing The treatment team's Values such as honesty,
& Whoolery faith and trust in faith in the Source community, and
(Laura) "the Source" as a (God) as a valid responsibility could
guide in her life, source of guidance in still have been taught,
as well as her adolescents' lives, as but they would not
acceptance and well as their belief in have been anchored
internalization of theistically based in a spiritual
theistically based moral values, totally perspective that such
values such as shaped the treatment values are universal
honesty, altruism, philosophy and and emanate from
responsibility, approach. Their faith God. Also, the client
community, and helped the client would not have
service, played a believe in and learned that "the
central role in her internalize these Source" could be a
recovery and beliefs and values, reliable guide.
change. which helped her
change her life in a
positive manner.
Hardman, The client's faith and The therapist's faith in Spiritual interventions of
Berrett, & spiritual God led him to prayer and scripture
Richards experiences encourage client to reading would not
(Jan) reassured her of read scriptures, and have been used. The
God's love and to pray and meditate. client would probably
strengthened her When the client not have received
eternal spiritual reported her spiritual spiritual assurances
sense of identity experiences, the of her worth and of
and worth. These therapist's faith led God's love. It is
assurances him to validate the questionable whether
served as an truth of what she had her sense of identity
anchor during the learned about her and worth would have
challenging worth and identity. healed so quickly and
recovery The therapist's faith deeply.
process—gave led him to tap into the
her the courage resources of the
to take risks in client's faith and
therapy and to spirituality during
face her pain from treatment.
the past (e.g.,
abuse).
Miller (Renee The clients' faith in The therapist's faith in In secular therapy it is
& liana) God influenced God influenced the unlikely that moral
their choice to way she universals would have
have baby rather conceptualized her been discussed and
than to have an client's problems and affirmed. It is
abortion. Their issues—as
continues

CONCLUSIONS AND RECOMMENDATIONS 295

 TABLE 17.2 (Continued)

Differences in case
Therapist Influence of Influence of without theistic
(Case) client's faith therapist's faith perspectives

faith influenced quest to find spiritual unlikely that the

their desire to love and to live in young mothers'
love and protect harmony with the decision to have their
their babies and Spirit of Truth and babies would have
be good mothers. moral universals been conceptualized
Their faith in regarding and framed in such a
spiritual truths motherhood. The positive manner (as a
influenced them therapist's faith also quest for spirituality
to take influenced her and spiritual love).
courageous decision to affirm
stands on behalf moral universals
of their babies' during therapy.
welfare.
Krejci (Mary & The couple's faith in The therapist's faith in A secular therapist may
John) God motivated God led him to view have failed to tap into
them to work on spirituality as highly the healing power of
their marriage relevant to the the couple's shared
and to overcome couple's progress. spiritual beliefs. The
and forgive each Rather than viewing couple's motivation
other of their the couple's religious and ability to forgive
differences, even differences solely as may not have been as
their religious a cause of problems, great without their
differences. It he viewed their faith Christian belief that
also led them to commitments as a forgiveness is
pray with and for resource. He desirable and
each other. encouraged the possible. Also,
Ultimately, their couple to use their without faith in prayer,
faith and shared interest in the couple would not
spirituality helped spirituality to have enjoyed the
heal the conflicts strengthen their benefits that came
in their marriage relationship. from praying with and
and brought them for each other.
greater marital
happiness.
Dobbins The client's faith in The therapist's faith in In secular therapy the
(Kathy) God motivated her God had a major client would not have
to pray, read impact on his view of been encouraged to
scriptures, and the client, goals for pray, read scriptures,
seek spiritual help therapy, and the or ask God for
in healing her spiritual interventions assistance in
pain. Her faith he prescribed. The changing her
also gave her therapist's faith led unhealthy
added strength to him to encourage interpretations of her
help her client to include God childhood
overcome her in the healing experiences. The
alcohol problem. process. therapist would not
The client's faith have appealed to
in the atonement
of Jesus Christ
continues

296 RICHARDS AND BERGJN

 TABLE 17.2 (Continued)

Differences in case
Therapist Influence of Influence of without theistic
(Case) client's faith therapist's faith perspectives

helped her forgive Christ's atonement to

herself for "hating help client forgive
her father" and herself.
"betraying her
mother."
Rabinowitz The clients' faith The therapist's faith in A secular therapist may
(multiple made them willing God caused him to have viewed client's
cases) to examine view religion and religious beliefs in a
religious issues spirituality as pathological manner.
and to engage in important in the The client's faith and
discussions and treatment process. beliefs may not have
readings about He recognized that been used as
their religious religion can be potential resources in
issues and understood and used therapy. The clients'
problems. in dysfunctional orthodox religious
ways, but he also values may not have
viewed the client's been so readily
religious beliefs as a understood and
potential resource. accepted.
Because of the
therapist's faith he
engaged in religious
discussions with
clients and
recommends spiritual
interventions.
Sperry The client's faith in The therapist's faith in In secular therapy it is
(Gwen) God led her to God led him to unlikely that the
request that accept client's client's religious
spiritual issues be request to include beliefs and
included in her discussion of spiritual community would
treatment. Her issues as a part of have been used as a
faith led her to treatment. It also led resource during
engage in spiritual him to encourage therapy. In fact, the
practices (e.g., and recommend client's initial negative
prayer). Her faith several spiritual attitude toward her
and spiritual interventions that religious community
practices helped were helpful to may have been
her overcome her client's treatment reinforced. The client
perfectionistic and progress. would not have
obsessive- experienced the
compulsive benefits of praying,
tendencies, meditating, and
including her participating in her
bulimic behaviors. religious community.

continues

CONCLUSIONS AND RECOMMENDATIONS 297

 TABLE 17.2 (Continued)
Differences in case
Therapist Influence of Influence of without theistic
(Case) client's faith therapist's faith perspectives

Shafranske The client's faith The therapist's faith led Secular therapist may
(Joan) was central both him to view religion have viewed client's
to the conflicts as an important religious beliefs in a
she was facing variable in mental pathological manner.
and to their health and The client's faith and
ultimate psychological beliefs may not have
resolution. The treatment. As a been viewed as
client's faith made result, the therapist potential resources in
her willing to was alert to religious therapy. The client's
examine her themes during religious values may
religious issues treatment and not have been so
during treatment. interpreted them readily understood
when appropriate. and interpreted.
The therapist viewed
client's religious
beliefs as a potential
resource in
treatment.
Cook (Grace) The client's faith in The therapist's faith in The spiritual
God influenced God had a major interventions and
her goals for impact on her practices the client
therapy and the conceptualization of engaged in would not
interventions she the client, treatment have been used. The
was willing to goals, and client would not have
participate in interventions she had spiritual
(e.g., prayer, used. The therapist's experiences with God
meditation). faith that spiritual that affirmed her
Because of the resources are worth and lovability.
client's faith in available to help Spiritual healing
God and Jesus people heal would not have
Christ, and her influenced her to tap occurred and so other
willingness to into these resources. avenues to helping
reach out to them Her faith influenced the client heal socially
in prayer, she had her to encourage the and psychologically
spiritual client to seek God's would have been
experiences assistance through necessary.
during therapy prayer and
where she felt meditation.
their love and
guidance. This
helped her
establish more
appropriate
boundaries and
feel less lonely.
Ray burn The client's faith in The therapist's theistic A secular therapist may
(Paul) God helped worldview, which have challenged the
motivate him to included a belief in client's sexist
examine the the worth and attitudes and
incongruences equality of men and behaviors but may

continues
298 RICHARDS AND BERGIN
 TABLE 17.2 (Continued)
Differences in case
Therapist Influence of Influence of without theistic
(Case) client's faith therapist's faith perspectives

between his women, influenced have lacked the

beliefs and her treatment goals. religious credibility to
behavior. Prayer She sought to help challenge the
helped him begin the client live more religious justifications
to see himself as congruently with of the client's sexism.
a creation of God Christian teachings The therapist's
and increased his about sexuality and Christian faith and
self-confidence. in his attitudes knowledge allowed
His desire to live toward women. The her to use religious
more in harmony therapist's belief in rationales to
with God and the God also led her to challenge some of
Holy Spirit led him encourage Paul to Paul's distorted
to spend more pray about his religious
time with his problems. understandings about
family and less women. Also, in
time with his secular therapy, the
extramarital lover. client would probably
not have been
encouraged to pray or
benefited from doing
so.
West The client's faith in The therapist's faith In secular therapy,
(Matthew) God led him to influenced him to spiritual interventions
discuss spiritual view the client's would not been used.
issues during issues, in part, as a The moments of
treatment. His spiritual journey and spiritual presence and
faith also allowed quest. The therapist's experiencing during
him to experience faith also led to his therapy sessions
moments of use of spiritual would probably also
spiritual presence interventions in not have happened.
during therapy, therapy. It also led
which helped him him to be open to
trust his therapist moments of spiritual
and contributed to experiencing during
healing and therapy sessions
growth where he and the
concerning his client felt spiritually
family issues and connected.
conflicts at work.
Nielsen The client's faith The therapist's faith in A secular therapist may
(Aisha) made her willing God caused him to have viewed the
to examine the view religion and client's religious
effects of her spirituality as beliefs as irrelevant or
religious important in the as a barrier to
understandings treatment process. effective treatment.
on her emotions. His belief in the value Scriptural teachings
The client's belief of scriptural and rationales would
in scriptural teachings led him to not have been used
writings
continues

CONCLUSIONS AND RECOMMENDATIONS 299

 TABLE 17.2 (Continued)

Differences in case
Therapist Influence of Influence of without theistic
(Case) client's faith therapist's faith perspectives

made her willing use scriptural to help dispute

to discuss rationales to dispute irrational beliefs. The
scriptural client's irrational religious roots to the
teachings in beliefs. client's irrational
therapy. beliefs may have
gone unexamined.
Hedayat-Diba Client's faith in God The therapist's spiritual A secular therapist
(Mrs. A) made her willing proclivity led her to would probably not
to discuss be open to have provided such a
spiritual issues discussions with spiritually safe
during therapy. client about spiritual relationship. Therapy
Her therapy matters. This also led probably would not
became a the therapist to have become both a
spiritual quest encourage the client psychological and
and journey, as in her spiritual spiritual healing
well as a journey. The journey — only
psychological therapist's implicit psychological healing.
healing process. spiritual beliefs and
faith helped her to
affirm her client's
faith.
Johnson Influenced client's Therapist's faith led him A secular gay affirmative
(Gary) views about to treat the client as therapist may have
homosexuality — worthwhile and been more
made him good — he adopted a aggressive in
depressed and nonjudgmental challenging the
anxious about it. affirming attitude. client's religious
Therapist's faith also beliefs about
led him to challenge homosexuality —
client's catastrophic perhaps even to the
beliefs about extent of seeking to
homosexuality and to challenge or
encourage the client undermine core
to be more self- aspects of the client's
accepting. faith.
Lovinger & Clients' religious Therapists' faith in God Secular therapists may
Lovinger issues were and their loving, not have been as
(Alfred, intertwined with tolerant view of effective at accepting
Danny, & their humanity contributed their clients' religious
Jody) psychological to their humorous beliefs and
issues and and tolerant manner differences. Also, they
emerged as with their clients, may have been more
themes during including their inclined to view the
therapy. It is not complete acceptance religious themes that
clear whether of the
their belief or faith
promoted healing, continues

300 RICHARDS AND BERGIN

 TABLE 17.2 (Continued)

Differences in case
Therapist Influence of Influence of without theistic
(Case) client's faith therapist's faith perspectives

but the religious religious differences surfaced in therapy as

themes did that existed. indicators of neurosis,
provide therapist rather than treating
with insight at these themes as
times into their valuable (but
psychological nonpathological)
dynamics. interpretive material.

and diagnosed their clients. Their theistic beliefs also helped them avoid
ascribing pathology to normative religious beliefs and practices. Most often,
they recognized the healing potentialities of their clients' faith and spiritual-
ity, and they sought to tap into these resources during therapy.
Because of their theistic beliefs, both clients and therapists often iden-
tified spiritual issues and concerns as an important focus for treatment. Thera-
pists were willing to recommend spiritual interventions during treatment and
clients were willing to participate in them. Many of the therapists regarded
the spiritual interventions and faith of their clients as essential aspects of the
therapeutic process. For the clients, their faith in God and personal spiritual-
ity seemed to enhance their motivation, courage, and willingness to risk and
work in therapy—and ultimately, for many of them, were central to their
healing and recovery.

CHALLENGES OF INTEGRATING THEISTIC PERSPECTIVES

INTO MAINSTREAM PSYCHOTHERAPY

In this book we have emphasized the positive aspects and potential

benefits of integrating theistic perspectives into mainstream psychotherapy,
but we would be negligent if we did not acknowledge some of the objections
or concerns that have been raised about doing so. One objection that has
been raised about integrating theistic perspectives into mainstream psycho-
therapy is that leaders and members of some theistic religions have been
responsible for much harm and discrimination in the world. We agree that
this is so. In advocating for theistic psychotherapy, we wish to reaffirm that
we do not endorse all theistic beliefs or practices. As we have written else-
where:
We recognize that there has been, and still is, much harm done in the
name of religion. For example, the oppression of minority groups and
women, acts of violence, and war have been waged in the name of reli-
gion. . . . We deplore the use of religion for such destructive purposes.

CONCLUSIONS AND RECOMMENDATIONS 301

 We endorse in the theistic world religions only that which is healthy and
beneficial to all of humankind. (Richards & Bergin, 1997, p. 12)

We think psychotherapists need to be discriminating about religion

and recognize that there are healthy and unhealthy, constructive and de-
structive, ways of being religious (Bergin, 1980a, 1991). We hope that theis-
tic psychotherapists will be careful not to endorse all theistic beliefs and prac-
tices. Fortunately, there is a growing body of literature about religion and
mental health that not only provides empirical evidence concerning the posi-
tive aspects of theistic religion but also helps identify some of the unhealthy
and destructive forms of it (e.g., Galanter, 1996; Lovinger, 1984; Pruyser,
1971; Meadow & Kahoe, 1984; Meissner, 1996; Richards & Bergin, 1997,
2000). Conversely, we hope that the negative possibilities in the theistic
religions will not cause professionals to close their minds to the therapeutic
potential that also exists (e.g., Benson, 1996; Koenig, McCullough, & Larson,
2001; Plante & Sherman, 2001; Richard & Bergin, 1997). We encourage
theistic psychotherapists to carefully consider what theistic beliefs and prac-
tices they will accept and recommend, and help their clients learn to do this
for themselves. The case reports in this book provide numerous examples of
therapists doing this.
Another objection that has been raised about integrating theistic per-
spectives into mainstream psychotherapy is the concern that theistic psy-
chotherapists may be more likely to impose their religious beliefs and values
on clients (e.g., Seligman, 1988). We have written about this complex ethi-
cal issue in some detail elsewhere (Bergin, 1980a, 1980b, 1980c, 1985, 1991;
Bergin, Payne, & Richards, 1996; Richards & Bergin, 1997; Richards, Rec-
tor, & Tjeltveit, 1999), and will not revisit it fully here. But we will com-
ment on a few points that we think are especially pertinent to this book of
case reports.
First, we do not believe that theistic psychotherapists are more likely to
violate their clients' value autonomy than other therapists. Although it is
true that we advocate that therapists use a moral framework to guide and
evaluate psychotherapy, we also strongly oppose attempts to coerce or im-
plicitly influence or change clients' core values and doctrinally correct reli-
gious beliefs. We recommend that therapists adopt an explicit minimizing
valuing approach, which simply means that therapists are open and explicit
with clients about their values and beliefs when appropriate, but at the same
time are strongly affirming of their clients' rights to disagree with them about
value and doctrinal issues (Richards & Bergin, 1997; Richards et al., 1999).
We think that therapists who honestly acknowledge the moral and
worldview framework that guides their therapeutic approach, and who adopt
an explicit minimizing valuing approach during therapy, are actually much
less likely to impose or coerce their clients into alien value and worldview
frameworks than are therapists who claim to be "value-free." We have writ-

302 RICHARDS AND BERGIN

ten elsewhere about the problems of ethical relativism (Bergin, 1980a; Bergin
et al., 1996; Richards et al., 1999). All we wish to say about it here is that we
think therapists who attempt to adopt a relativistic therapeutic stance—
often with the claim that they are doing so out of tolerance for diversity—are
actually at greater risk of implicitly and covertly manipulating or coercing
clients with alien value or doctrinal perspectives (Bergin, 1980a, 1980b, 1980c;
Bergin et al., 1996).
Having said this, what do we think therapists should do when they
encounter clients who have religious beliefs that seem to be contributing to
their emotional distress or relationship problems? We think that if clients'
religious beliefs are intertwined with or contributing to their presenting symp-
toms and problems, these beliefs in all likelihood will need to be examined
during therapy in order for therapeutic change to occur. Perhaps the first step
in doing so is to explore the belief so that both the therapist and client accu-
rately understand it and how it affects the client emotionally, behaviorally,
and spiritually.
The next step may be to ascertain whether the client's belief is doctri-
nally correct. That is, is it in harmony with the official teachings of the client's
religious tradition? If the therapist is a member of the client's religious tradi-
tion, or an expert in its doctrines, this may immediately be apparent. If not,
the therapist may wish to invite the client to do some doctrinal study or
research (through study or by visiting with church leaders) to find out if his
or her understanding of the doctrine is in harmony with official church teach-
ings. Once the doctrinal accuracy or inaccuracy of the client's religious belief
is ascertained, the therapist will have a better idea about how to proceed. If a
client's problematic religious belief is found to be doctrinally incorrect, this
can give the therapist and client leverage to modify it, hopefully into an
understanding that is less dysfunctional for the client. If the client's religious
belief is doctrinally correct, we think the therapist needs to help the client
examine why it is a problem in her or his life, and then defer to the client
about how she or he wishes to handle it.
We think that to avoid imposing their religious views on clients, thera-
pists need to show deference and respect toward official doctrines of their
clients' religious traditions. We do not think therapists should challenge or
dispute official church teachings, nor should they recommend that clients do
so. Of course, if clients choose to do this of their own accord, then we think
therapists are obligated to listen and help clients explore their reasons for
doing so. But therapists should not actively align themselves against church
teachings or attempt to challenge and displace religious authority and teach-
ings (Richards & Bergin, 1997).
In conclusion, although integrating theistic psychotherapy into main-
stream practice can raise the specter of values imposition in the minds of
some professionals, we do not think that theistic psychotherapists are any
more likely to do this than are other therapists. Nevertheless, theistic psy-

CONCL17SZONS AND RECOMMENDATIONS 303

chotherapists must be aware of this issue and do their best to handle it
appropriately.
Another concern that has been raised about integrating theistic per-
spectives into mainstream psychotherapy regards the question of whether
psychotherapists can do this in a philosophically and theoretically defensible
manner. Most psychotherapists seek to integrate theistic perspectives and
interventions with mainstream secular therapy traditions. As discussed in
chapter 1 and elsewhere (e.g., Richards & Bergin, 1997; Slife, 2003), the
mainstream secular traditions are grounded in the naturalistic-atheistic
worldview, and in philosophies and theories that rather dramatically conflict
with theistic perspectives. How will theistic psychotherapists resolve these
conflicting philosophical and theoretical notions so that their conceptual
frameworks and therapeutic approaches are not riddled with inconsistencies?
We think that the first step for therapists in developing a sound theistic
conceptual framework consists of carefully examining the philosophical and
theoretical assumptions that underlie their approach—both the theistic and
secular ones (Slife, 2003; Slife & Williams, 1995). Psychotherapists may find
that to be conceptually consistent, they have to abandon, revise, or reframe
some of the secular perspectives they accepted earlier in their careers. The
process of developing a conceptually consistent and sound theistic frame-
work will probably not be an easy task for most psychotherapists.
We did not ask the therapists who contributed to this book to make it
clear how they have resolved the conflicts between their theistic and secular
perspectives—and few of them chose to do so. In the future we plan to give
this issue more attention. We invite psychotherapists who wish to integrate
their theistic beliefs with mainstream secular traditions to make efforts to
resolve the conceptual conflicts. We hope that many of them will share how
they have done this through publications and presentations. We think this is
necessary if the theory and practice of theistic psychotherapy is to advance
in a respected and influential manner.

RECOMMENDATIONS

The ethical guidelines of most mental health professions prohibit their

members from practicing outside the boundaries of their professional compe-
tence. In light of such guidelines, we encourage therapists who wish to incor-
porate theistic perspectives and interventions into their work to seek ad-
equate training before doing so. Unfortunately, it is still the case that most
mental health training programs are inadequate at preparing therapists to
intervene in the spiritual dimensions of their clients' lives. Few mainstream
mental health programs provide course work or supervision on religious and
spiritual issues in mental health and psychotherapy (Kelly, 1993; Shafranske
& Malony, 1996). Thus, most psychotherapists will need additional educa-

304 RICHARDS AND BERGIN

tion and training beyond graduate school to ethically and effectively use a
theistic spiritual strategy.
Fortunately, many resources are now available to help therapists ac-
quire training and competency in the religious and spiritual domains. There
is a large body of professional literature that provides insight into the rela-
tions among religion, spirituality, mental health, and psychotherapy. Some
universities now offer specialized courses on the psychology and sociology of
religion and on religious and spiritual issues in counseling and psychotherapy.
Continuing education workshops on these topics have become more widely
available. We recommend that psychotherapists do the following as they
seek to obtain and enhance their competency in this domain (Richards &
Bergin, 1997, p. 166):

1. Obtain training in multicultural counseling.

2. Read good books on the psychology of religion and spiritual
issues in psychotherapy.
3. Read scholarly literature about religion and spirituality in
mainstream mental health journals and in specialty journals
devoted to these topics.
4- Take workshops or classes on the psychology of religion and
spiritual issues in psychotherapy.
5. Read good books or take a class on the theistic world reli-
gions.
6. Seek in-depth knowledge about religious traditions that you
frequently encounter in therapy.
7. Consult with colleagues when you first work with clients from
a particular religious tradition, when clients present challeng-
ing spiritual issues, and when you first use spiritual interven-
tions.

We also encourage leaders of graduate training programs to include re-

ligious and spiritual content in graduate curriculum and clinical training ex-
periences. Shafranske and Malony (1996) proposed that the ideal curricu-
lum would include four components: "a 'values in psychological treatment'
component, a 'psychology of religion' component, a 'comparative-religion'
component, and a 'working with religious issues' component" (Shafranske &
Malony, 1996, p. 576). We wish that every graduate training program in the
mental health professions would incorporate these recommendations fully.
At the least, we hope that program administrators will find a way to offer at
least one course that explores spiritual issues in mental health and psycho-
therapy, as well as provide supervisors who have competency in this domain.
We also encourage scholars and researchers to join with our colleagues
and us in doing research about a theistic spiritual strategy for psychotherapy.
More philosophical, theoretical, and research work is needed if this approach

CONCLUSIONS AND RECOMMENDATIONS 305

is to advance and mature. Philosophical and empirical work is needed about
the following topics (Richards & Bergin, 1997, p. 335):
1. implications of a theistic view of human nature and personal-
ity;
2. effectiveness of theistic integrative psychotherapy;
3. nature of spirit, spirituality, and spiritual well-being;
4. religious and spiritual development across the life span;
5. spiritual needs and issues of human beings;
6. prevalence and role of intuition and inspiration in therapeu-
tic change and scientific discovery;
7. nature, prevalence, effects, and meaning of spiritual experi-
ences (e.g., near-death experiences, afterlife visions, inspira-
tional and revelatory experiences, conversion experiences,
healings);
8. implications and usefulness of epistemological and method-
ological pluralism; and
9. assessment and outcome measurement of religious and spiri-
tual functioning.
As can be seen, there is no shortage of fascinating and challenging
projects for the future in this domain. We invite those with interest to join us
in investigating these and other philosophical and research questions. We
are pleased that financial and political support for research on spirituality,
mental health, and healing has increased dramatically during the past de-
cade. We hope that such support continues to grow.

CONCLUSION

Jones (1994) argued that religious worldviews could contribute to the

progress of psychological science and practice "by suggesting new modes of
thought. . . and new theories" (p. 194). We agree with this. We think that
the theistic worldview, in particular, contributes important insights into pre-
viously neglected aspects of human nature, personality, therapeutic change,
and the practice of psychotherapy.
The most serious deficiency in modern mainstream theories of person-
ality and psychotherapy is their neglect of God and the human spirit. This
needs to be rectified. As we have expressed elsewhere:
The human spirit, under God, is vital to understanding personality and
therapeutic change. If we omit such spiritual realities from our account
of human behavior, it won't matter much what else we keep in, because
we will have omitted the most fundamental aspect of human nature.
With this dimension included, our ability to advance psychological sci-

306 RICHARDS AND BERGIN

 ence, professional practice, and human welfare can truly soar. (Richards
&Bergin, 1997, p. xi)
We believe that theistic psychotherapy will help psychological prac-
tice soar. It will enhance the ability of mental health professionals to under-
stand and work more sensitively and effectively with their theistic clients.
The case reports presented in this book provide support for our optimism.

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308 RICHARDS AND BERGIN

 AUTHOR INDEX
Numbers in italics refer to listings in the references.

Adler, G., 246 Brown, L. S., 257, 264

Aletti, M., 169 Buber, M., 210, 211
Allport, G. W., 63, 71 Bunker, D., 179, 180, 184
American Psychiatric Association (APA), 6, Burchfield, Q, 39, 53
28, 58, 71, 79, 86, 107, 117, 144, Burlingame, G. M., 63, 72, 229
152, 153, 167, 200, 218, 228, 256, Butcher, J . N , 63, 71
263 Byrd, A. D., 256, 264
Anderson, D. K., 55, 72
Arasteh, A. R., 235, 245 Callender, J. S., 55, 72
Arlow.J, 160, 168 C'deBaca,J.,17, 30
Atmanspacher, H., 53 Chamberlain, R. B., 17,29
Atwood, G., 159, 163, 169 Chevron, E. S., 75, 86
Auerbach, A., 158, 168 ChrislerJ.C, 200
Church of Jesus Christ of Latter-Day Saints,
Bachrach, H., 167, 168 The, 67, 71
Baldwin, B., 58, 72 Clark-Sly, J. B., 55, 58, 72
Baldwin, S., 37, 52 Cohn, L., 55, 71
Ball, R. A., 16, 28, 292-293, 307 Collins, G. R., 3, 29, 36, 37, 52
Barbour, I. G., 8, 28 Collins, L. H., 200
Barley, D. E., 167, 168 Cook, D., 174, 185
Baron, A., 216, 228 Cooper, A.M., 158, 169
Barrett, D. B., 4, 28 Cooper, P. ]., 63, 71
Beal, D., 222, 228 Cooper, Z., 63, 71
Becvar, D. S., 52 Crisp, A. H., 55, 72
Benedict, J. G., 263
Benson, H., 4, 15, 17, 28, 302, 307
Bergin, A. E., xiii, xiiin, 3, 4, 6, 7, 8, 10, 12, Damasio, A. R., 244, 246
12n, 13,15, 16, 17,19n, 20, 21,22, Dandelion, B. P., 202, 211
28, 29, 30, 31, 36, 37, 39,53, 59, D'Augelli, A. R., 252, 255, 257, 264
60,70,72,73,76,86,119,121,127, Davidson, M. G., 252, 257, 263
139, 140, 167, 168, 169, 176, 177, Dean, T., 228, 229, 284
179, 186, 208, 209, 210,211, 227, Debord, K. A., 263, 264
230, 241, 246, 258, 264, 284, 292, DeNardi, F., 169
293, 302, 303, 304, 305, 306, 307, DeVries, R., 215, 229
307, 308 DiGiuseppe, R., 222,228,259,261,263,265
Bernstein, R.J., 38, 52 Dorst, B., 235, 246
Berrett, M. E., 55, 58, 59, 72 Drum, D. ]., 216, 228
Biale, D., 192, 200 Dryden, W., 248, 253, 254, 259, 260, 261,
Bieschke, K. ]., 263, 264 263, 264, 265
Bishop, R., 40, 52, 53 Dueck, A., 35, 52
Blazer, D., 121, 137, 139 Dunlap, M. R., 200
Bohart, A., 167, 168
Boman, T., 35, 52 Eccles.J., 8, 29
Borysenko, J., 17,29 Eckert, M., 127, 140
Borysenko, M., 17,29 Elijah of Vilna, 139
Brokaw, B. F., 69, 71 Elkins, D. R, 4, 29

309
Elliott, R, 167, 168 Haftorahs, 139
Ellis, A., 4,30, 214, 215, 218, 221,229, 248, Haldeman, D. C., 251, 256, 257, 263, 264
253, 254, 259, 260, 261, 264 Hall, L., 55, 71
Ellison, C. W., 63, 72 Hall, T. W., 69, 71
Emmons, R. A., 17,29 Hamilton, A., 79, 86
Endean, P., 177, 179, 184 Handelman, S., 122, 139
Enright, R. D., 96, 102 Hansen, N. B., 229
Epstein, M, 3, 29 Hardman, R. K., 55, 58, 59, 72
Epstein, S., 63, 72 Heatherton, T., 30
Erlander, Rev. M., 55, 72 Hedayat-Diba, Z., 3, 29, 232, 246
Hellwigg, M., 178, 185
Fairburn, C. G., 63, 71 Helminiak, D. A., 4, 30
Faiver, C., 4, 29 Helms,]., 174, 185
Falender, C. A., 153, 168 Henning, L. H., 21,30
Feltham, C., 211 Herek, G., 264
Fernandez, T., 246 Hermann, R. L, 8, 31
Fischer, L, 55, 72 Hershberger, S. L., 252, 255, 257, 264
Fisher, A. M., 40, 53 Hertz,]., 130, 139
Fisher-Smith, A. M., 39, 52 Higgins, E. T., 49, 52
Fitzmyer, J. A., 274, 283 Hill, C. H., 24, 30
Fleming, D., 174, 175, 177, 178, 184 Hill, D. B., 53
Fletcher, L. A., 55, 72 Hoge, D. R., 267, 284
Fordham, M., 246 Hollis, ]., 233, 246
Foster, R., 253, 264 Honer, S. M., 36, 52
Powers, B. ]., 38, 53 Hood, R. W., 24, 30, 169, 200
Freedman, S., 96, 102 Hope, C, 8,31,36, 53
Freud, S., 160, 168, 244, 246 Horvath, A. O., 167, 168
Friedman, 234 Howard, G. S., 40, 52
Frost, H. A., 55, 58, 72 Hsu, L. K., 55, 72
Fullerton, J. T., 92, 102 Hull, R. F. C., 246
Hunsberger, B., 92, 102
Gabbard, G. O., 157, 163, 168 Hunt, T. C, 36, 52
Galanter, M., 302, 307
Galatzer-Levy, R. M., 167,168 Inayat Khan, P. V., 246
Garfield, S. L, 31,167, 168 Ingersoll, R. E., 4, 29
Garfinkel, P. E., 63, 71
Garner, D. M., 63, 71 Jackson, S. W., 162, 168
Gaskin, T. A., 29 Jacobson.N. S., 219, 229
Gendlin, E., 145, 152 Jennings,]., 122, 139
Gill, M. M., 165, 168 Jennings, J. P., 122, 139
Gillman, H., 202, 207, 211 Jensen, J. P., 16, 30, 292, 293, 307
Glasse, C., 235, 246 Johnson, T. M., 4, 28
Glassgold, J. M, 257, 264 Johnson, W. B., 4, 30, 215, 229, 248, 253,
Goodyear, R. K., 16, 28, 293, 307 258, 261, 264
Gorman, 50 Jones, J.W., 160,168
Greenberg, L. S., 167, 168 Jones, R., 207, 211
Greene, B., 264 Jones, S. L., 8, 15, 30, 306, 307
Griffin, D. R., 8, 12, 29, 36, 37, 52 Jung, C. G., 233, 246
Griffith, J.L., 4,29
Griffith, M. E., 4, 29 Kahoe, R. D., 302, 308
Guignon, C. B., 38, 53 Keller, R. R., 4, 30
Gunton, C. E., 36, 40, 52 Kelly, E. W., 4, 16, 30, 304, 307

310 AUTHOR INDEX

Kenkel, M. B., 263 Nathan, 50
Kernberg, O., 158, 160, 168 Natterson, 234
King, D. B., 36, 37, 53 Nebeker, R. S., 8, 31,36,53
Klerman, G. L, 75, 86 Newman, B. S., 257, 264
Koenig, H. G., 302, 307 Nicolosi, J., 256, 264
Kohut, H., 163,168,234,246 Nielsen, S. L, 4,30, 214, 215, 220, 228, 229,
Kopec, A. M, 222, 228 230, 248, 253, 261, 264
Kocler, A., 137, 139 North,]., 102
Krai, M. ]., 53
O'Brien, E., 4, 29
Lachman, F., 283, 284 O'Brien, E. J., 63, 72
Lambert, M.J., 31,53, 63, 72,167, 168, 218, Okiishi, J., 229
229 Ostrom, R., 228, 229, 284
Larson, D. B., 3, 30, 302, 307
Larson, S., 3, 30
Lawton, B., 211 Paloutzian, R. F., 63, 72
Leahey, T. H., 36, 52 Pargament, K. I., 130, 139
Ledoux,]., 159, 168 Payne, I. R., 22, 29, 302, 307
Lerman, H., 200, 200 Peck, M. S., 3, 30
Lillas, C., 244, 246 Pentateuch, 139
Loewald, H. W., 163, 168 Perez, R. M., 263, 264
Lohfink, G., 35, 52 Perry, S., 158, 169
Lonsdale, D., 179, 180, 184, 185 Peterson, D., 215, 229
Lovinger, R. ]., 4, 30, 268, 270, 272, 284, Pettorini, D., 215, 229
302, 308 Plante, T. G., 302, 308
Lowenthal, W., 245, 246 Porter, N., 200, 200
Luborsky, L., 158, 168 Potts, R. W., 16, 22, 31, 59, 72, 256, 264,
Lunnen, K., 229 293, 308
Propst, L. R., 228, 229, 283, 284
Malony, H. N., 15, 30, 293, 304, 305, Provine, W., 12, 30
308 Pruyser, 157
Mashburn, D., 228, 229, 284 Pruyser, P., 302, 308
Masters, K. S., 29 Pyle, R. L., 55, 72
May, G., 185, 186
Mayman, 157 Rabinowitz, A., 3, 30, 120, 121, 131, 139
McCullough, M. E., 96, 102, 302, 307 Rachal, K. C., 96, 102
McLellen, A.T., 158, 168 Rangell, L, 159, 163, 169
McNally, C., 4, 29 Rayburn, C. A., 192, 200, 200
McWilliams, N., 157, 168 Read, H., 246
Meadow, M. J., 178, 179, 186, 302, 308 Rector, J.R., 15,31,302,308
Mearns, D., 210, 211 Reiff, P., 160, 169
Meissner, W. W., 160, 169, 302, 308 Reynolds, E. M., 29
Melton, J.G., 26, 30 Richards, P. S., xiii, xiiin, 3, 4, 6, 7, 8, 10,
Menninger, K. A., 157, 169 12, 12n, 13,15, 16, 17, 19n, 20, 22,
Michels, R., 158, 169 29, 30, 31, 36, 37, 39, 53, 55, 56,
Miller, L, 270, 284 58, 59, 60, 63, 70, 72, 73, 76, 86,
Miller, W. R., 3, 17, 30, 31, 122, 139, 308 119, 121, 127, 139, 140, 169, 176,
Mitchell, J.E., 55, 72 177, 179, 186, 208, 209, 210, 211,
Mitchell, L. J., 36, 54 227, 230, 241, 246, 258, 264, 284,
Money, J., 252, 264 292, 293, 302, 303, 304, 305, 306,
Moore, T., 244, 246 307, 307, 308
Muzzonigro, P. G., 257, 264 Richardson, F. C., 38, 40, 41, 52, 53

AUTHOR INDEX 311

Richmond, L. J., 192, 200, 200 Spiegelman, M., 236, 246
Ridley, C.R., 215,229, 248, 264 Stern, D., 241, 246
Rique, ]., 96, 102 Stern, E. M., 30
Rizzuto, A.-M., 160, 160-161, 169 Stinchfield, R. D., 29
Robb, H., 215, 228, 230 Stolorow, R., 159, 163, 169, 283, 284
Robin, M. W., 263 Strachey, ]., 246
Robinson, D. N., 8, 29, 261 Sue, D., 20, 31
Rogers, C.R., 210, 211,211 Sue, D. W., 20, 31
Rorty, M., 55, 72 Sue, S., 20, 31
Rosenblatt, B., 163, 169 Sullivan, C. E., 29
Ross,]., 163, 169 Swidler, A., 252, 265
Ross, ]. M., 63, 71 Swidler, L, 192, 200, 200
Rossotto, E., 55, 72 Swinton, ]., 4, 31
Rounsaville, B.J., 75, 86
Rowan,]., 208, 210, 211 Tan, S. T., 94, 102
Rubin,]. B., 3,31 Taylor, M., 63, 71
Rychlak, J. F., 37, 40, 53 Templeton, J. M., 8, 31
Thorne, B., 210, 211
Sacks, H., 179, 186 Throckmorton, W., 256, 265
Sandier,]., 163,169 Tirrell, F.J., 21,30
Sarason, I. G., 214, 229 Tisdale, T. C., 69, 71
ScharmanJ. S., 17, 29 Tjeltveit, A. C., 15, 22, 31, 32, 302,
Schneider, M. S., 257, 264 308
Schneiman, C. R., 215, 230 Truax, P., 219, 229
Schore, A. N., 159,169
Schroeder, G. L, 8, 31,264 Ulrich, W. L., 60, 73
Schroeder, M., 256, 257 Umphress, V., 229
Seligman, L., 302, 308
Serra, R., 252, 264 Valentine, E. R., 37, 53
Shafranske, E. P., 3, 29, 31, 32, 59, 72, 102, VanHerik,]., 170, 169
139, 153, 160, 161, 162, 168, 169, Vandenbos, G. R., 263
284, 293, 304, 305, 307, 308 Vaughan, F., 4, 32
Shapiro, F., 239, 246 Viney, W., 36, 37, 53
Sharma, A. R., 3, 31
Shaver, R., 40, 53 Waldron, W.,]r., 167, 168
Sherman, A. C, 302, 308 Walen, S. R., 259, 265
Shidlo, A., 256, 257, 264 Wallach, L., 127, 140
Siegel.D.J., 159,169 Wallach, M., 127, 140
Skolnikoff, A., 167, 168 Wallerstein, R., 159, 170
Slife, B. D., 8, 12,31, 36, 37,38, 39, 40, 41, Walsh, R., 4, 32
50, 52, 53,54, 292, 304, 308 Watkins, P., 228, 229, 284
Smart, N, 7, 16,31 Watson,]. C., 167, 168
Smedes, L. B., 252, 265 Watzlawick, P., 54
Smith, A. M., 39, 53 Webster, 39
Smith, F. T., 55, 59, 72 Weinberger,]., 30
Smith, H., 36, 40, 53 Weiss,]., 163,170
Smith, T. B., 63, 72 Weissman, M. M., 75, 86
Snyder, D. K., 92, 102 West, W. S., 4, 32, 202, 203, 204, 206, 208,
Soloveitchik, J. B., 121, 123, 137, 140 210,211,211,212
Spero.M. H., 3, 31,160, 169 Whoolery, M., 36, 54
Sperry, L., 4, 31,147, 152, 153, 169 Wicklund, R. A., 127, 140

312 AUTHOR INDEX

Williams, R. R, 37, 38, 50, 53, 292, 304, Yalom, 1. D., 39, 54
308 Yarhouse, M. A., 252, 257, 263, 265
Wittine, B., 4, 32 Young, K., 20, 3 J
Worthington, E, 96, 102 Younggren, J. N., 22, 32

Yager, J., 55, 58, 72, 73 Zane, N., 20, 31

AUTHOR INDEX 313

 SUBJECT INDEX

A, Mrs. (case report), 236-239, 244-245, and Laura's therapeutic journey, 42,
291, 300 45, 47, 50
assessment and diagnosis of, 239-240 of John and Mary, 98
treatment process for, 240-244 as non-naturalistic assumption, 38, 39
Abortion, urged on pregnant girls with de- in theistic vs. naturalistic-atheistic
pression, 77, 78, 79 worldview, 11
Abraham, 122, 129 American Psychological Association
Absolutistic evaluations, 227 Psychology of Religion Newsletter of, 87
Adopted clients, 206 on therapeutic responses to sexual ori-
Agency entation, 256-257
at Alldredge Academy, 43, 45 Angst, in Western society, 121
and Laura's therapeutic journey, 47, Anorexia
51 case report of (Jan), 60—71
as non-naturalistic assumption, 11, 38, See also Eating disorder treatment pro-
39-40 grams
theistic psychotherapy on, 14 - Asceticism, and Judaism vs. Christianity, 268
Aisha (case report), 215-217, 290, 299-300 Assessment
assessment and diagnosis of, 217—218 in case reports
and theistic stance, 227-228 Mrs. A, 239-240
treatment process and outcomes for, Aisha, 217-218
218-221 Alfred, 271
and Qur'anic REBT, 221-226 of Danny (9-year-old), 277
Akiva, Rabbi, 133 Gary, 250-253
Alcoholics Anonymous (AA), and Kathy Grace, 176-177, 184
(case report), 106, 112, 116 Gwen, 143-144
Alcoholism, and Kathy (case report), 106- Jan, 63-65
117 Joan, 157-158
Alfred (case report), 270-276,283, 291,300- Jody, 279
301 Kathy, 107-108
and therapist's characteristics, 269-270 Mary and John, 92-94
Alldredge Academy, 5, 41-42, 52 Matthew, 204-205
assumptions of Paul, 191-193
agency, 40 Renee, 79
altruism, 39, 41 religious and spiritual, 7, 22-24
dialectical approach, 40 Assumptions, naturalistic vs. non-naturalis-
hedonistic approach, 41 tic, 8, 11,37-38,49-50
value-laden methodology, 39 atomism vs. holism, 11, 38, 40-41
Laura as client at, 5, 42-51, 52, 288, determinism vs. agency, 38, 39—40
295 hedonism vs. altruism, 38, 39
and naturalistic assumptions, 49-51 and Laura's therapeutic journey, 50-
phases in experience of 51
mountain search and rescue, objectivity (vs. value-laden methodol-
school, 47-49 ogy), 38-39
village, 45-47 rational vs. dialectical approach, 38, 40
Altruism Atomism
and Alldredge Academy, 39, 41 vs. Alldredge Academy program, 51

315
 as naturalistic assumption, 11, 38, 40— Gwen, 142-152, 289, 297
41 hassidic client, 127-128
Attachment disorder, of Jody, 279 liana, 82-85, 288, 295-296
Attention deficit/hyperactivity disorder Jacob, 128-129
(ADHD), of Laura, 42 Jan, 60-71,288, 295
Joan, 154-167, 289, 298
"Battle of the sexes," 198 Jody, 279-282, 291, 300
Beck Depression Inventory (BDI), 144, 251, Jonathan, 136-137
262 Joseph, 139
Beliefs Kathy, 106-117, 289, 296-297
irrationally evaluative (lEBs), 218,253- Laura, 4-5, 42-52, 288, 295
254, 260 Mary and John, 88-102, 288, 296
See also Religious beliefs Matthew, 203-211, 290, 299
Benjamin (case report), 133-134 Norman, 129-131
Bergin, Allen, 214 Paul, 5, 188-200, 290, 298-299
Berrett, Michael E., 56-57,67, 288, 291, 295 Renee, 5-6, 79-82, 288, 295-296
Bias-free research, and Alldredge Academy, Center for Change (CFC), 55-56
50 and Jan (case report), 60-66, 70-71
Biopsychosocial traditions, 147, 289 postdischarge functioning of, 69-70
Body, need to recognize, 244 psychological and spiritual outcome
Body Shape Questionnaire (BSQ), for Jan measures, 68-69
(case report), 63, 64, 65, 68 role of faith and spirituality for, 66-
Brigham Young University (BYU) 68
counseling center of, 215 theistic convictions of, 70
and culture of Aisha vs. sexual harasser therapists in, 56-57
(case report), 226 spiritual component of treatment pro-
Brown, Rev. Tim, S.J., 174 gram at, 59-60
Buber, Martin, 210-211 treatment setting and program at, 57-
Buddhists 59
and Mrs. A, 238 Chi Gong, and Mrs. A. (case report), 243
as clients, 203 Children's play, 280
religion as positive force in therapy with, Chofetz Chayim, 129, 138
102 Christianity, 7
Bulimia, of Gwen (case report), 143 and freedom from law, 273, 274
BYU. See Brigham Young University vs. Judaism, 268
of Danny (9-year-old), 277
Case reports, 27-28, 167 See aho Jesus
Mrs. A, 236-245, 291, 300 Christian life, Blazer on, 121
Aisha, 215-228, 290, 299-300 Christian love
Alfred, 269-270, 270-276, 283, 291, of Mary and John, 100
300-301 vs. Paul's treatment of women (case re-
Benjamin, 133-134 port), 192
Danny (9-year-old), 276-279,282-283, Christian Orthodoxy Scale, 92
283, 291, 300 Christian principles in marriage, 94
Danny (17-year-old rabbinical student), forgiveness as, 100 (see also Forgiveness)
125-126 Christian therapists, vs. atheist therapists,
David, 126-127 227-228
Deborah, 134, 135 Client's faith, influence of, 295-301
Ehud, 132-133 Client's role in therapy (theistic psycho-
Gary, 249-255, 258-63, 291, 300 therapy), 18-19
Grace, 5, 173,175-178, 180-184,185, Cognitive-behavioral therapy, in case of Paul,
290, 298 195

316 SUBJECT INDEX

Cognitive-psychodynamic-theistic tradi- and Scriptures (Blazer), 121
tions, 288, 289, 290 Descartes, Rene, 244
Cognitive therapy, 120 Determinism
Common spiritual resources, between thera- and Laura's therapeutic journey, 50-51
pist and client, 117 as naturalistic assumption, 38, 39-40
Community, and theism, 35 in theistic vs. naturalistic-atheistic
Community, church (case of Gwen), 151, worldview, 11, 50
152 Diagnosis, in case reports
Community-theistic traditions, 288 Mrs. A, 239-240
Compulsive habits Aisha, 217-218
of Gwen (case report), 147, 151 Alfred, 271
See also Perfectionism of Danny (9-year-old), 277
Confessional act, 162 Gary, 250-253
Conservative religious viewpoint, and sexual Grace, 176-177
orientation, 255, 256, 257, 263 Gwen, 143-144
Contemplation Jan, 63-65
and Catholic spirituality, 177 Joan, 157-158
by Jan (case report), 67 Jody, 279
and psychotherapy, 177 Kathy, 107-108
See also Meditation Mary and John, 92-94
Contextuality, in theistic vs. naturalistic- Matthew, 204-205
atheistic worldview, 11 Paul, 191-193
Contraindications, to spiritual intervention, 25 Renee, 79
Cook, Dr. Donelda, 5, 174-175, 290, 291, Diagnostic and Statistical Manual of Mentai
298 Disorders, 4thed. rev. (DSM-/V-R),
Counseling Concerns Survey, 216 79, 82, 83, 85, 107-108, 144, 157,
Counter-transference, in case of Jody, 282 191
Diagnostic and Statistical Manual of Mentai
Danny (case report; 9-year old), 276-279, Disorders, 4th ed. text rev. (DSM-
282-283, 283, 291, 300 IV-TR), 217-218
Danny (case report; 17-year-old rabbinical Dialectic approach
student), 125-126 at Alldredge Academy, 43-44
David (case report), 126-127 and Laura's therapeutic journey, 47,
Deborah (case report), 134, 135 48,49
Deism, 37 as non-naturalistic assumption, 38, 40
Delusional patients, spiritual intervention Disputation
contraindicated for, 25 in case of Aisha, 224
Denominational therapeutic stance, 20 in REBT, 258, 260-262
Depression Diversity, value in, 4
of Alfred's mother (case report), 272 Dobbins, Richard, 105, 289, 291, 296
of Alfred's wife (case report), 271 Don Quixote (Cervantes), and therapist's re-
of Gary (case report), 249, 250-251, lationship with Paul, 193
254, 258, 259-260 Dual relationships, 21-22
and Gwen (case report), 143, 144, 145, Dysfunction
146 and theistic psychotherapist, 292
interpersonal psychotherapy on, 75-76 See also Psychopathology
of Joan (case report), 157 Dysthymia
and Kathy (case report), 106-117 of Kathy (case report), 108, 117
in pregnant girls (interpersonal psycho- See also Depression
therapy for), 76-78, 85-86
and liana (case report), 82-85 Eating Attitudes Test (EAT), for Jan (case
and Renee (case report), 79-82 report), 63, 64-65, 68

SUBJECT INDEX 317

Eating disorder, of Owen (case report), 143 psychic structure proposed by, 233-234
Eating disorder treatment programs, 55 on religion, 160
at Center for Change, 55-59, 70
and case report (Jan), 60-71 Gary (case report), 249-250, 262-263, 291,
spiritual component of, 59-60 300
Ecumenical therapeutic stance, 20, 294 assessment and diagnosis of, 250-253
Ehud (case report), 132-133 rational emotive behavioral therapy
Elijah of Vilna (Gra), Rabbi, 138 with, 254-255, 258-261, 262
Ellis, Albert, 214-215, 221, 248, 262 disputing of religious beliefs in, 261-
EMERGE Ministries, 105 262
and Kathy (case report), 106-107, 117 treatment process and outcomes for,
assessment and diagnosis of, 107- 253-255
108 Gender-fair psychotherapy, 199
treatment process and outcome for, Gender relations
108-117 in case of Paul, 191-192, 193
Emotion, Ellis on, 221 harm from inequality in, 198
Empiricism, as naturalistic-atheistic assump- Gestalt exercise, in case of Paul, 196
tion, 11-12 Global Assessment of Functioning, 218
Epistemological pluralism, in theistic vs. Goals of therapy, in theistic psychotherapy,
naturalistic-atheistic worldview, 11— 18-19, 24-25
12 God, 7-8
Ethical concerns, 7 affirmation of required, 137
in theistic psychotherapy, 21-22 believers in, 13
See also Morality in case reports
Ethical hedonism, in theistic vs. naturalis- Mrs. A., 237-238, 241, 245
tic-atheistic worldview, 11 Aisha, 222, 228
Ethical relativism, 302-303 Alfred, 275
rejection of, 293 Deborah, 134, 135
in theistic vs. naturalistic-atheistic Gary, 261-262, 262
worldview, 11 Grace, 182-183
Evaluations, absolutistic, 227 Gwen, 144, 145, 150, 151
Expressive-supportive psychotherapy, 163 and Jacob, 129
Jan, 65, 67, 68, 70-71
Faith, in case of Jan, 66-68 Joan, 166
"Faith factor," 17 Kathy, 115, 116
Family therapy Mary and John, 93,98
at Center for Change (Jan), 66 Matthew, 206
See also Marital therapy case Norman, 130-131
Forgiveness Paul, 196, 197, 198, 199
and Mrs. A, 240 in Center for Change, 70
and Aisha (case report), 223 in Christianity vs. Judaism, 268
and Judaism vs. Christianity, 268 distorted views of, 198
and Laura at Alldredge Academy, 48- and dream of crying man, 232
49 female images and identity of, 192
in marital therapy, 94, 95-96, 98-100, in Ignatian prayer and spirituality, 179,
100, 101 184
and Matthew (case report), 209 and I-Thou relationship, 211
and teshuva, 137 Jews' belief in, 278
Foster, Richard, 252-253 Judaic tradition on, 124, 129, 268
Free will, as theistic assumption, 11 love from, 184
Freud, Sigmund mainstream neglect of, 306
on body ego, 244 and naturalism, 36, 37

318 SUBJECT INDEX

 on spiritual vs. naturalistic-atheistic Holism
worldview, 9-10, 11 and Alldredge Academy, 42, 46
and Sufi meditation, 236 in Laura's therapeutic journey, 45,
and theistic psychotherapists, 292, 293 46,49
and theistic realism, 258 (see ako The- as non-naturalistic assumption, 11, 38,
istic realism) 40-41
and theistic view of personality, 13 Holocaust, 138
and world religions, 8 Homework assignments, in case reports
God representations, 160-161, 162 of Aisha, 223
Grace (case report), 5, 173, 175-176, 185, ofKathy, 109, 112
290, 298 Homosexuality
assessment and diagnosis of, 176-177 and Gary (case report), 251-253, 255,
delusional thinking ruled out in, 184 258-263
and Ignatian prayer methods, 173,180- and psychotherapy, 255-257
184 Humanistic-cognitive-theistic traditions, 288
treatment process and outcomes for, Humanistic-theistic traditions, 290
177-178 Human nature
Grace (theological), and Alfred (case report), in spiritual vs. naturalistic-atheistic
275 worldview, 9—10
Graduate training programs, religious and and spiritual realities, 306
spiritual content in, 305 and theistic psychotherapy, 14, 292
Griffin, David, 12-13 Human rating, 218, 220, 222, 227
Guilt, REBT on, 220-221 Human spirit, mainstream neglect of, 306
Gwen (case report), 142-143, 289, 297
assessment and diagnosis of, 143—144 Ignatian prayer methods, 177-180, 184-185
goal of therapy for, 147-148 and Grace (case report), 173, 177, 178,
interplay of psychological and spiritual 180-184
dynamics in, 151-152 liana (case report), 82-85, 288, 295-296
psychological transformation of, 148- Individuation
150 body in, 244
spiritual transformation of, 150-151,151 Jung's theory of, 232, 233
therapeutic strategy for, 148 spiritual (liana), 84
treatment focus and modalities for, 144- Influence of client's faith, 295-301
145 Influence of therapist's faith, 295-301
treatment process and outcomes for, Informed consent documents, and explora-
145-146 tion of spiritual issues, 21
theistic beliefs in, 152 Instinct theory, and unconscious, 120
Integration of spiritual issues, explicit vs.
Hamilton Rating Scale for Depression, 79, implicit level of, 94
82, 83, 85 Integrative spiritually oriented psycho-
Hardman, Randy K, 56, 67, 288, 295 therapy, 146-147
Healthy functioning, theistic psychotherapy for Gwen (case report), 142-143
on, 14 assessment and diagnosis of, 143-
Hedayat-Diba, Zari, 231, 291, 300 144
Hedonism goal of therapy for, 147-148
and Laura's therapeutic journey, 50 and interplay of psychological and
as naturalistic assumption, 38, 39 spiritual dynamics, 151-152
Hellwigg, Monika, 178 psychological transformation of,
"Helpless-hopeless" syndrome, 107 148-150
Hillel, 124 spiritual transformation of, 150-151
Hindus, religion as positive force in therapy theistic beliefs in treatment process
with, 102 and outcomes of, 152

SUBJECT INDEX 319

 therapeutic strategy for, 148 in case of Kathy, 112
treatment focus and modalities for, and freedom, 273
144-145 grace-filled purpose of, 261
treatment process and outcomes of, and homosexuality, 261
145-146 and Ignatian spirituality, 179, 184
Interaction log, in marital therapy, 95 with Grace (case report), 178, 180,
International Journal for the Psychology of Reli- 181-183
gion, 232 on inner self, 233
Interpersonal psychotherapy and Jewish belief (case of Danny), 278
on depression, 75-76 on lusting in heart, 271
for pregnant girls with depression, 76- as savior not moralist, 252
78, 85-86 and women, 192
and liana (case report), 82-85 See also Christianity
and Renee (case report), 79-82 Joan (case report), 154-157, 167, 289, 298
Interpersonal relationships assessment and diagnosis of, 157-158
and religious philosophy, 122 treatment process and outcomes for,
and theistic religious traditions, 16 158-163
Interpersonal-theistic traditions, 288 psychotherapeutic process in, 163-
Intersubjectivity, Kohut on, 234 166
Interventions Jody (case report), 279-282, 291, 300
deterministic, 50 Johnson, W. Brad, 247-249, 291, 300
dialectical (Alldredge Academy), 43-^t4 Jonathan (case report), 136-137
over sexual orientation, 256 (see also Joseph (case report), 139
Sexual orientation) Journaling
spiritual, 6, 7, 25-26, 209, 288-291 by Grace (case report), 177, 183
in case of Matthew, 209-210 by Gwen (case report), 151-152
for eating disorders, 55 by Jan (case report), 67
theistic, 52 Judaic therapeutic spiritual counseling. See
and theistic psychotherapist, 292 Therapeutic spiritual counseling,
Inventories. See Tests and other measures Judaic
Irrationally evaluative beliefs (lEBs), 218, Judaism, 7, 26
253-254, 260 childhood narratives in, 282
Isaac, 129 and Christianity, 268
Islam, 7, 26 in case of Danny, 278
and Aisha (case report), 215-216 as communal, 122-123
and Qur'anic REBT, 221-226 Jung, Carl G., 232-233, 241
Sufism, 26, 232, 235-236 (see also theory of individuation of, 232, 233
Sufism) Jungian psychotherapy, and Ignatian spiri-
tuality, 179
Jacob (case report), 128-129
Jacob (patriarch), 129 Kathy (case report), 106-107,117, 289, 296-
Jan (case report), 60-63, 70-71, 288, 295 297
assessment and diagnosis of, 63-65 assessment and diagnosis of, 107-108
medical issues and outcomes for, 65 treatment process and outcome for,
postdischarge functioning of, 69-70 108-117
psychological and spiritual outcomes Kohut, Heinz, 233-235
measures for, 68—69 Kotler, Rabbi, 137
psychosocial issues and outcomes for, Krejci, Mark, 87, 288, 296
65-66
role of faith and spirituality in, 66-68 Laura (case report), 4-5, 42, 52, 288, 295
Jesus (Christ) in mountain search and rescue phase,
incaseofjody, 280, 281 42-45

320 SUBJECT INDEX

 and naturalistic assumptions, 49-51 Meditative or prayerful moments, 17
in school phase, 47—49 Meir of Radin, Rabbi Yisroel (Chofetz
in village phase, 45-47 Chayim), 138
Lesbian, gay or bisexual (LGB) persons, 252, Metaphysical assumptions, of spiritual vs.
256 naturalistic-atheistic worldview, 8
psychotherapy with, 256-257 Midrash, 120, 122, 124, 137
See also Sexual orientation Miller, Lisa, 6, 75-76, 288, 291, 295
Life after death, in spiritual vs. naturalistic- Millon Clinical Multiaxial Inventory-II
atheistic worldview, 9-10, 12 (MCMI-II), 144
Life transitions, 76 Mind-body relationship, 244
Lipkin, Rabbi Israel (Yisroel Salanter), 122 Minnesota Multiphasic Personality Inven-
Log of Interactions, in marital therapy, 95 tory-2 (MMPI-2)
Lovinger, Robert]., 267, 269-270, 291, 300- for Jan (case report), 63, 64
301 for Kathy (case report), 107
Lovinger, Sophie L., 267, 269-270, 291, Minors, spiritual intervention contraindi-
300-301 cated for, 25
Mitchell, L.J., 41-42, 288, 295
Maharal of Prague, 135 Modernistic naturalistic-atheistic worldview,
Maimonides, 136, 276 8-13
Mantra, of Gwen (case report), 149, 150 Mood disorder
Marital Satisfaction Inventory, 92 in case of Gary, 250-251
Marital therapy case, 88-92, 100-102 See abo Depression
assessment and diagnosis in, 92—94 Morality
treatment process and outcome in, 94— as framework for psychotherapy, 15
100 on spiritual vs. naturalistic-atheistic
Mary and John (case report), 88-92, 100- worldview, 9—10
102, 288, 296 and theistic view of psychotherapy, 16
assessment and diagnosis of, 92-94 See also Ethical
treatment process and outcome in, 94- "Mortal overlay," 127
100 Motherhood
Materialism/mechanism, as naturalistic-athe- and Mrs. A, 241,242
istic assumption, 11 for pregnant girls with depression, 76,
Matthew (case report), 203-204, 208-211, 77-78, 85-86
290, 299 liana, 84, 85
assessment and diagnosis of, 204-205 Renee, 80, 81
and spiritual intimacy, 207, 208, 210 Mountain search and rescue phase at
treatment process and outcomes for, Alldredge Academy, 42-45
205-208 Mrs. A. (case report), 236-239, 244-245,
May, Gerald, 185 291, 300
Meaning, in case of Jan, 69, 70 assessment and diagnosis of, 239-240
Measures. See Tests and other measures treatment process for, 240-244
Meditation Multicultural-person centered-theistic tradi-
and Catholic spirituality, 177 tions, 290
and Gwen (case report), 144 Multicultural psychotherapy approaches, 4
Ignatian, 180 Multicultural spiritual sensitivity, 7, 20
by Grace (case report), 180-182 Multidimensional Self-Esteem Inventory
and psychotherapy, 177 (MSE1), for Jan (case report), 63, 64,
in Sufism, 235-236 65,68
Meditative prayer, 177, 184 Mystical experiences, of Grace, 183-184
and Grace (case report), 173, 175, 177, Mystical focus, in case of Matthew, 207
178, 182-183, 184, 185
and Spiritual Exercises, 178 Nachmanides, 123

SUBJECT JNDEX 321

Nagera, Umberto, 281 of Aisha (case report), 216
Native Americans, religion as positive force of Gwen (case report), 143, 148, 149,
in therapy with, 102 150, 151
Naturalism, 36 in obsessive-compulsive personality,
assumptions of (vs. non-naturalistic), 147
37-38 Person, uniqueness of, in Judaic tradition,
atomism vs. holism, 11, 38, 40-41 124
determinism vs. agency, 38, 39-40 Personality, theistic view of, 13-15
hedonism vs. altruism, 38, 39 Philosophical foundations, for theistic psy-
and Laura's therapeutic journey, 49- chotherapy, 7-13
51 Play of child, 280
objectivity (vs. value-laden method- Posttraumatic stress disorder
ology), 38-39 of Mrs. A. (case report), 239
rational vs. dialectical approach, 38, of Aisha (case report), 217-218
40 Potential ethical concerns, in theistic psy-
and theism, 36-37 chotherapy, 21-22
in therapeutic communities, 35-37 Prayer
Naturalistic-atheistic worldview, 8-13, 304 in case reports
Naturalistic therapeutic communities, 35-37, Aisha, 223
51, 51-52 Gwen, 150
Natural laws, in theistic vs. naturalistic-athe- Jan, 67
istic worldview, 11 John, 97
Needs, Kohut on, 234-235 Laura (at Alldredge Academy), 47
New Age clients, 203 Matthew, 209
Nielsen, StevanLars, 213-215, 290,299-300 in Cook's practice, 174
Norman (case report), 129-131 Ignatian prayer methods, 177-180,
184-185
Objectivity and Grace (case report), 173, 177,
and Laura's therapeutic journey, 50 178, 180-184
as naturalistic assumption, 38-39 in marital therapy, 99, 101
Obsessive-compulsive personality "praying through" (in case of Kathy),
of Gwen (case report), 144, 147, 151 113-116, 117
See also Perfectionism of the senses (Ignatius), 179
Obsessive thoughts, of Jonathan (case re- Prayerful moments, 17
port), 136 Pregnant girls, treatment for depression of
Oedipal issues, in case of Alfred, 271, 272 (Interpersonal Psychotherapy), 76-
Outcome Questionnaire (OQ 45), 63,64,65, 78, 85-86
68, 218, 219, 223, 224, 225 and liana (case report), 82-85
and Renee (case report), 79-82
Pain, psychological, and religion or spiritu- Presence, Rogers on, 210, 211
ality, 119 Professional Psychology: Research and Prac-
Pathology. See Dysfunction; Psychopathol- tice, sexual orientation articles in,
ogy 255
Paul (case report), 5,188-191,198-200,290, Provine, William, 12
298-299 Psalms
assessment and diagnosis of, 191-193 and Deborah (case report), 135
treatment process and outcomes for, and Kathy (case report), 114
193-198 Pseudoautonomy, of Mrs. A. (case report),
Paul, Apostle 240
on "dark glass," 114 Psychiatry, and religion, 121
and "putting off the old self. . .," 108 Psychoanalytic approach
Perfectionism to case of Joan, 159-160

322 SUBJECT INDEX

 and Sufism, 235 discriminating view of religion in, 301-
Psychoanalytic clinical approach, to religious 302
experience (case of Joan), 160-163 and imposition of religious beliefs, 302-
Psychodynamic case report (Joan), 154—157, 304
167 influence of theistic perspective on,
assessment and diagnosis in, 157—158 294-301
treatment process and outcomes for, process guidelines for, 17
158-163 implementing interventions, 25-26
psychotherapeutic process in, 163— multicultural spiritual sensitivity, 20
166 potential ethical concerns, 21-22
Psychodynamic-cognitive-theistic traditions, religious and spiritual assessment,
289 22-24
Psychodynamic-theistic traditions, 289 setting appropriate goals, 24-25
Psychodynamic theory, in case of Paul, 195 spiritually open and safe relation-
Psychological pain, and religion or spiritual- ship, 20-21
ity, 119 Psychotic patients, spiritual intervention
Psychological and spiritual outcome mea- contraindicated for, 25
sures, in case of Jan at CFC, 68-69 Public tax-supported setting, spiritual inter-
Psychological transformation, forGwen (case vention contraindicated for, 25
report), 148-150 Purpose of life
Psychology in case of Jan, 69, 70
body excluded by, 244 in spiritual vs. naturalistic-atheistic
and religion, 3, 121 worldview, 9-10
Psychology of Religion Newsletter, 87 "Putting off the old self and putting on the
Psychopathology new self," and Kathy (case report),
as integral to personality (case of 108, 110-111, 112, 117
Norman), 130
theistic view on, 14 Quakers, 201-202, 207
See also Dysfunction Questionnaires. See Tests and other measures
Psychotherapeutic process, in case of Joan, Questions
163-166 for assessment, 23-24
Psychotherapists about case reports, 27-28
theistic, 292-293 Qur'an, in case of Aisha, 215, 227
See aho Therapist(s) Qur'anic REBT, 221-226
Psychotherapy
gender-fair, 199 Rabinowitz, Aaron, 119-120, 289, 291, 297
Ignatian prayer methods in, 184-185 Rabkin, Leslie, 214
(see aho Ignatian prayer methods) Rape, of Aisha (case report), 216, 217, 220,
integration of theistic perspectives into, 227
301-304 Rashi, 123
self-centered vs. other-centered results Rating, human, 218, 220, 222, 227
of, 127 Rational approach
and sexual orientation, 255-257 as naturalistic assumption, 38, 40
theistic, 307 and Laura's therapeutic journey, 51
and traumatic memories, 239 Rational emotive behavior therapy (REBT),
Psychotherapy, theistic, 6-7, 307 195, 213, 214, 228, 248, 253-254
conceptual framework for A-B-C model of, 218, 220, 221, 253
theological and philosophical foun- elegant solution in, 259
dations, 7-13 and Gary (case report), 254-255, 258-
view of personality, 13—15 261,262
view of psychotherapy, 15—17, 18— and disputing of religious beliefs,
19 261-262

SUBJECT ZNDEX 323

 on guilt, 220-221 with Danny, 278, 279, 282-283 (see
Qur'anic, 221-226 also Danny, 9-year old)
rational and religious neutrality in, 226- Religious experience, psychoanalytic clinical
227 approach to (case of Joan), 160-163
and religion, 214-215 Religious Orientation Scale (ROS), for Jan
See also REBT-theistic traditions (case report), 63, 64, 65
Rayburn, Carole A, 5, 187-188, 290, 298- Religious and spiritual assessment, 22-24
299 Religious worldviews, insights from, 306
RCIA (Rite of Christian Initiation for Renee (case report), 5-6, 79-82, 288, 295-
Adults), 90 296
Realism, theistic, 11, 258 Repentance (teshuva)
Griffin on, 13 and case report of Aisha, 223
Realism/positivism, in theistic vs. naturalis- and therapeutic spiritual counseling,
tic-atheistic worldview, 11 135-138, 138
Rebecca (Biblical figure), 133 Research, on theistic spiritual strategy for
REBT. See Rational emotive behavior psychologists, 305
therapy Retreats
REBT-theistic traditions, 290, 291 for Gwen (case report), 145, 151
Reconciliation, RC sacrament of, 97, 162 Ignatian, 179, 183, 185
Reductionism/atomism, as naturalistic-athe- Richards, P. Scott, 288, 295
istic assumption, 11 Rite of Christian Initiation for Adults
Reductive naturalism. See Naturalism (RCIA), 90
"Refraining the individual," 130 Rogers, Carl, on presence, 210, 211
Relativism, ethical, 11, 293, 302-303 Rorschach test, 143
Relaxation response, and spiritual convic- Rosh Hashana, 137
tions, 17 Rumi, 203, 235
Religion
body excluded by, 244 Salanter, Yisroel, 122
and children in therapy, 282, 283 Sarason, Irwin, 214
conservative viewpoint in (on sexual Satan
orientation), 255, 256, 257, 263 and Job, 126-127
harm done in name of, 301 and Kathy (case report), 113
North American traditions and groups, Scales. See Tests and other measures
26 Schedule for Affective Disorders and Schizo-
and U.S. population, 267 phrenia for Children (K-SADS), 83
and popular ideology (Soloveitchik), School phase of Alldredge Academy, 47^1-9
121 Science, and naturalism, 36
and psychiatry or psychology, 3, 121 "SefatEmet," 125-126
and REBT, 214-215 Self, Kohut on, 234, 235
Religious authority and teaching, therapists' Self-acceptance, by Aisha (case report), 221,
respect for, 303 222-224, 226, 227
Religious beliefs Self-image
communicating respect for, 228 and religious philosophy, 122
disputing of, 261-262 and therapeutic spiritual counseling,
distress-producing, 303 123-124, 138
therapists' imposition of, 302—304 of Norman (case report), 131
"Religious capacity," Jung on, 233 Self-psychology, in case of Joan, 159
Religious differences between therapist and Seligman, Martin, 75
client, 283, 294 Sentence Completion Blank (SCB), for
Jewish-Christian, 268 Kathy (case report), 107
with Alfred, 276, 283 (see also Sentence Completion Questionnaire, 251
Alfred) Sexual abuse

324 SUBJECT INDEX

 girls' fleeing to escape, 78 Spiritually oriented psychotherapy, 4
against Jan, 61, 66, 68 and optimal range of functioning, 147
by Paul's mother (case report), 189 in treatment of depression in women,
Sexual addiction, of Paul, 191, 193, 194, 196, 77
198, 199 See also Theistic perspective
Sexual assault, on Aisha (case report), 216, Spiritual outcome measures, for Jan at CFC
217,220,227 (case report), 68-69
Sexual orientation Spiritual Outcome Scale (SOS), for Jan at
Christian framework for, 252 CFC (case report), 63, 64, 65, 68,
and Gary (case report), 251-253, 255, 69
258-263 Spiritual relaxation, in case of Matthew, 209
and psychotherapy, 255-257 Spiritual resources, in common between
Shadow, the, 45 therapist and client, 117
Shafranske, Edward, 153-154, 289, 298 Spiritual sensitivity, multicultural, 7, 20
Sikhism, 7 "Spiritual solo time," in case of Jan, 67, 68
Sin, and Judaism vs. Christianity, 268 Spiritual Strategy for Counseling and Psycho-
Slife, Brent D., 288, 291,295 therapy, A (Richards & Bergin), 6,
Smedes, Lewis, 252 292
"Source," the, 5, 41, 45, 46^7, 48, 49, 50, Spiritual techniques, in theistic psycho-
51,52 therapy, 18-19
"Spirit of the times," as spiritually open, 3 Spiritual transformation, 152
Soloveitchik, Rabbi Dr., 121, 123, 137 of Gwen (case report), 150-151, 151
Song of Solomon, and Grace (case report), 181 Spiritual warfare
Sperry, Len, 141-142, 289, 297 of Kathy (case report), 113
Spirit of Truth, 76 between two souls, 138—139
Spiritual component of treatment program, Spiritual Well-Being Scale (SWBS), in case
at Center for Change, 59-60 of Jan, 63, 64, 65, 68-69
Spiritual counseling, therapeutic. See Thera- Spiritual Zeitgeist, 3
peutic spiritual counseling Sufism, 26, 232, 235-236
Spiritual Exercises of St. Ignatius, 174-175, and Mrs. A. (case report), 241, 242
177-178 of Matthew (case report), 203-204, 206,
Spiritual growth, through life transitions, 76 207, 209
Spiritual growth group, in case of Jan, 67 Sullivan, Harry Stack, 269
Spiritual individuation, of liana (case report), Symptoms
84 and inner self, 233
Spiritual interventions, 6, 7, 25-26, 209, and mind-body relationship, 244
288-291
in case of Matthew, 209-210 Tai Chi, 244-245
for eating disorders, 55 and Mrs. A. (case report), 244
Spiritual intimacy, in case of Matthew, 207, Talmud, 120, 122, 124
208, 210 "Tenderness," 210
Spiritual intuition or inspiration, 210 Teshuva (repentance), and therapeutic spiri-
Spiritual issues tual counseling, 135-138, 138
as appropriate during therapy, 294 Tests and other measures
and Owen (case report), 152 Beck Depression Inventory (BDI), 144,
level of integration into therapy for, 94 251,262
Spirituality Body Shape Questionnaire (BSQ), 63,
in case of Jan, 66-68 64, 65, 68
and Torah observance, 124—125 Christian Orthodoxy Scale, 92
and whole of life (case of Matthew), 205 Counseling Concerns Survey, 216
Spiritually open and safe relationship, 7, 20— Eating Attitudes Test (EAT), 63, 64-
21 65,68

SUBJECT INDEX 325

 Global Assessment of Functioning, 218 Theistic realism, 11, 258
Hamilton Rating Scale for Depression, Griffin on, 13
79, 82, 83, 85 Theistic spiritual strategy, 4, 6-7
Marital Satisfaction Inventory, 92 conceptual framework for theistic psy-
Millon Clinical Multiaxial Inventory- chotherapy
II (MCMI-II), 144 theological and philosophical foun-
Minnesota Multiphasic Personality In- dations, 7-13
ventory-2 (MMPI-2), 63, 64, 107 view of personality, 13-15
Multidimensional Self-Esteem Inven- view of psychotherapy, 15-17, 18-19
tory (MSEI), 63, 64, 65, 68 process guidelines for, 17
Outcome Questionnaire (OQ45), 63, implementing interventions, 25-26
64,65,68,218,219,224,225 multicultural spiritual sensitivity, 20
Religious Orientation Scale (ROS), 63, potential ethical concerns, 21-22
64,65 religious and spiritual assessment,
Rorschach test, 143 22-24
Schedule for Affective Disorders and setting appropriate goals, 24-25
Schizophrenia for Children (K- spiritually open and safe relation-
SADS), 83 ship, 20-21
Sentence Completion Blank (SCB), Theistic theoretical assumptions, 288-291
107 Theistic therapist, 227
Sentence Completion Questionnaire, Thematic Apperception Test (TAT), 143
251 Theobiology, 187
Spiritual outcome measures, 68-69 Theodicy, 138
Spiritual Outcome Scale (SOS), 63, 64, Theological foundations, for theistic psycho-
65, 68, 69 therapy, 7-13
Spiritual Well-Being Scale (SWBS), 63, Theoretical frameworks
64, 65, 68-69 conceptual framework for theistic psy-
Thematic Apperception Test (TAT), chotherapy, 7—13
143 and theistic perspectives, 287-293,304
Theism Therapeutic change, theistic psychotherapy
and community, 35 on, 14, 15, 292
and naturalism, 36-37 Therapeutic community(ies), 51—52
Theistic interventions, 52 Alldredge Academy, 41-42 (see aho
See aho Interventions Alldredge Academy)
Theistic perspective naturalistic, 35-37, 51, 51-52
in case of Paul, 199-200 and naturalistic vs. non-naturalistic as-
and case reports, 4-6 sumptions, 37-41, 50-51
insights from, 306 Therapeutic relationship (alliance)
integration of into psychotherapy, 301- in assessment (case of Matthew), 205
304 in case of Joan, 163
in marital therapy, 101 clients' perceptions of therapists in, 274
and theoretical frameworks, 287-293, Kohut on, 234
304 spiritually safe and open, 20-21
and therapy processes or outcomes, 294— theistic vs. atheistic therapists in, 227-
301 228
training in, 304—305 in theistic psychotherapy, 18-19
See also Spiritually oriented psycho- in therapeutic spiritual counseling, 124
therapy and therapist's personal qualities, 267-
Theistic therapists or psychotherapists, 227, 268
292-293 Therapeutic spiritual counseling, 120
Theistic psychotherapy. See Psychotherapy, and complexity of religious conscious-
theistic ness, 121-122

326 SUBJECT INDEX

 guiding principles in, 122-125 Training, in theistic perspectives and inter-
Therapeutic spiritual counseling, Judaic, vention, 304
124-125, 126-127 Transactional analysis, in case of Paul, 195—
case histories in, 134-135 196
Benjamin, 133-134 Transcendent spirit/soul, in theistic vs. natu-
Danny, 125-126 ralistic-atheistic worldview, 11
David, 127 Transference, in case of Mrs. A, 245
Deborah, 134, 135 TV, and Ehud (case report), 132
Ehud, 132-133
hassidic client, 127-128 Unconscious
Jacob, 128-129 in psychoanalytic approach, 159
Jonathan, 136-137 and religious nature of Joan (case re-
Joseph, 139 port), 160
Norman, 129-131 in therapeutic spiritual counseling, 120,
and clients' feeling of unworthiness, 122
138-139 and Danny (case report), 125-126
and problem of evil, 138 Universals/absolutes, in theistic vs. natural-
and teshuva (repentance), 135-138, istic-atheistic worldview
138 and laws of nature, 11
Therapist(s) and moral principles, 11
atheistic vs. Christian compared, 227- Using Race and Culture in Counseling and
228 Psychotherapy: Theory and Process
humor of (case of Alfred), 69-70 (Cook and Helms), 174
as nonjudgmental, 199
and spiritual issues, 24-25 Value-laden methodology, as non-naturalis-
theistic, 227 tic assumption, 38-39
See also Psychotherapists Value ladenness, at Alldredge Academy, 45
Therapist-patient relationship. See Thera- Values
peutic relationship and theistic view of psychotherapy, 16
Therapist's faith, influence of, 295-301 See oho Ethical concerns; Morality
Therapist's role, in theistic psychotherapy, Village phase at Alldredge Academy, 45-47
18-19
West, William, 201, 202-203, 205, 290, 299
Therapy. See Psychotherapy; Psychotherapy,
Whoolery, Matthew, 288, 295
theistic
Women with eating disorders, Center for
Therapy processes and outcomes
Change program for, 55-59, 70
influence of theistic perspectives on,
and case report (Jan), 60-71
294-301
spiritual component of, 59-60
See also individual case reports
Therapy relationship. See Therapeutic rela- Yom Kippur, 137
tionship
Torah, 124-125, 136, 137 Zadok of Lublin, Rabbi, 131
Torah observance, 137 Zeitgeist, as spiritually open, 3
and spirituality, 124-125 Zoroastrianism, 7

SUBJECT INDEX 327

 ABOUT THE EDITORS

P. Scott Richards received his PhD in counseling psychology in 1988 from

the University of Minnesota. He has been a faculty member at Brigham Young
University since 1990 and is a professor in the Department of Counseling
Psychology and Special Education. He is coauthor of A Spiritual Strategy for
Counseling and Psychotherapy (American Psychological Association [APA],
1997) and coeditor of the Handbook of Psychotherapy and Religious Diversity
(APA, 2000). He was given the Dissertation of the Year Award in 1990 from
Division 5 (Evaluation, Measurement, and Statistics) of APA for his psycho-
metric investigation of religious bias in moral development research. In 1999,
he was awarded the William C. Bier Award from APA Division 36 (Psychol-
ogy of Religion). He is a fellow of Division 36, served as secretary of the
division from 2000 to 2003, and is currently president-elect of the division.
Dr. Richards is a licensed psychologist and maintains a small private psycho-
therapy practice at the Center for Change in Orem, Utah.

Allen E. Bergin received his PhD in clinical psychology in 1960 from Stanford
University. He was a faculty member at Teachers College, Columbia Uni-
versity, from 1961 to 1972. He was a professor of psychology at Brigham
Young University from 1972 until his retirement in 2001. Dr. Bergin is past
president of the Society for Psychotherapy Research and coeditor of the clas-
sic Handbook of Psychotherapy and Behavior Change. He is coauthor of A Spiri-
tual Strategy for Counseling and Psychotherapy (APA, 1997) and coeditor of
the Handbook of Psychotherapy and Religious Diversity (APA, 2000). In 1989,
he received the Distinguished Professional Contributions to Knowledge Award
from the APA. In 1990, Division 36 (Psychology of Religion) of APA pre-
sented him with the William James Award for Psychology of Religion Re-
search. He has also received the Society for Psychotherapy Research's Dis-
tinguished Career Award (1998) and the American Psychiatric Association's
Oskar Pfister Award in Psychiatry and Religion (1998).

329