Spirituality , religiousness and psychotherapy

Religious/spiritual beliefs and practices constitute an important part of culture and principles clients use to shape judgments and process information. Psychotherapists may use knowledge of these belief systems and appreciation of their potential to leverage client adherence and achieve better outcomes. However, many approaches have yet to do so and the variety of concepts of religiosity/spirituality may place obstacles to this important interface. This article raises certain concepts that we see as consistent, accessible, and capable of facilitating professional dialogue in the therapeutic sphere. We discuss the impact of subjectivity, states of consciousness and perceptions influenced by religiosity/spirituality, on mental health as well as the importance of psychotherapists actually focusing clients and their belief systems, developing models to mobilize hope, and boosting coping abilities. Despite the current distance between controlled studies and clinical practice, we discuss the integration of spiritual/religious dimensions in psychotherapy with ethical professionalism, knowledge, and the ability to align the collected information so as to benefit clients. Since only 7.3% of Brazilians have no religion, and very few psychotherapeutic approaches or practitioners do actually engage religiosity/spirituality, we point to the relevance of research on this issue and the importance of testing related psychotherapeutic proposals in clinical trials. Peres, J.F. P. et al. / Rev. Psiq. Clín. 34, supl 1; 58-66, 2007 Key-words: Religiousness, spirituality, psychotherapy. Correspondence address: Julio Fernando Prieto Peres. Rua Maestro Cardim, 887 – 01323-001 – São Paulo, SP. Fone: (11) 3288.6523. E-mail: julioperes@yahoo.com Introduction Interest in spirituality and religiousness has been a constant feature of human history at all times and in all different cultures. However, science has only recently shown interest in investigating this subject. The first specialized journals emerged in the early 1960s, with the Journal of Religion and Health, but research was still dispersed at that time. Since then, more research on spirituality and religiousness in specific situations (e.g. serious illnesses, depression, anxiety disorders) has proved pertinent to the task of examining the impact of such practices on mental health and quality of life (Propst, 1992; Azhar et al., 1995; Pargament, 1997; Koenig, 2001; Berry, 2002). Religious belief is an important part of culture, principles and values used by clients to shape judgments and process information. Confirming their beliefs and perceptive leanings may boost the ability to organize or comprehend painful, chaotic, or unexpected events (Carone and Barone, 2001). Several studies have shown that knowing clients’ belief systems and valorizing them assists adherence to psychotherapy and helps to achieve better outcomes (Giglio, 1993; Razali et al. 1998; Sperry and Sharfranske, 2004). However, very little research on religiousness, spirituality, and psychotherapy has been done in Brazil. We conducted a review of the literature based on articles published prior to January 2007 by searching Medline/PubMed and PsycINFO using the descriptors religiousness spirituality psychotherapy. Articles, books, and theories we saw as pertinent to the aims of this article were selected as a basis for analyzing and discussing research findings in this field, the clinical implications, and the relevance of the theme for further research in Brazil. 59 Peres, J.F. P. et al. / Rev. Psiq. Clín. 34, supl 1; 58-66, 2007 Spirituality and religion concepts There is currently growing emphasis on the theme of spirituality in the psychological literature (Crossley and Salter, 2005). A recent study showed that the main domains discussed by Americans in individual psychotherapy included work, family, friends and sexuality. Religion and spirituality were seen as equally important subjects and clients thought that therapists were open to discussing these domains (Miovic et al., 2006). However, not all approaches found a way of adjusting the subject to their therapeutic interventions. Qualitative methods with semi-structured interviews were used to examine the way in which clinical psychologists understood and approached spirituality during psychotherapy; they saw spirituality as a subject capable of providing balance and harmony for their clients. However, the wide range of concepts relating to spirituality was noted as a crucial aspect of the difficulty in working with this field during psychotherapy. The study pointed to the importance of making religion and spirituality concepts more coherent and accessible in order to facilitate professional dialogue in the therapeutic context (Miovic et al., 2006; Crossley and Salter, 2005). In this article, therefore, we have used the definitions suggested by Koenig (2001), who conceptualizes religion as an organized system of beliefs, practices, rituals and symbols designed to help the individual with sacred and/or transcendent aspects, and spirituality as a personal quest for answers in relation to the meaning of life and relationships with sacred and/or transcendent aspects. Psychotherapy, its basis and validation Humanity has always reflected on itself and on our lives, feelings, and the reasons we exist, are born and die, thus giving rise to philosophy, which is recognized as the cradle of psychology. The roots of psychology go back to Ancient Greece, when the philosopher Aristotle (384-322 B.C.) wrote De Anima, often referred to as the first handbook of psychology (Aristotle, 1956). “Psychology”, from the etymological root psyche (soul) plus the suffix logos (reason, study), emerged in the late 16th century with Rodolfo Goclenio and the publication of Psychologhía, hoc est de hominis perfectione, animo et in primis ortu eius, commentationes ad disputationes, its original purpose to study and understand the spirit —from the Latin spiritus, literally ‘breathing’. The limitations of scientific method in ancient times favored psychology’s remoteness in relation to the study of the “intangible”, while medicine developed methods to investigate the body (from the Latin corpus: essential part) (Finger, 1994). In the mid-19th Century, psychotherapies emerged in the West for the purpose of treating, removing or modifying symptoms of an emotional nature, and to promote growth or development of personality, their contents varying with the philosophical schools, epistemological perspectives, theories and methods underlying their practical interventions. Rosenzweig’s 1936 article “Some implicit common factors in diverse methods of psychotherapy” was a point of departure for discussing different psychotherapies in terms of their differences, similarities, and effectiveness. This article published 70 years ago (Samstag, 2002, p. 58) foreshadowed the more general finding that there were little or no differences between the main schools of psychotherapy in terms of global efficacy, and Goldfried’s discussion (1999) revisited the issue. Areas of agreement between psychotherapeutic approaches are currently more substantial than differences, especially in relation to four aspects: (i) objectives are similar, (ii) the therapist-client relationship plays a central role in the processes, (iii) the client assumes responsibility for choices, and (iv) they aim to have clients understand their “ego” (Duncan, 2002). Indeed, after examining 17 meta-analyses in comparative studies of several modalities of psychotherapies, Luborsky et al. (2002) found no significant differences in outcomes, but admitted that “non-significant outcomes do not indicate that the treatments compared have the same effects for all patients. ” On the other hand, Bohart (2000) suggested that the client should be seen as the most important common factor in psychotherapy and posed the concept of “resilience” the ability to go through difficulties and regain satisfactory quality of life to argue that clients rather than therapists are the agents of curing. Previous studies of resilience concluded that human psychological development is highly refined and self-correcting (Prochaska et al., 1998; Masten et al., 1998). The types of treatment therapists provide are self-healing processes and take place naturally in humans, although in a more refined and systematic manner (Neno, 2005). Psychotherapy should therefore look to clients and their respective belief systems in the sense of potentiating their capabilities, since therapy functions to the extent that a client accepts involvement and learning as pre-conditions. Moreover, it is crucial for psychotherapy to develop collaborative models based on this relationship, that emphasize the mobilization of hope and optimism, with active involvement of clients and helping them mobilize their intrinsic intelligence to find solutions (Bohart, 2000, p.145). In that sense, one may reasonably suppose that religiousness and spirituality should be part of therapists’ approaches and that psychotherapeutic strategies valorizing the role of belief systems should be formulated and investigated for efficacy of treatment. Latest-generation research on the effectiveness of psychotherapy has been influenced by the financing policy of the National Institute of Mental Health, in which the medical model consolidated in pharmacological studies is prescribed for evaluating psychotherapies (Goldfried and Wolfe, 1998, p. 144). Methodological innovations included: a) use of the DSM-IV (American Psychiatric Association, 1994) for defining problems 60 Peres, J.F. P. et al. / Rev. Psiq. Clín. 34, supl 1; 58-66, 2007 and measuring outcomes; b) selecting patients on the basis of their strictly fitting into a certain diagnosis; c) randomly distributing participants among groups; d) refining guidelines for intervention (detailed manuals); e) training therapists to follow manuals and f) creating mechanisms for verifying