Addressing religious differences in therapy: a case study from behind bars.

Aten, Jamie D.

The purpose of this case study is to provide an example of how conflict can arise in therapy when therapists and clients hold opposing worldviews. Moreover, conceptual guidelines will be outlined that clinicians can implement to address problems that arise from religious differences by sharing my own experience. These guidelines for working through religious differences grew out of my clinical work as a correctional therapist at a maximum-security male facility. The steps that I will outline for successfully addressing religious differences developed from my clinical work with Bill (pseudo name), a 22-year-old offender who presented to therapy with dysthymic disorder. By no means are the guidelines offered meant to be seen as an all inclusive list, but rather are offered as a starting place for addressing religious differences. I also realize that this case study may in some regards be viewed as ungeneralizable to most clinicians because of the setting or unique characteristics of the client. However, I hope that the uniqueness of this example will make the principles that are to follow salient. All though these guidelines were derived from within the walls of a correctional facility, their application supercedes such settings.

The Setting

Several years ago I worked as a correctional therapist at a maximum-security correctional facility for men. My primary duties entailed providing individual and group counseling services to youthful offenders who were incarcerated as adults. Most of the clients I worked with were between the ages of 15 and 22. The majority were either tried as adults because of extensive criminal histories or because their crime was severe enough to warrant such a sentencing. The sentences that were handed down to the clients I worked with ranged from as short as a few months (this was extremely rare) to life (sometimes several life sentences). My office was literally a converted prison cell along the "block." The housing unit resembled a large empty gymnasium made of concrete, with cells along three of the four walls, each cell housing two inmates, for a total of 90 offenders.

The Client

Bill was a 22-year-old Caucasian male client who had struggled with dysthymic disorder for approximately three years. The client had not sought previous mental health services because, "My mom was depressed, and I know I ain't got it that bad." Still, he reported that he felt "numb all the time" and that he "just can't seem to shake it." Problems sleeping, feeling worn-out, poor self-esteem, and feelings of hopelessness further characterized Bill's experience. He had grown up in a physically and emotionally abusive household, though he thought of it as "normal." Isolation and feelings of abandonment marked his childhood. Bill reported being kicked out of his house by his mother at age 16, "Because we were so much alike there just wasn't room in the house for both of us." Shortly after this event he was arrested and charged with a series of drug related offenses. During our second session together we worked on developing a treatment plan together. As we were working collaboratively on the treatment plan, Bill struggled to articulate his strengths because his focus was set on his weaknesses. Then after a short stint of silence, Bill offered up a strength, "My religion is very important to me, in fact, it is probably the most important aspect of my life."

The "Set Up"

Before working at the correctional facility, I had worked primarily with faith communities or in faith-based settings. After coming to the correctional facility, I had worked with very few clients who identified themselves as religiously committed. So I'm sure I probably sat-up a little straighter in my chair when Bill told me that his religion was important to him. I began listening closely to Bill as to how I might be able to integrate his faith into treatment. Thoughts such as "I might be able to incorporate scripture into the cognitive restructuring process," and "maybe I can get him connected with one of the prison ministries for support" raced through my mind. He went on to tell me that not only was his belief system important to him, but that it informed his political views, and that it was "The lens through which I see the world." Then Bill told me he was an "Odenist:"

Therapist: "I'm sorry, could you please repeat that?"

Client: "I'm an Odenist, that is my religion."

Therapist: "I'm not familiar with Odenism, tell me more."

Client: "My religion is an ancient Northern Scandinavian religion, it is a pagan religion ... It is a white Aryan religion. And it is the guiding philosophy behind lots of white supremacy groups. I consider myself a Nazi ..."

Therapist: Silence.

It was in that moment that I first experienced feelings of anger for the first time in a session toward a client. "How can he claim that God gives him the right to hate?" "How can you believe that?" These were the types of thoughts that came to mind. I fell silent for most of the rest of the session. My neck and shoulder muscles got tighter. I grew more uncomfortable. I also felt guilty for feeling so frustrated with a client. I just wanted the session to end. I felt like I had been "set-up."

After the session I felt completely confused, "What had just happened?" I thought to myself. I sat there in my cell converted to an office, I decided I would just focus on the clinical symptoms and ignore my client's religion. I soon found this experience juxtaposed with my recollections of advocating for the use of client religiosity and spirituality to my peers and colleagues; I found myself in a paradox. How could I advocate for one client's belief system to be used as a source of therapeutic gain while intentionally ignoring another's? More troubling to me still was the question of how do I work with a person whose religious beliefs differ so greatly from my own?

Seek Supervision or Consultation

When religious differences create obstacles, mental health professionals should seek appropriate supervision or consultation. Survey findings suggest that few mental health professionals receive the training necessary to competently work with religious or spiritual issues in therapy (Russell & Yarhouse, 2006; Worthington et al., 2009). The ethical guidelines and principles outlined by most mental health organizations, such as the American Psychological Association (2002), recommend that professionals who fall into this category obtain supervision or consult with another professional for guidance. In my case, discussing my client in supervision was the first step to successfully resolving the conflict I was experiencing. My supervisor acted as a "sounding board" and helped me to explore and process the thoughts and emotions I was experiencing as a result of this particular client. By discussing my case conceptualization of the client, and by examining my own experience within the context of supervision, the source of my discomfort became clear. My supervisor also began to help me work through the strong emotional feelings I was having.

Differentiate Beliefs

Therapists need to differentiate between their religious beliefs and their clients' religious beliefs. Why was I having such a strong emotional and affective reaction toward Bill? What had made me become so uncomfortable and frustrated with him? Social psychology studies (e.g., Jones & Harris, 1967) have shown that people tend to project their personal experience, and even their beliefs onto other people until disconfirming evidence surfaces. In this particular case I had over identified with my client, and had done so prematurely. Bill reported that he grew up in a small rural town, had played a musical instrument, and was religious; are backgrounds first appeared quite similar. When he told me during the intake that his religion was important to him, I made the mistake of projecting my faith tradition onto him. After he told me that his religion was very important to him, I immediately started thinking about using spiritual interventions congruent with my religious ideology. Thus, when Bill told me that his religion taught hatred and racism, it was as though he was telling me that what I believed taught hatred and racism. I had not differentiated between my religious convictions and his religious convictions--I had made the mistake of assuming.

Take a "Teach Me" Approach and Set Boundaries

Learning about clients' religious belief systems by taking a "teach-me" approach can help psychotherapists further differentiate their beliefs from their clients' beliefs. Implementing this approach with clients can also yield valuable therapeutic information. As a result of the religious differences that I had experienced in my early sessions with Bill, I was reluctant to explore his religious belief system. Furthermore, I knew nothing about Odenism before meeting Bill, and did not know if I wanted to know more. However, I decided to be honest with Bill about my lack of familiarity with his religion and asked him to tell me more about his beliefs. As a result of this conversation, I was able to garner a more clear understanding of his religious beliefs, writings, and rituals. This conversation also gave me the opportunity to use immediacy and set boundaries with my client. I was able to let him know that I recognized how important his religion was to him, and that I believe religion can be a great source of therapeutic gain. At the same time I was honest with him and told him that my own religious beliefs did not condone racism, and that I felt very uncomfortable when he used racist language. Taking a "teach me" approach demonstrated my interest in his religion, and made our sessions a safe place for him to talk about his faith. This approach also allowed me to communicate boundaries that discouraged racism.

Perspective Shift

Counselors can reduce the impact of religious differences by perspective shifting. The following questions can be asked of clients to enhance counselors' understanding of their clients' religious perspective. How did you come to believe what you believe? Are there significant events in your life that have shaped your religious beliefs? How does your faith impact your life? Viewing clients' religion within a cultural context and situational context also enhances this process. For example, by asking the above questions I found that Bill's belief in Odenism was relatively new. When he came to prison he felt vulnerable and isolated:

   I had all the white guys telling me
   not to talk to the black guys, and all
   the black guys telling me to stay
   away from the white guys. Here I
   was, just a teenager, sitting in a
   super-max facility. I didn't want anyone
   to know, but I was scared. I
   even slept in my boots for the first
   week. What was I going to do? There
   was no way I could do my "bit"
   alone. I felt like I had to choose a
   side, so I chose.

Bill believed that joining a white supremacy group would provide him with the safety, security, and sense of community that he needed. Likewise, my client stated that two African-American offenders had tried to assault him early in his sentence, which reinforced the racist stereotypes that the white supremacy group he joined was teaching him. The deeper his affiliation with the white supremacy group grew, the stronger his commitment to Odenism became. Though I held different religious beliefs than Bill, and disagreed with many of his beliefs and actions, perspective shifting allowed me to get a glimpse into how he came to see the world through such a lens.

Listen for Compatible Beliefs

Mental health professionals can address religious differences by listening and implementing clients' religious beliefs that are compatible with their theoretical orientation. Even after I understood the source of my struggles, had differentiated my religion from my client's religion, set boundaries, and sought to understand how my client came to believe as he does, I still wondered how I could possibly use his religion for therapeutic gain. Once again, I took a one-down learning approach to my client by inquiring specifically about his religious rituals and practices:

Therapist: "I know we have touched on this just briefly in one of our last sessions, but could you tell me more about your religious rituals and practices?"

Client: "Actually, I was in the middle of one when you called me down, I was practicing thought-watching."

Therapist: "I'm not familiar with thought-watching."

Client: "You see, it's kind of a form of meditation. If I am going to be strong like my ancestors, then I need to not only be physically strong, but I also need to be mentally tough."

Therapist: "How do you accomplish that, to become mentally tough?"

Client: "First you try to block out all the distractions around you, and then you examine your thought life, and try to bring your negative thoughts under your will."

Bill did not realize it, but he had just described a religious ritual that was congruent with a cognitive therapy technique I had suggested he use about a week earlier. When I first introduced Cognitive Behavioral Therapy (CBT) to Bill as a means of treating his dysthymic disorder along with medication, he rejected CBT as "psychobabble." However, I was able to implement several CBT strategies and techniques by using his religious language to describe them. By approaching Bill in this manner, I was able to utilize specific religious rituals from his faith perspective that were also congruent with my theoretical orientation.

Engage in On-Going Self-Reflection

To reduce any negative impact of religious differences therapists should engage in on-going self-reflection. Informal methods of self-reflection that can be implemented to counter this problem include monitoring one's feelings and thoughts toward religious clients. Socratic questioning can also be engaged in throughout the therapeutic process with religious clients to heighten therapists' self-awareness. What does my client believe? How might this impact their treatment? How is my worldview similar to this client? How is my worldview different from what this client believes? How might my worldview impact this client's treatment? These are just a few examples of the type of questions that I asked myself when I was working with Bill, and that can be used to increase therapists' sensitivity to religious issues. Obtaining a support system, such as meeting with other professionals regularly, joining a professional organization that interfaces religion and psychology (e.g., APA Division 36; Christian Association for Psychological Studies), obtaining supervision, and/or acquiring consultation can be used by mental health professionals to overcome potential problems that may result from addressing religious differences.

A more formal method for increasing counselors' awareness about their own religious beliefs and heritage is the spiritual genogram (Frame, 2000). By developing more awareness of their worldview, mental health professionals can begin to identify how their own beliefs could potentially lead to religious differences. Similarly, if therapists suspect that they might be dealing with issues caused by religious differences, the spiritual genogram can be used to identify the area or areas of conflict.

Conclusion

The fact that Bill and I adhered to different and opposing religious beliefs threatened to interfere with the therapeutic process. Early on I made the mistake of over identifying with my client, and had projected my worldview onto him when he disclosed that he considered himself to be a religious person. Thus, I was surprised when he told me that he held racist views that stemmed directly from his religion. In that moment I became confused and frustrated with Bill. By (a) seeking supervision, (b) differentiating between my beliefs and my clients beliefs, (c) taking a one-down learning approach, (d) setting boundaries, (e) perspective shifting, (f) listening for compatible beliefs, and (g) engaging in ongoing self-reflection, I was able to work through the frustration that stemmed from our religious differences.

I believe these steps and experience opened the door for positive change for both my client and myself. For me, it helped me grow as a therapist. The experience helped me continue to learn about myself as a professional helper and to learn new clinical skills. For Bill, it helped him grow as a person. Over our months of work together, Bill made significant gains in reducing his dysthimic symptoms. Further, on my last day at the facility, Bill stopped me on my way out to say thank you. He also disclosed that he had been thinking a lot about all our conversations, and as he was getting closer to his parole, he had begun to differentiate between the beliefs that he felt were truly his and those he felt forced into adopting--he informed me he was planning on leaving the Aryan group once he was released. It is hoped that this case study will raise clinicians' awareness of problems that result from religious differences, as well as the positive possibilities and the guidelines that evolved will aid clinicians in addressing such issues.

Jamie D. Aten, Ph.D.

Wheaton College

References

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.

Frame, M. W. (2000). The spiritual genogram in family therapy. Journal of Marital and Family Therapy, 26, 211-226.

Jones, E. E., & Harris, V. A. (1967). The attribution of attitudes. Journal of Experimental Psychology, 3, 1-24.

Russell, S. R., & Yarhouse, M. A. (2006). Training in religion/spirituality within APA-accredited psychology predoctoral internship sites. Professional Psychology: Research and Practice, 3 7, 430-436.

Worthington, E. L., Jr., Sandage, S. J., Davis, D. E., Hook, J. N., Miller, A. J., Hall, E. L., & Hall, T. W. (2009). Training therapists to address spiritual concerns in clinical practice and research. In J. D. Aten and M. M. Leach (Eds.), Spirituality and the therapeutic process: A comprehensive resource from intake to termination. Washington, DC: American Psychological Association.