Considerations and recommendations for use of religiously based interventions in a licensed setting.

Hunter, Linda A. ; Yarhouse, Mark A.

Human beings are uniquely created with varying degrees of biological, psychological, sociological, and

spiritual differences. Research suggests that many clients bring spiritual issues and concerns to counseling

and request religiously accommodating interventions often in the form of prayer, scripture reading or

referral to scripture, assurances of forgiveness by God, or forgiveness of self or others. These heightened

requests from clients for religiously accommodating interventions must be matched by the clinician's

heightened sensitivity to the disclosure of religious views, cultural diversity, and religious diversity through

use of an advanced informed consent. This article will examine the ethical considerations in the use of

religiously-congruent interventions through a more in-depth analysis of one specific approach to religiously

accommodating interventions, i.e., Theophostic Prayer Ministry. It closes with suggestions for expanded

informed consent when assisting clients requesting religiously accommodating interventions.

Belief in the existence of God in the U. S. has remained consistently above 90% over at least the last 50 years and a similar percentage of individuals hold religion to be a fairly integral part of their lives (Wade, Worthington, & Vogal, 2007; Gallop Poll, 2005; Yarhouse & VanOrman, 1999; Alport, 1950). In response, the Zeitgeist in the mental health profession appears to be moving toward an increase in integration of psychology and religion in licensed clinical settings (Worthington, Kurusu, McCullough, & Sandage, 1996; Moon, Willis, Bailey, & Kwasny, 1993; Worthington, Dupont, Berry, & Duncan, 1988; c.f., Russell & Yarhouse, 2006). As these changes are taking place, they are being paralleled by alterations in church based counseling. Pastoral counseling is being augmented by an increased emphasis in lay counseling within the church setting. With these developments in the field came many discussions about the ethical and professional practice issues relevant to offering religiously congruent interventions to clients who request them.

The purpose of this article is to explore these considerations and offer specific recommendations for navigating ethical and professional practice concerns. To facilitate a more in-depth discussion, we use one specific example of religiously accommodating interventions, that is,

Theophostic Prayer Ministry (TPM), and raise considerations that are applicable to TPM and other related approaches.

Background Information

It was mentioned above that church based counseling and ministry is being augmented in important ways by lay counseling, as members of the church community are playing more of a role in providing front line services to people in need. Interestingly, church-based ministry had an impact on the development of TPM. Ed Smith, the originator of TPM, had seventeen years of traditional ministry experience before he began offering Christian counseling services in 1991 (personal communication, March 11, 2004). Part of this service included leading a women's group for those who had suffered from past sexual trauma. Believing that something was lacking in the women's recovery Smith prayed for guidance and over the "next few weeks a series of simple yet profound principle's began to emerge in [his] thinking as [he] studied the Scriptures and sought God's leading" (Smith, 1996, p. 9). It was from this experience that TPM was birthed.

Smith continues to refine the techniques of TPM accordingly where he sees fit. Smith's end goal was not to design a therapeutic model for use in a clinical setting by licensed mental health professionals; rather, he wanted to assist a small group of women who were victims of past sexual abuse (personal communication, March 26, 2004). However, TPM developed beyond these modest beginnings. One might say the Naturalistic theory that the "times make the person or at least make possible the acceptance of what they have to say" (Jenson, personal communication, May 9, 2006) propelled Smith and TPM to the forefront of discussions of psychotherapeutic and religious integrative techniques.

The resulting tension was almost immediate and was evidenced by critical discussions on the use, efficacy, and ethical considerations of TPM in professional journals and at Christian professional conventions such as the American Association of Christian Counselors (AACC) and the Christian Association for Psychological Studies (CAPS). Rather than resolving the issues at hand and subsequently reaching consensus, the discussions are ongoing and most likely will continue as more individuals seek licensed professionals who practice TPM (Meadows, personal communication, February 3, 2004; Vanvalin, personal communication, April 13, 2005).

McMinn holds that while "prayer-based interventions have a place in psychotherapy" doing so elevates the risk of role identity confusion between the client and therapist (personal communication, November 15, 2005) and some suggest that the TPM model--again, as one specific prayer-based intervention--increases the possibility of role identity confusion that results in blurred boundaries and subsequent ethical infractions (Vanvalin, personal communication, April 13, 2005). There may be some validity to this concern as according to Vanvalin, some licensed practitioners who use TPM almost exclusively in a clinical setting have recently been reprimanded or surrendered their license as a result of ethical violations. The tension then becomes: is there a manner in which licensed clinical psychologists can meet the integrative demands of clients and at the same time hold true to the tenets of the APA Code of Ethics. The discussion to follow is not intended to be a blanket recommendation that fits all licensed psychologists but rather it is hoped that the reader will be provoked to think about where he or she might fit on the following continuum: (1) explicit use of non-religious based interventions; (2) use of religiously based interventions in alternate locations outside of clinical practice; (3) use of religiously based interventions as an adjunct to clinical practice; and (4) exclusive use of religiously based interventions in a clinical setting. Recommendations for integration of psychology and religion in the licensed clinical setting are also being made.

Explicit use of non-religiously based interventions

While some people will forego the use of explicitly religious interventions, this should not prevent them from keeping abreast of the latest research on these and similar models (Worthington et al, 1996; Moon, Willis, Bailey, & Kwasny, 1993; Worthington, Dupont, Berry, & Duncan, 1988). Awareness of current research and relevant professional concerns regarding use of religiously based interventions would enable clinicians to make informed referrals to other mental health professionals with the caveat that they cover some of the potential benefits and risks of such methods as well as a summary of the empirical literature (American Psychological Association, 2002, Standard 10.01 Informed Consent to Therapy).

Use of religiously based interventions in alternate locations outside of clinical practice

Some practitioners will not feel comfortable with integration of religious techniques within the arena in which they practice but may be supportive of such interventions in non-clinical settings. issues such as role identity confusion and billing issues may have driven the decision to practice TPM or other religiously based interventions in another setting such as an office space at a church. Regardless of the path taken to arrive at this decision, several areas of concern will need to be pondered before implementing this decision.

One immediate consideration is what informed consent might look like. A properly constructed informed consent will have already addressed spiritual issues such as those mentioned by Yarhouse and VanOrman (1999) prior to the initial therapy session. one must then decide if the original informed consent is sufficient to proceed with religiously based interventions at another location or if a safer route would be to introduce an additional advanced informed consent that specifically delineates the complexities of and issues surrounding the use of these interventions. The most conservative course would be to have a separate informed consent that speaks to not only the change in location of the sessions but to the specifics of TPM or another religiously based intervention and also offers for consideration the newness of the treatment modality such as is recommended by the ASPPB Code of Conduct, Revised 2005: "the psychologist shall inform clients of the innovative nature and the known risks associated with the services, so that the client can exercise freedom of choice concerning such services" (p. 4).

Another area of concern is that of billing issues when offering a service in an alternate location outside of the routine clinical practice: who pays for the service--the insurance company or the client? In part this decision will be informed by the posture the therapist has with TPM as a therapeutic technique or a spiritual intervention. If the therapist has reached the decision that TPM is indeed a therapeutic technique and is changing location in an attempt to lower the risk of role identity confusion, then most likely he or she will have no qualms billing the insurance for services rendered while at an alternate location such as an office provided within a church. The therapist would need to be forthcoming with third party payors such as insurance companies, listing both the primary location of practice (the clinical setting) and the secondary location (the church office), being clear to delineate the difference in therapeutic practices that occur in each location.

The therapist who has determined TPM to be a spiritual intervention also has to address the options for reimbursement. According to McMinn (1996) the client must be informed of the potential to receive the same or similar services at a lesser cost or possibly for free at some churches. When the client chooses to remain with the therapist then three possibilities exist: billing the client for the session at the same rate as is available elsewhere in the community; engaging the church where sessions are being held to assist in underwriting the expense of the sessions; or pro bono the session as part of therapist's service back to the community.

This is an area that must carefully be thought through and it is essential for the therapist to exhibit the ability to clearly articulate the stance taken. Entwistle holds that "[i]f you decide it [TPM] is a therapeutic technique and bill for the services, be prepared to defend why this is the case as you may find the need arises for you to do so before the board of ethics" (Entwistle, personal communication, March 11, 2004). So while intentions to avoid role identity issues is of concern and may drive the decision to provide TPM at an alternate location, one should not overlook the significance of informed consent and billing issues when making this decision.

Use of religiously based interventions as an adjunct to clinical practice

Some practitioners may decide TPM and/or other similar integration modalities are best used in conjunction with other psychotherapeutic techniques. At this point, the considerations then become somewhat similar to those discussed in the previous section, which are issues of informed consent and billing practices. Smith (2005) recommends therapists not conflate TPM with other techniques in a single session setting. He asserted that holding TPM sessions apart from clinical interventions will assist in avoiding confusion on the client's part about what is being done in a single session.

Once again, the issue of informed consent should be considered in the previously suggested manner. Additionally a therapist practicing within a group setting should consider fully disclosing to other clinicians the model (e.g. TPM) being used and obtain informed consent from the other members of the practice setting. This would move the practice toward not only awareness of what is occurring within the group practice but allow for a consensus that this is acceptable for all involved. Entwistle (personal communication, March 11, 2004), noted that issues involving the TPM treatment modalities may very well be addressed by the ethics board in the near future. Hathaway (personal communication, July 25, 2006) noted there has already been an increase in the amount of violation complaints being filed. It is not out of the realm of possibility that client complaints could eventually reach the civil courts at which time all partners might suffer financial ramifications dependant upon the legal structure of the clinical practice.

Exclusive use of religiously based interventions in a clinical setting

Practitioners who choose to fully implement TPM in the clinical setting as the exclusive treatment modality offered to clients face additional ethical concerns. Psychologists holding this posture would most likely have the need for one informed consent that clearly delineates the basic tenets of TPM, the current status of the research, and other viable treatment options, some of which may be empirically validated. In addition as recommended by Yarhouse and Vanorman (1999), the psychologist would fully disclose and be willing to discuss the views held on prayer, visual imagery, and any other spiritual or religious issues that might arise.

The issues of billing third party payors versus client pay or subsidization by a church has previously been discussed and will only be briefly summarized at this time; however this is probably one of the most critical decisions for psychologists exclusively practicing TPM as the totality of the clinical income would be derived from this intervention. For psychologists opting to bill insurance companies, full disclosure of the interventions being used is imperative to avoid confusion on the part of the third party payors as to the services being provided. For those choosing to bill the client, psychologists should inform the client that these same services may be available elsewhere in the community at a reduced rate (McMinn, 1996). A third option would be to have an arrangement with a church or other community organization that subsidizes the involved fees. ultimately, those exclusively practicing TPM must carefully think through all available options and select the one that is a best fit for them personally, professionally, and ethically.

Recommendations

As we consider TPM as one example of religiously accommodating intervention, we turn our attention now to recommendations for the general use of TPM. Smith (2005) offers these recommendations in the Basic Training Seminars as well as at professional conferences as suggestions for use by lay counselors and licensed professionals. Entwistle (2004a, 2004b) offered a critique of TPM and highlighted numerous ethical considerations that would need to be addressed if a licensed clinician was considering the use of TPM. While one will note general similarities between the two lists below, there are significant nuances of differences between the two and a brief discussion of these similarities and differences will follow.

Recommendations from Smith

Smith often presents the TPM model at conferences and concludes the presentation with recommendations for those interested in learning about and using TPM. To follow are his recommendations:

1. Determine if TPM is the model for you.

2. Receive training in TPM.

3. Read and follow the research.

4. Educate current clientele load of what you are doing.

5. use informed consent.

6. Do not judge the efficacy of the process based on your own initial success rates.

7. Operate within the bounds and limits of your own training and network support base.

8. identify to the client who and what you are --professional, pastoral, lay minister.

9. Avoid the eclectic approach to counseling ministry when using TPM.

10. if you augment, tweak, or modify TPM call it something else. (Smith, CAPS presentation, 2004)

Smith (2005) further encourages individuals electing to use TPM to undergo the process themselves on a regular basis as a means of self-awareness, to consult and network with other mental healthcare professionals within the community, and to refer when necessary.

Recommendations from Entwistle

As previously noted Entwistle (2004a, 2004b) has voiced serious concerns on several levels with the use of TPM and takes a more cautious approach in recommendations for those entertaining the possibility of its use. Here are Entwistle's recommendations:

1. Be able to clearly articulate your position on TPM.

2. Be able to clearly support your position.

3. Be able to provide evidence that supports and disputes your stance.

4. Provide your client with all the pertinent information on TPM.

5. Encourage your client to think through the implications of using TPM.

6. use informed consent.

7. Follow the APA guidelines to the fullest extent.

8. Decide if TPM is a spiritual ministry or a therapeutic technique.

9. if you decide TPM is a spiritual ministry, do not bill for the services but seek other methods for reimbursement (churches, etc.).

10. if you decide TPM is a therapeutic technique and bill for the services, be prepared to defend why this is the case as you may find the need arises to do so before the board of ethics. (personal communication, March 11, 2004)

Entwistle, among others previously mentioned, continues to voice concern regarding additional aspects of TPM that have been previously mentioned, such as the risk of iatrogenetically inducing false memories, returning symptomology, and the theological foundations of the model.

Similarities and differences in recommendations

A review of the two lists reveals that Smith and Entwistle hold in common the emphasis placed on client education and informed consent, with nuanced differences in the driving purpose. What they hold in common is the desire for client understanding of the TPM model so that confusion with other models of therapy is lessened and understanding of the TPM process is increased. The nuance of difference between Smith and Entwistle on client education is that Entwistle would suggest that the client should also be educated as to the status of the research on TPM as well as other available techniques that have shown to be effective with the presenting client issue. By so doing the stage would then be set for the client to arrive at an informed decision as to the viability and personal fit of the TPM model.

The two also agree on the need to obtain client permission for treatment through the use of informed consent. However there appears to be a qualitative difference in the content and purpose of the informed consent. For Smith the informed consent has more of a flavor for forewarning the client to the negative emotions and feelings that might surface as a result of TPM sessions. Four specific areas of concern are listed on the informed consent as follows:

1. Distressing unresolved memories may surface through the use of Theophostic Ministry which could result in my experiencing emotion distress until it can be resolved.

2. Some ministry recipients have experienced reactions during the ministry sessions that neither they nor their facilitators may have anticipated, including a high level of emotional and/or physical sensations.

3. Subsequent to the ministry sessions, the processing of incidents/material may continue and other dreams, memories, flashbacks, feelings, etc. may surface.

4. I may find that my emotional state worsens before it improves as I am able to embrace the memory content of what may surface in my session. (Smith, personal communication March 11, 2004)

Coming from a psychological framework, Entwistle is envisioning an advanced informed consent somewhat similar to that recommended by Yarhouse and Vanorman (1999). To this end the informed consent would be more directed to client awareness of the other therapeutic models available for the presenting concern as well as caveats for the use of the TPM model.

Further differences emerge in the areas of billing and reimbursement as well as considerations for the APA code and scientific basis for treatment recommendations. in a pastoral setting TPM sessions would most likely be part of the salary of the pastoral counselor or recommended donations to the church would be accepted (Hardy, personal communication, April 05, 2004; Smith, personal communication, March 11, 2004). However as previously discussed, billing issues for licensed psychologists are much more complex with considerable forethought and research needed before arriving at a decision of when and how to bill for TPM services.

Differences in accountability may also be noted between the two recommendation lists. Allowing that there is no licensing board for pastoral counselors, Smith recommends recognizing personal limitations, operating within the parameters of one's training, and maintaining a network base for support of and accountability to the model (personal communication, March 11,

2004). For licensed psychologists the ethical standards put forth by the American Psychological Association are of necessity more stringent in purpose and practice.

Further Considerations

At a recent conference (CAPS International Conference, Panel discussion, April 7, 2005) voices were given to both those sympathetic to and critical of TPM as a scholarly discussion ensued (see recap on CAPS panel discussion presented by Hunter & Yarhouse, 2009). It soon became evident that the panel members share in common the belief that they have a calling to help others in need of mental heath services. Where the panel members differ is in the preferred methodology of assisting a client in navigating the road to recovery. So although common starting places and end goals are shared, differences abound on therapy modalities.

Practitioners who are sympathetic to TPM typically assert that TPM does not pose significant harm to clients so long as it is practiced consistently with TPM training (Renn, CAPS International Conference, Panel discussion, April 7, 2005). However, practitioners who are critical of TPM express concerns about what they see as an under-appreciation of the potential for TPM to cause adverse consequence. While several religiously based interventions focus on the client's current and past God image, many of them specifically take precautions to protect against possible adverse consequences (e.g. McMinn, personal communication, November 15, 2005; Tan, personal communication, November 10, 2005; Monroe, personal communication, November 10, 2005; and Richards and Bergin, 2005), and such protections seem lacking in TPM materials and training.

There are several reasons that caution is needed when dealing with God representations. First, the client may not know and understand the difference between God image and God concept. For example, knowing that Scripture says "God will supply all of my needs" is a God concept that a client may affirm cognitively, even though he or she might currently hold the view that God has turned His back and is disregarding his or her current needs. in this example, the individual's God image and God concept are dichotomous: "God provides all my needs" versus "I am experiencing financial difficulties." only after a careful spiritual assessment can one hold hope for understanding a client's God image and God concept and even then this must be an assessment that is ongoing throughout the course of therapy (McMinn, 1996).

Second, not all clients are immediately forthcoming with personal details about religious affiliation at intake. it is the clinician's responsibility to remain sensitive to the cultural diversities and the idiosyncratic beliefs embedded within each client and tailor the treatment plan accordingly. Clients often request religiously based interventions as part of the treatment plan, with prayer often being one of the most requested forms of religious interventions (Wade, Worthington, & Vogel, 2007; National Institute for Healthcare Research, 1997; Moon, Willis, Bailey, & Kwasny, 1993; Worthington, Dupont, Berry, & Duncan, 1988). Research indicates that some psychologists are answering this call and engaging in prayer with the client before, during, or at the conclusion of a psychotherapeutic session (McMinn, personal communication, November 07, 2005; Monroe, personal communication, November 07, 2005; Tan, personal communication, November 10, 2005). TPM is only one of several models that use prayer to achieve inner healing and positive mental health.

While religiously based interventions, such as prayer, may be congruent with other psychotherapeutic interventions and treatment goals, the request for use of these interventions on the client's part must be matched by the heightened sensitivity on the clinician's part to cultural diversity, idiosyncratic beliefs, possibilities of role identity confusion and subsequent boundary violations, and awareness of research on religiously based interventions, ethical guidelines, and best treatment practices.

Third, there are at least three dynamics at work in the therapy room (Brockington, personal communication, January 10, 2005): what the client brings to the table, what the therapist brings to the table; and what happens at the table. undoubtedly the client brings a unique past and all that it entails into the therapy room. With much sensitivity the therapist must carefully comb through the presenting issues, untangle the hurts, and arrive at a treatment plan that is compatible with the client's treatment goals. only then and by the grace of God can what happens at the table leave the client not only in a better place for having been there but also equipped with the tools necessary to successfully move forward in life.

A specific concern relevant to the use of TPM and other religiously based interventions in general concerns their propriety when used in a licensed clinical setting. one common thread across all domains when considering the use of TPM and other religiously based interventions is the concern for the use of informed consent. We will now put forth recommendations for an expanded informed consent.

Expanded informed consent

Advanced or expanded informed consent in the above offered situations should include: (1) disclosure of religious views/cultural/spiritual diversity, (2) assessing the client's openness to use of religiously based interventions or other religiously congruent interventions, (3) change in locations when implementing religiously based interventions (if applicable), (4) newness of religiously based treatment modality, (5) availability of other treatment options, (6) possibility of other similar services at reduced rates and (7) reimbursement of fee options.

1. When offering religiously based interventions one should consider offering expanded disclosure of religious beliefs and orientations within the informed consent: "For clients to make informed decisions, therapists may, as part of informed consent, advise clients as to how they address spiritual concerns and whether or how religious resources may be used in therapy" (Yarhouse and Vanorman, 1999, p. 559). Providing this information can provide a platform for an open discussion for not only religious beliefs but also for the possibility of inclusion of a clergy or other community resources as part of the support system for the client.

2. The advanced or expanded informed consent should delineate the specific religious interventions used during the session including but not limited to the use of prayer, visual imagery, and the evoking of emotions embedded within past memories. Awareness of this information upfront will assist the client in arriving at an informed decision about whether a religiously based intervention is a model of treatment congruent with the client's expectations for therapy and will provide the opportunity for concerns to be voiced before treatment is begun. Additionally, an ongoing assessment of the client's experience of the religious intervention being used in treatment is also recommended.

3. When opting to adjunct a religiously based intervention in another location, the advanced informed consent should fully disclose where the alternate location is, at what juncture in treatment the location will be used, and the purpose behind using the alternate location. Disclosure of this information up front can serve to bring clarity to the nature of the religious intervention and assist in reducing possible role identity confusion.

4. The advanced informed consent should also include full disclosure as to the newness of the religiously based intervention treatment modality such as is recommended by the ASPPB Code of Conduct, Revised 2005: "the psychologist shall inform clients of the innovative nature and the known risks associated with the services, so that the client can exercise freedom of choice concerning such services" (p. 4). Taking care to not present the "techniques as more established than it is" (Hathaway, personal communication, March 31, 2004) is necessary and this section of the informed consent should also include any relevant research available on the success or lack thereof of religiously based interventions. The therapist should also be prepared for an informed discussion with the client regarding the TPM "proven effective" claims that may have been seen on some business websites such as that of Christian Psychotherapy (Retrieved February 19, 2006, from http//www.christianpsychotherapy.com/theophos.htm).

5. other viable treatment options for the presenting problem should also be communicated to the client through the advanced informed consent. The "best guidance ethically and scientifically" is to consider the needs of the client first and foremost taking care to 'do no harm' and secondly to use a carefully and thoughtfully constructed informed consent that clearly delineates treatment choices (Hathaway, personal communication, March 31, 2004). Having research readily available on alternate religiously congruent interventions would allow the client to make an informed decision regarding best fit and provide the impetus for designing a mutually agreed upon treatment plan.

6. The advanced informed consent should clearly state that the possibility exists that religiously based interventions may be available through a church or other location without charge: "If a fee-for-service counselor is using spiritual interventions exclusively and if those same interventions are available elsewhere at little or no cost, the counselor should inform potential clients of the other options before beginning counseling" (McMinn, 1996, p. 91). The client then is afforded the option of remaining with the therapists for the agreed upon fee or pursuing assistance at another location at a reduced rate.

7. The advanced informed consent should clearly present the client with options for fee reimbursement. This is a personal decision and one that should be pondered carefully before preparation of the advanced informed consent. Due to ethical and/or legal ramifications, one must be able to clearly articulate the posture taken on billing practices and be prepared to defend this posture if necessary (Entwistle, personal communication, March 11, 2004). Available billing options will most likely be driven by the therapist's posture on religiously based interventions as a therapeutic technique or as a religious intervention; the location of the religiously based intervention; and the agreement one has with other partners if practicing in a group setting.

Concluding Thoughts

The goal of the current article was to bring to light some of the key controversies and concerns being expressed about the use of religiously based interventions while remaining true to the APA practice recommendations and ethical guidelines. Due to the recent popularity TPM has received in professional journals and at Christian conferences, this model was selected as a case study in the relationship between religiously accommodating interventions and professional services. But the recommendations that have emerged have widespread general implications for licensed psychologists interested in weaving religious interventions with psychotherapeutic practices. Considerations for issues such as the client's past experiences of God as well as present God image, growing research in the integration of religious based interventions into licensed clinical practices, best treatment practices, and ethical standards must all be continually revisited. Likewise licensed psychologists must remain sensitive to the cultural diversities of the clients whom they serve, and they must strive to clearly delineate the role portrayed during the therapeutic sessions in order to avoid client confusion and to diminish the possibility of conflation of professional roles and personal identities as they seek to provide competent, ethical clinical care.

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Linda A. Hunter

Nebraska Mental Health Centers

Mark A. Yarhouse

Regent University

Linda A. Hunter, Psy.D., received her doctoral degree in Clinical Psychology from Regent University. She is a provisional licensed psychologist completing her clinical psychology residency at Nebraska Mental Health Centers in Lincoln, Nebraska. Her research interest continues to be ethical concerns in integration of religiously based interventions and psychotherapy in clinical practice.

Mark A. Yarhouse, Psy.D., received his doctoral degree in Clinical Psychology from Wheaton College. He is the Hughes Chair of Christian Thought in Mental Health Practice and Professor of Psychology at Regent University, Virginia Beach, Virginia. His research interests include sexual identity, family therapy, and applied/clinical integration.

Please address correspondence regarding this article to Linda A. Hunter, Psy.D., Nebraska Mental Health Centers, 4545 S. 86th Street, Lincoln, Nebraska 68526. Email lhunter@nmhc-clinics.com