Applied clinical integration in psychotherapy with children and adolescents: a look ahead.

Walker, Donald F.

In this article, I briefly review the integration movement beginning with the early 1970's. Early integration efforts focused on interdisciplinary integration. Beginning in the mid 1990's, integrative scholarship has moved increasingly from interdisciplinary integration to applied clinical integration. Applied clinical integration with children and adolescents is an area of clinical practice in its infancy. I discuss the future of applied clinical integration with children and teens. In doing so, I advocate for the development of developmentally sensitive measures of religion and spirituality with children and teens. I then discuss promising spiritually oriented interventions with children and suggest areas for research in trauma focused therapy with children. I also suggest areas of research and practice related to training Christian therapists.

A Jain version of the story of the six blind men and the elephant has been told this way: six blind men were in the jungle and asked to describe what an elephant looks like by touching it. A blind man who feels a leg says the elephant is like a pillar. One who feels the elephant's tail says the elephant is like a rope. One who feels the trunk says the elephant is like a tree branch. One who feels the ear says the elephant is like a hand fan. One who feels the belly says the elephant is like a wall. The one who feels the tusk says the elephant is like a solid pipe. Afterward, a king explains to them that all of them are right, and the reason they each told it differently is because each of them touched a different part of the elephant. The elephant has all the features they mentioned.

Integration in the 1960s through 1980s

When I have taught integration classes before, I often begin by telling this story to the class, and suggest that the process of interdisciplinary integration between psychology and theology is akin to the process of describing an elephant as a blind man. In attempting to describe human nature, formulate ways to help hurting people, and understand ultimate Truth, the disciplines of psychology and theology are presented with the challenge of speaking to each other about these matters from their unique vantage points, without the benefit of completely understanding the other discipline's point of view. In the late 1960s and early 1970s, the integration movement saw a number of efforts to reconcile psychological approaches to understanding human nature with theological approaches. Some of the major proponents of the integration approach at this time focused on the compatibility of aspects of the Christian faith with various psychological theories (e.g., Carter & Narramore, 1979; Collins, 1977). Other equally devoted Christian scholars, when asked to describe ultimate Truth, found little in psychology of value and advocated instead for a uniquely Biblical approach to counseling and psychotherapy (Adams, 1976). I have often thought that one unspoken influence driving the integration movement during that time was the need for Christian colleges and seminaries to defend having a psychology department on campus to their institutional leadership.

Integration from the 1990s Onward

As an increasing number of Christian programs (such as Azusa Pacific University, George Fox University, Seattle Pacific University, and Wheaton College) gained accreditation by the American Psychological Association and scholars grounded in psychology and theology learned to listen to and respect each discipline's unique vantage point, the integration movement seems to have gradually shifted its focus from defending itself to Christian universities to attempting to evangelize the academic and clinical populace. Beginning with Shafranske (1996), the past fifteen years have seen an increase in practice-oriented integration publications from the American Psychological Association. The major focus of a number of these books has been to describe the practical process of addressing client religion and spirituality in the therapy room itself (e.g., Aten & Leach, 2009; Men, McMinn, & Worthington, 2011). These publications are noteworthy because the subject matter marks a noteworthy shift from interdisciplinary integration focusing on the compatibility of psychology and theology to more practical consideration of how to "do" integration in the psychotherapy office--applied clinical integration. In making this shift, the field of integration seems to have learned to take the tension between disciplines as a given. As a result, the integration movement has moved increasingly toward applied clinical integration in the past 15 years.

Where Is Applied Clinical Integration with Children and Adolescents Headed?

In a real way, integrative child and adolescent psychotherapy is in its infancy as a discipline (Hathaway, personal communication, June 10, 2011). As a clinical child psychologist, I am proud of the modest but notable increase in efforts to engage in applied integration in clinical child psychology. In this next section, I discuss several areas within clinical integration in child and adolescent psychotherapy that I see becoming important issues for the field to address in the next ten to twenty years.

Measurement of Religion and Spirituality in Clinical Child Psychology

Not surprisingly, the psychometric development of tests and measures with children and teens has not traditionally been a "hot" topic in the field of integration. Only recently have psychotherapists begun to write in earnest about addressing religious and spiritual issues among child and adolescent clients. However, if the field of integration is to move forward in clinical child psychology, then collectively, we must make progress in this area.

For research, developmentally sensitive measures of religion and spirituality are needed that that are comprehensible to children and teens of various ages (Gorsuch & Walker, 2006). My suggestion is not to simply write child versions of current adult religiousness measures. Rather, researchers should identify theoretically important domains of childhood religion and spirituality that need to be better measured, and create age appropriate measures of them. For example, developmentally sensitive measures of children's God images have already been created (De Roos, Miedema, & Iedema, 2001).

Also needed are clinically useful assessment measures for therapists to use with children and teens in clinical settings. Such measures largely do not exist, though there are some notable exceptions. For example, the Faith Situations Questionnaire (Hathaway, Douglas, & Grobowski, 2003) assesses clinical impairment in religious settings related to children's problems with inattention and hyperactive behaviors. The FSQ represents an exemplar for developing clinically useful assessment measures. However, additional clinical measures tapping other domains of religious and spiritual functioning with children and teens are sorely needed.

One conceptual issue that also needs to be addressed concerns the development of childhood measures of religion and spirituality for research purposes versus those of clinical assessment purposes. Some have suggested that measures developed exclusively for research may not be meaningful assessment tools (Hathaway, personal communication, June 10, 2011). This assertion remains to be tested.

Spiritually Oriented Interventions in Child and Adolescent Psychotherapy

As a child psychotherapist who has worked in both explicitly Christian settings as well as secular ones, I am particularly excited about the prospect of developing spiritually-oriented interventions that can be used in empirically supported treatment packages. Toward that end, I have been developing a spiritually-oriented version of trauma-focused cognitive behavior therapy (SO-TF-CBT; Walker, Reese, Hughes, & Troskie, 2010). We have also developed a model for incorporating Scripture in secular parent training programs for child behavior problems (Walker & Quagliana, 2007). I look forward to seeing outcome research on these and other spiritually-oriented interventions for children and teens.

In developing spiritually oriented interventions with children and teens, researchers are left with several options. They could either (a) utilize spiritual practices for psychotherapeutic goals, or (b) take secular models of treatment and incorporate religious and spiritual content (Post & Wade, 2009). I prefer the latter method of developing spiritual interventions. I believe spiritual interventions utilized in the context of empirically supported child and adolescent psychotherapies represent the "best of both worlds" from theology and psychology. At their best, they combine spirit led, Biblically based theology with high quality empirical psychological science to produce a more complete treatment than either discipline could create alone.

In considering integrative treatment development in child and adolescent psychotherapy, Worthington (1994) proposed a blueprint for intradisciplinary integration that is helpful to consider. Worthington compared model building to building a house, and proposed that researchers evaluate several areas. He argued that the foundation of any Christian integrative treatment is Christ, and that the weight-bearing pillars for a constructed theory are the fundamental beliefs of Christianity. These two considerations should make child and adolescent integrationists seriously consider cognitive behavioral models of treatment for model development. Worthington also suggested that the "frame" of an integrative psychotherapy model is determined by the goals and methods of psychotherapy.

Worthington (1994) further proposed that the goals of psychotherapy are determined by the therapy context. Although Worthington contrasted private Christian outpatient psychotherapy with pastoral counseling in his article, my personal interest lies in developing integrative models of psychotherapy that can be delivered in both explicitly Christian as well as decidedly secular settings. Increasingly, secular psychologists have recognized religious and spiritual diversity as an aspect of diversity that must be treated with respect. For this commitment to religious and spiritual diversity to be realized, we must develop spiritually oriented versions of treatment that can also be delivered within a secular context.

Worthington (1994) also suggested that the method of therapy would be determined by the context, psychotherapist, community, and clients. This assertion is echoed by Tan (1996), who emphasized these variables as determining where therapists should intervene on the explicit-implicit integration continuum. Moon and Benner (2004) also proposed two dimensions (secular versus spiritual treatment methods, secular versus spiritual treatment goals) resulting in four potential "quadrants" of intervention. The quadrants include: (1) Secular methods/Secular goals, (2) Secular methods/Spiritual goals, (3) Spiritual methods/Secular goals, and (4) Spiritual methods/Spiritual goals. I believe that, as an ideal, integrative psychotherapy models would be flexible enough to be utilized anywhere along Tan's implicit-explicit integration continuum, or within any of the four quadrants identified by Moon and Benner. This flexibility would allow integrative therapists the opportunity to openly use spiritual interventions in Christian settings to explicitly honor Christ, while also allowing them to apply them less explicitly in secular treatment settings in fulfillment of the ethical provision to respect client religion and spirituality.

Psychotherapists can develop spiritual interventions within secular treatment models by identifying empirically supported treatments for different childhood disorders (most of which are cognitive behavioral in nature) and examining the various modules within a given treatment for secular interventions that lend themselves to religious content. For example, in the Relaxation module of TF-CBT for children who have been abused, we have suggested that religious children will be helped to relax if some form of prayer is included in the relaxation training (Walker et al., 2010). During the Trauma Narrative module, we have encouraged psychotherapists to ask children where God was during their traumatic event, and to talk to God (pray) about the traumatic event.

Depending on the client's (and their family's) personal religiousness, the nature of their presenting problem, and the treatment context, psychotherapists can choose to apply spiritual interventions more or less explicitly when using this model for integration. For example, a therapist working with a child client on relaxation training in the TF-CBT relaxation module might openly pray with a client in the office if therapy was taking place in a Christian private practice setting. Conversely, if the same therapist and client were working together in a community mental health center, the therapist might suggest to the client that he or she try praying during the relaxation exercises when they are implementing them at home. A psychotherapist using this intervention is utilizing prayer in therapy in either setting. Only the implementation is different. This is the elegance of an integrative framework that uses spiritual interventions within secular treatment models.

Spiritually Oriented Trauma Psychotherapy with Children and Adolescents

This is an area of research and practice that is only beginning to gain momentum within the research literature. Previous studies have found that victims of childhood abuse often experience ambivalence about their religious and spiritual faith; growing in some areas after abuse and experiencing damage to other areas of their faith (Walker, Reid, O'Neill, & Brown, 2009). Studies are needed that examine the process of trauma-focused psychotherapy from the perspective of both the psychotherapist and the client in order to understand: what can therapists do to help their child trauma clients preserve their faith and draw on their faith as a resource for coping and meaning-making in psychotherapy? Outcome research is also needed that examines the utility of SO-TF-CBT against its secular counterpart in producing therapy outcomes.

Both in and outside the context of psychotherapy, additional research is needed that examines the impact of different types of trauma (e.g., physical abuse, sexual abuse, disasters) on mental health functioning. Also needed is research that specifically examines the unique damage caused by and processes of recovery from religion-related abuse such as physical abuse in which the Bible was used to justify the abuse, or clergy sexual abuse.

Integrative Psychotherapy Training

In a series of empirical articles about training Christian therapists to do integration, Sorenson concluded that in many ways, integration is "caught not taught" (see Sorenson et al., 2004, for a discussion). As I was finishing up my doctoral studies at Fuller Theological Seminary, I conducted several studies examining the role of personal religiousness in relation to various kinds of integrative training in helping therapists to use spiritually-oriented interventions in counseling and psychotherapy (Walker, Gorsuch, & Tan, 2005; Walker, Gorsuch, Tan, & Otis, 2008). My general conclusion was that, personal religiousness accounted for a substantial portion of variance in predicting self-reported frequency and competency using spiritual interventions. Apart from personal religiousness, intervention-specific coursework and clinical training helped therapists use spiritual interventions more than broad courses on theology or integration.

Do these findings mean that Christian therapists shouldn't study theology and integration broadly? No, but I have often wondered why we, as integration scholars, don't do more research on integrative training components and their effectiveness in producing integrative therapists. For example, Sorenson and Hales (2002) found that religious psychologists trained at secular institutions were more conservative and more likely to use spiritual interventions than were their counterparts trained in Christian institutions. Why is this? My own experience taking theology classes during my training was that theology professors typically want to expand, rather than conserve, student viewpoints on faith. Theology classes also tend to focus on obtaining theological knowledge, rather than on fostering one's relationship with Christ. There is nothing inherently wrong with this, but, I suggest that we need to help Christian therapists in training to be aware of their own relationship with Christ and consider training as building on that relationship. Personally, I have often found John 15:5 to be a powerful verse in my own personal spiritual life and professional life as well. This verse states "I am the vine, you are the branches, if you remain in me and I in you, you will bear much fruit;. apart from me you can do nothing." This seems a good place to begin, but not to end for a Christian psychotherapist in training.

Consequently, I believe that in our training efforts at Christian counseling and psychology programs, we need curriculum mapping that coordinates coursework to supervision so that religious and spiritual issues are discussed in courses and spiritual interventions are taught at the classroom level. Afterward, religious and spiritual issues need to be brought up and discussed in supervision, and workshops or other presentations need to be offered that allow therapists in training to practice actual spiritually oriented interventions, if they are relevant to the client's presenting problem, and the client consents. Of course, not all Christian psychotherapists work in explicitly Christian settings. As a result, training needs to be intentional in helping students to navigate the implicit-explicit continuum for integration (Tan, 1996), to account for client presenting problems, the practice setting, and both client and therapists' personal religious faith. Are all integration training components equal in their ability to help students to become aware of the role of Christ in their personal life and in translating their experience of Christ into their work as therapists in various settings? Surely this is not the case. Therefore, we also need to conduct comprehensive research on the efficacy of our training methods to produce Christian therapists.

Conclusion

In this brief article, I've suggested that the field of integration has advanced considerably past a point where psychology and theology (and the integration scholars studying them) resemble blind men in a jungle, trying to describe their various points of view to one another. Our discipline has advanced beyond conceptual models of integration to applied clinical integration over the past several decades. This increased focus on applied clinical integration has only recently been extended to clinical practice with children and teens. As the field of integration progresses, I look forward to seeing Biblically grounded, spiritually sensitive, empirically supported work in psychotherapy with children and adolescents.

References

Adams, J. E. (1976). What about nouthetic counseling? A question and answer book with history, help, and hope lb r the Christian counselor. Grand Rapids, MI: Baker Book House.

Aten, J. D., & Leach, M. (Eds.). (2009). Washington, DC: American Psychological Association.

Aten, J. D., McMinn, M. R., & Worthington, E. L., Jr. (2011). Spiritually oriented interventions in counseling and psychotherapy. Washington, DC: American Psychological Association.

Carter, D. D., & Narramore, B. (1979). The integration of psychology and theology: An introduction. Grand Rapids, MI: Zondervan.

Collins, G. R. (1977). The rebuilding of psychology: An integration of psychology and Christianity. Wheaton, IL: Tyndale House.

De Roos, S., Iedema, J., & Meidema, S. (2001). Attachment, working models of self and others, and God concept in kindergarten. Journal for the Scientific Study of Religion, 40, 607-618.

Gorsuch. R. L., & Walker, D. F. (2006). Measurement and research design in studying spiritual development. In E. C. Roehlkepartain, P. E. King, I., Wagener, & P. Benson (Eds.), The handbook of spiritual development in childhood and adolescence (pp. 92-104). Thousand Oaks, CA: Sage Publications.

Hathaway, W. L., Douglas, D., & Grobowski, K. (2003). Faith situations questionnaire: Childhood normative data. Journal of Psychology, and Christianity, 22, 141-154.

Moon, G. W., & Benner, D. (2004). Spiritual direction and the care of souls. Downers Grove, IL: Intervarsity Press.

Post. B.C. & Wide, N.G. (2009). Religion and spirituality in psychotherapy: A practice friendly review of research. Journal of Clinical Psychology, 65, 131-146.

Shafranske, E. P. (1996). (Ed.). Religion and the clinical practice of psychology. Washington. DC: American Psychological Association.

Sorenson, R. L., Derflinger, K.R., Buffbrd, R., McMinn, Ni. R. (2004). National collaborative research on how students learn integration: Final report. Journal of Psychology and Christianity, 23, 355-365.

Sorenson, R. L., & Hales, S. (2002). Comparing evangelical Protestant psychologists trained at secular versus religiously affiliated programs. Psychotherapy, 39, 163-170.

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.

Walker, D. F., Reese, J. B., Hughes, J. P., & Troskie, M. J. (2010). Addressing religious and spiritual issues in trauma-focused cognitive behavior therapy with children and adolescents. Professional Psychology: Research and Practice, 41, 174-180.

Walker, D. F., Reid, H., O'Neill, T, & Brown, L. (2009). Changes in personal religion/spirituality during and after childhood abuse: A review and synthesis. Psychological Trauma: Theory, Research, Practice, and Polity, 1, 130-145.

Walker, D. F., Gorsuch, R. L., Tan, S. Y., & Otis, K. E. (2008). Use of religious and spiritual interventions by trainees in APA-accredited Christian clinical psychology programs. Mental Health, Religion, and Culture, 11, 623-633.

Walker, D. F., & Quagliana, H. (2007). Integrating Scripture with parent training in behavioral interventions. Journal of Psychology and Christianity, 26, 122-131.

Walker, D. F, Gorsuch, R. L., & Tan, S. Y. (2005). Therapists' use of religious and spiritual interventions in Christian counseling: A preliminary report. Counseling and Values, 49, 107-119.

Worthington, E. L., Jr. (1994). A blueprint for intradisciplinary integration. Journal of Psychology and Theology, 22(2), 79-86.

Donald F. Walker

Regent University

Author Information

WALKER, DONALD, F. Address: Regent University Virginia Beach, VA 23464. Title: Director, Child Trauma Institute Regent University. Degree: PhD. Research and Clinical Interests: spiritual issues in child abuse treatment and the use of spiritual interventions in child and adolescent psychotherapy.

Correspondence can be sent to me at the address above, or at my email address: dfwalker@regent.edu