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What, then, does the mental health professional, pastoral counsellor or clergy do with this information? The suggestions I make below are based on the evidence from research, 35 years of clinical experience providing counsel to Protestant Christian clients, and a whole lot of common sense when addressing something as personal and sacred as a person’s religious faith. But, first, let us consider the case below.
Case Vignette
Jeff experienced a back injury as a result of a car accident about six months ago. This forced him at age 40 to stop work and go on disability due to limitations in his mobility. Since then he has required multiple back operations, with minimal return of functioning. Besides the physical disability, the accident and surgeries that followed left him with chronic pain unrelieved by muscle relaxants, high-dose gabapentin, various new stimulation devices (both superficial and implantable), and even narcotic pain killers (which his pain was not responsive to due to its neuropathic nature). He was now experiencing severe shooting pains into his hip and legs virtually day and night, and was told by doctors at the chronic pain clinic that there was not much more they could do. Jeff’s depression worsened and he soon began contemplating suicide. As a result, his psychiatrist placed him on a combination of antidepressants and low dose benzodiazepines, and encouraged him to see a psychologist to help him cope with the pain.
On initial evaluation, the psychologist (who was Jewish) took a spiritual history. He discovered that Jeff was a religious man and member of a large conservative Protestant congregation. He also learned that Jeff was a deacon in his church, and when the pain was not too severe, would go out with other deacons to visit people around the neighbourhood “witnessing” to them. Jeff told the therapist that his faith in the Bible, role in the church, and his family were the only things that stopped him from committing suicide. The psychologist decided to treat his depression with standard cognitive behavioural therapy, but one that was sympathetic to and supportive of his religious faith. After three months of therapy, Jeff continued to feel depressed on and off as the pain waxed and waned, but his suicidal urges lessened as he continued to remain engaged in his church and use his faith to give meaning to his life, both of which his therapist strongly supported (despite having different beliefs than Jeff). This included the therapist listening respectfully and gently tolerating Jeff’s efforts to convert him.
Given the large amount of observational research and numerous clinical trials reviewed above that document the benefits that religious involvement has on mental health in Protestant Christian-majority populations, several clinical applications flow naturally from these findings.
1. Take a Spiritual History
A primary task of the clinician, whether or not a religiously-integrated approach to therapy is considered, is to take a detailed spiritual history in order to identify the client’s religious beliefs (or lack thereof) and the role those beliefs and practices play in the patient’s mental health and psychopathology. Not only is this necessary to provide respectful mental health care in the context of the Protestant patient’s belief system, but also in deciding on whether those beliefs are a resource or a liability. In cases where religious beliefs appear to be a liability standing in the way of progress, further consultation will be needed with someone who is an expert in the patient’s faith tradition (and perhaps co-therapy conducted with that person).
A detailed mental health spiritual history in Protestant clients should include the following information, divided here into general information about the client’s religious beliefs and more specific information related to their particular Protestant tradition.
General information:
Protestant-specific information:
Armed with this information, the mental health professional is now ready to proceed with a mental health care plan in the context of the client’s Protestant faith background.
2. Provide a Safe Place
Provide a friendly and safe place where clients can talk freely about their religious faith, good or bad, without judgement. Maintain a respectful, interesting receptive attitude at all times to the client’s Protestant faith (whether the person is currently active or not, whether he or she speaks well of it or not).
3. Guilt
Listen for feelings of excessive guilt over real or imagined transgression. Don’t try to immediately rationalise or remove the guilt; rather, seek to understand it better from the client’s faith perspective. Identify core beliefs that may be driving the guilt but be careful in overtly challenging religious beliefs.
4. Non-Religious Protestant Clients
If the client is not actively religious, then the mental health professional should proceed with secular psychotherapy that is respectful of their personal and cultural beliefs. Aggressive attempts to reconnect the person to his/her Protestant faith tradition should be avoided. If the client was once religious and has not become socially isolated or is despairing for lack of meaning in life, the therapist might gently ask if the client has considered re-establishing connections with their faith community (or a different one). The therapist may help the client weigh the plusses and minuses of such re-involvement, but again following the client’s lead.
5. Utilise Faith Resources
If the client is religious, but not a candidate for religiously-integrated therapy or does not prefer this approach, then the therapist should provide secular psychotherapy that is supportive and respectful of the client’s religious beliefs. There may be times during secular psychotherapy, though, when the client’s religious beliefs may be utilised to support changes in attitude and behaviour. In-depth knowledge about those religious beliefs, though, is usually necessary.
6. Consider Religiously-Integrated Therapy
If the client wishes to have therapy from a religiously-integrated approach, then the mental health professional must decide on whether he or she is qualified to provide this type of therapy or needs to refer the client to someone with these qualifications (e.g., a certified pastoral counsellor). An evidence-based Christian form of religiously-integrated cognitive behavioural therapy (CBT) for depression has been developed that relies heavily on Biblical scriptures consistent with Protestant beliefs (Koenig et al., 2015; Pearce, 2016). A therapist manual for this form of Christian CBT and both patient and therapist workbooks, along with a training video, are freely available on the Duke University’s Centre for Spirituality Theology and Health website (CSTH, 2014).
7. Challenge/Re-Educate
If the client’s Protestant beliefs are contributing to their psychopathology, and this is confirmed following consultation with an expert in that particular Protestant denomination, then the following approach is suggested. First and foremost, the mental health professional should inquire about and listen respectfully, learning as much as possible about the role that religious beliefs are playing in supporting psychopathology. Gathering as much information as possible about the natural history of how religion became intertwined with the mental condition is the therapist’s goal. This must be done in an open and receptive manner and without confrontation (at least during this initial information gathering stage). There will come a time, once the therapeutic relationship is firmly established and the patient feels safe and accepted, when gradual, gentle, and persistent Socratic questioning may help to guide the patient towards a more “healthy” use of their Protestant beliefs. Emphasis here is placed on gradual, gentle, and persistent within an atmosphere that is safe and comfortable. Arguments over religious beliefs will almost always be unsuccessful and will adversely affect the therapeutic alliance.
8. Be Supportive and Neutral
Whether religious resources are utilised in therapy or not, the supportive of the Protestant religious beliefs/practices the client finds helpful (or might find helpful in the future as a way of coping with emotional issues, but do so from the client’s perspective). If the client is receptive and open to healthy religious practices, and these are not clearly pathological, then they may be encouraged; if the client shows any resistance, don’t push. However, as with non-religious clients, it may be informative to gently explore where the resistance is coming from in a future session. Never give clients the impression that they are not religious enough, since they probably get plenty of that from family and fellow church members. Whether it is a psychiatrist prescribing biological therapies or a therapist providing counselling, the mental health professional should be viewed by the client is neutral, interested in, open to and supportive of the client’s Protestant faith, but always on the client’s side and never judgemental. The same applies to clergy who are counselling members of their congregation.