Lo estratégico: lucha por la hegemonía cultural y gubernamentalidad

CONSIDERING RELIGION AND SPIRITUALITY: CONTEXTUAL ISSUES

To understand the current relationship between religion/spirituality and mental health care, one must understand the context within which this relationship has developed. The historical relationship between religion/spirituality and mental health care has been a dynamic and complex one that has changed and grown along with significant shifts in societal thinking. This will be reviewed briefly, although for a more comprehensive review the reader is encouraged to consult David Wulff’s (1996) book, Psychology of Religion: Classic and Contemporary. Following this will be a discussion of current sociocultural and institutional influences that impact upon the consideration of religion/spirituality in mental health care, as well as issues that are often cited as impediments to this.

Before continuing, a definition of religious/spiritual ‘consideration’ is required. The involvement of religion/spirituality in mental health care is referred to variously as ‘integration’, ‘inclusion’, ‘intersection’, ‘interaction’, and ‘consideration’. The term ‘consideration’ is used throughout this dissertation as it appears to be the most inclusive and overaching term available. Consideration refers to the attention practitioners give to the influence of religion/spirituality on a client’s presentation and the delivery of mental health care. This is similar to Shafranske’s (2005) ‘intentional orientation’ toward religion/spirituality in mental health care. The consideration of religion/spirituality may involve explicit efforts to involve religion/spirituality in therapy, or implicit efforts such as being mindful of the way one responds to religious/spiritual topics when they arise.

HISTORICAL CONTEXT

Prior to the scientific revolution of the 16th _{to 18}th _{centuries, mental illness was readily}

explained within natural and supernatural contexts (Rosen, 1968), with seemingly little concern about contradictions between the two (Thielman, 1998). The role of physician and priest were considered as one, leaving the diagnosis and care of those with mental illness to religious authorities and institutions (Sevensky, 1984; Thielman, 1998). The scientific revolution marked a gradual shift in Western ontological and epistemological paradigms (P. S. Richards & Bergin, 2005). Illness was no longer considered to be the result of unseen, untestable and undiscoverable forces. References to the supernatural disappeared from the medical literature, replaced by positivist epistemologies (Sevensky, 1984; Thielman, 1998). As a result, mental health became the domain of medicine and the care of the mentally ill became the responsibility of non-religious institutions.

The opinions of the founding fathers of 20th century psychology reflected divergent views on the role of R/S in mental illness and mental health care. Psychologists and psychiatrists such as Carl Jung and William James tended to emphasise the positive role of R/S in mental health. In the field of psychoanalysis, Jung wrote of the role of R/S in helping to facilitate the process of integrating the conscious and unconcious minds (Jung, 1938), while James believed that R/S enriched and expanded human experience, helping both ‘healthy-minded’ and ‘sick souled’ individuals (W. James, 1902).

The three most well known psychologists who expressed somewhat negative views toward R/S in the early to mid 20th century included Sigmund Freud, B.F. Skinner, and Albert Ellis. Skinner interpreted the function of R/S as being to control and exploit human behaviour (Skinner, 1953), while Freud was most notably outspoken on the subject of religion in his book The Future of An Illusion (Freud, 2012 [1927]). Freud likened humanity’s attachment to religion as an infantile obsessional neurosis, arising out of the Oedipus complex. This, he wrote, would resolve as humanity matured. While Freud recognised the function of religious belief as protection from other forms of personal neuroses, he advocated for the separation of religion from society, stating that “Religious teachings [are] (…) neurotic relics, and we may now argue that the time has

probably come (…) for replacing the effects of repression by the results of the rational operation of the intellect” (p.41). The duality between religion and the ‘rational mind’ was also advocated by Albert Ellis in the 1980s, who wrote extensively about the harmfulness of religious/spiritual beliefs (e.g., Ellis, 1980; Ellis & Murray, 1980). Ellis argued that all devout religious/spiritual beliefs were associated with emotional disturbance (Ellis, 1980), and that the “less religious [people] are, the more emotionally healthy they will tend to be” (p.637). Further, Ellis advocated for the promotion of atheistic values in psychotherapy, proposing that “the elegant therapeutic solution to emotional problems is to be quite unreligious (....) [then people] would tend to give up all absolutist thinking and stop making themselves emotionally disturbed” (p.637).

A shift toward a more moderate view on the role of R/S in mental health in the late 20th century was helped, in part, by the publication of empirical evidence outlining the complex inter-relationships between R/S and mental health, including the positive impact of certain religious/spiritual beliefs. As a result, Ellis retracted his view that devout religiousness was inherently harmful and revised his position to state that “religious and nonreligious beliefs in themselves do not help people to be emotionally ‘healthy’ or ‘unhealthy’. Instead, their emotional health is significantly affected by the kind of religious and nonreligious beliefs that they hold” (Ellis, 2000, p. 30). This view has been reflected most significantly in Pargament’s work on the effect of positive and negative religious coping, discussed in Chapter Two (Pargament, 1997).

CURRENT CONTEXT

Political and philosophical paradigms

While the literature on religion/spirituality and psychology now leans toward a more moderate stance, it must be noted that secularism is the dominant sociopolitical environment within which the relationship between R/S and psychology is currently embedded in Western society (Cook, Powell, Sims, & Eagger, 2011; Reber, 2006). Secularism refers to the exclusion of religion from state policies, laws, and services that has occurred within a broader sociocultural process of secularisation; the movement of

society away from traditional religious beliefs and practices (D. Martin, 2005). Professional training in the mental health disciplines, funding for research, and the provision of mental health services are often a publically provided and/or publically mandated commodity, and therefore a secularised one where Western economies are concerned (Cook, et al., 2011). In addition, the disciplines of psychology and psychiatry have become entrenched within two major philosophical paradigms that are basically in conflict with those of religion and spirituality (P. S. Richards & Bergin, 2005): metaphysical naturalism, which is “essentially [a natural] explanation of everything without recourse to anything supernatural” (Carrier, 2005, p. 4), and positivism, which constrains the theory and practice of these disciplines to that which is based upon objective, observable evidence. These two paradigms are in conflict with the core tenets of many religious/spiritual orientations, which assume the existence of supernatural, unobservable, and immeasurable phenomena.

The dominance of science as the only source of knowledge and its assertions of universal truths has softened recently as scholars have recognised that scientific ‘truth’ is couched within a sociocultural context. In psychology, this has necessitated a movement toward social constructionism; the notion that knowledge, truth, and reality are constructed within ones’ social context. As writers argue that the very definition of social constructionism is socially constructed, few offer any definitive meaning to the phrase (Gergen, 2009). This shift in paradigm has assisted the discipline of psychology to become more sensitive to the impact of cultural differences, although psychology’s reliance on relativist interpretations of truth and reality are often in conflict with the universal truths asserted by some religious traditions.

Together, the increasing dominance of secularism and the philosophies of metaphysical naturalism and positivism over the 20th century and beyond contributed to the retreat of religion and spirituality from the theory, research, and professional practice of mental health care. Despite increasing attempts to reverse this trend and indications that this may be happening, those who wish to consider R/S in mental health care are doing so within a culture that in Cook et al.’s words is “deeply biased against the transcendent” (2011, p. 37).

Contextual issues unique to New Zealand: Biculturalism, wairua M!ori, and diversity.

The ‘bias against the transcendent’ also exists within secularised New Zealand, although an interesting pluralism exists here due to the political and ethical mandate of biculturalism (Turbott, 1996). On one hand, like other Western nations, New Zealand is a secularised country (Ahdar, 2006); R/S does not generally feature in or have any bearing upon healthcare policies. A significant exception to this is the attention paid to indigenous (M!ori) religion and spirituality in policy, which has arisen from New Zealand’s political and social commitment to an equitable partnership between the indigenous people of the land (tangata whenua / M!ori) and non-indigenous people (Pakeha). This equitable partnership is expressed in the form of biculturalism as a fulfilment of the Treaty of Waitangi, which was signed following British colonisation.

The recogition of M!ori religion/spirituality has led to the development of state and district health board policies that explicitly incorporate M!ori religious/spiritual values and practices (see Capital and Coast District Health Board, 2009; Chief Advisor Tikanga, 2003; Ministry of Health, 2002; 2006 for examples). Additionally, New Zealand practitioners have been socialised and trained to be aware of spirituality as an integral facet in M!ori models of health such as Te Whare Tapa Wha (‘The four sides of the house’). This is an influential and widely-utilised model that emphasises the importance of four aspects of health for M!ori: physical, psychological, familial, and spiritual (Durie, 1994). The spiritual aspect includes a sacred connection to wh!nau (family), whenua (the land), tupuna (ancestors), and an emphasis on traditional healing methods, although M!ori forms of R/S often incorporate aspects of Christianity as a result of missionary influence in the 1800’s. For some M!ori, spirituality forms an integral part of identity and everyday reality (Valentine, 2009). Connection, communication, and balance with the natural and transcendent world, and to ones’ wh!nau and whakapapa are thus considered an important aspect of taha hinengaro (mental health) (cf. Tse et al., 2005; Valentine, 2009). As a result, New Zealand mental health services generally espouse a commitment to considering M!ori spirituality, to the point that commentators have held up New Zealand mental health services as an exemplar of attention paid to indigenous spirituality (Egan, et al., 2011; Hollins, 2008).

It is possible that acknowledgement of M!ori spirituality has contributed to a greater recognition of spirituality within New Zealand mental health care in general, making the New Zealand context unique. A pluralism remains however; secularism continues to be the dominant influence, and mental health policy has a tendency to place relatively little emphasis on the religious/spiritual beliefs and practices of non-M!ori (cf. Adhar, 2003; Standards New Zealand, 2008; Stirling, Furman, Benson, Canda, & Grimwood, 2010). With changes in population demographics, it has become increasingly important to (a) continue to reaffirm our focus on spirituality and religion for M!ori, recognise its importance and continue our commitment to biculturalism, and (b) broaden our focus to ensure the religious/spiritual beliefs of non-M!ori are also considered. For example, the 2013 census found that nearly a quarter of those living in the most populous city in New Zealand identified as Asian (Statistics New Zealand, 2013). Asia is one of the most religiously/spiritually diverse continents on earth, where religions and spiritualities range from Dharmic (e.g., Buddhism and Hinduism) in South Asia, Taoistic (e.g., Confucianism and Daoism) in East Asia, and Abrahamic (e.g., Islam, Christianity) in West and South Asia. Following from this, fifty percent of the New Zealand Asian population identifies as Hindu, Buddhist, or Islamic (Statistics New Zealand, 2006). In parallel with New Zealand’s primary commitment to M!ori spirituality, it is important for mental health practitioners to be aware that religious/spiritual beliefs are potentially relevant to any client, and to be open and ready for diversity in this regard.

Institutional and practitioner views

Despite the influences of paradigms that are in conflict with religion and spirituality, views expressed in the literature on the consideration of R/S in mental health have become more moderate. This has been helped, in part, by empirical work that has helped the discipline to gain a better appreciation of the intricacies involved in the relationships between R/S and mental health. There have been an increasing number of conference symposia, fora, research grants and special issue publications devoted to the consideration of R/S in mental health care. The literature has undergone an exponential increase; a keyword search of ‘religio* or spiritu*’ and ‘psych* or mental’ in the title of artcles returned 313 publications from the 1980’s, 796 in the 1990’s, and 1520 in the 2000’s. In response to this and several other influences to be discussed later,

the consideration of R/S has been mandated by a number of influential institutions in the last twenty years. The American Psychological Association (2002) included the consideration of R/S in their Code of Ethics Principle E ‘Respect for People’s Rights and Dignity’, stating that:

Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices (p.4, emphasis added).

Similarly, the New Zealand Code of Ethics for Psychologists (New Zealand Psychologists Board, 2002, p. 5), Principle 1 ‘Respect for the Dignity of Persons and Peoples’ states:

Respect requires sensitivity to cultural and social diversity and recognition that there are differences among persons associated with their culture, nationality, ethnicity, colour, race, religion, gender, marital status, sexual orientation, physical or mental abilities, age, socio-economic status, and/or any other personal characteristic, condition, or status. Such differences are an integral part of the person (p.5, emphasis added).

Similar statements can be found in the British Psychological Society Code of Ethics under Principle 1.1: Standard of General Respect (Ethics Committee of the British Psychological Society, 2009) and in the Australian Psychological Society Code of Ethics under Principle A.1: Justice (Australian Psychological Society, 2007). In 1994 religious/spiritual problems were included in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) under ‘Other Conditions That May Be A Focus of Clinical Attention’, coinciding with the inclusion of a section on cultural formulation (Appendix

I; American Psychiatric Association, 1994). Additionally, the United States Accreditation Council on Graduate Medical Education added training in sensitivity and responsivity to culture, including R/S, in their 1994 requirements for psychiatry training (Accreditation Council on Graduate Medical Education, 1994). While not a standard for accreditation in the American Psychological Association, the consideration of R/S has been included within guidelines for multicultural considerations in training, practice, and organisational change (American Psychological Association, 2002).

When practitioners are asked about their attitudes toward the consideration of R/S in mental health care their responses are generally positive, although practitioners’ confidence in being able to competently consider R/S in practice tends to be low (Durà- Vilà, Hagger, Dein, & Leavey, 2011; Lawrence et al., 2007; J. Q. Morrison, Clutter, Pritchett, & Demmitt, 2009; Shafranske & Malony, 1990; J. S. Young, Wiggins-Frame, & Cashwell, 2007). A survey by Hathaway, Scott and Garver (2004) found that 74% of 332 American Psychological Association members believed clients’ religious/spiritual beliefs were an important area of functioning, while a later survey of the same group found that 82% believed religious and spiritual beliefs had beneficial effects on mental health (Delaney, Miller, & Bisono, 2007). A random sample of American Counseling Association members found that 92% agreed it was important to be sensitive and respectful toward clients’ religious/spiritual beliefs (J. S. Young, et al., 2007), although a large proportion (44%) believed they were unable to competently consider R/S in practice. An early survey of clinical psychologists (Shafranske & Malony, 1990) found that 74% believed that religious/spiritual issues were within the scope of their psychological practice and 87% believed it was important to know of their clients’ religious/spiritual background. However, 68% of the respondents in this study believed they did not have the knowledge or skill to help clients with religious/spiritual issues.

The attitudes of practitioners toward the consideration of R/S have been found to influence practitioner-reported consideration of R/S in the care of their clients (Kvarfordt & Sheridan, 2009; Shafranske & Malony, 1990; Sheridan, 2004). Kvarfordt and Sheridan’s study found that social workers’ attitudes accounted for 52% of the variance in practitioner-reported consideration of R/S. This was lower (21%) in

Sheridan’s study. Positive attitudes such as “knowledge of clients’ religious or spiritual beliefs is important for effective practice” and the eschewing of attitudes such as “religious concerns are outside of the scope of social work practice” were facilitative of greater religious/spiritual consideration. A smaller group of practitioners hold less favourable opinions toward the consideration of R/S and others are often conflicted on this matter despite their support of positive attitudinal items in surveys (Durà-Vilà, et al., 2011; Magaldi-Dopman, Park-Taylor, & Ponterotto, 2011). Such conflict arises from several sources, including perceptions regarding the role of R/S in psychotic illnesses and inflexible religious mindsets (sometimes referred to pejoratively as fundamentalist) (Koenig, 2008b; Magaldi-Dopman, et al., 2011; Neeleman & Persaud, 1995; Sullivan, 1993), a fear of opening a ‘pandora’s box’ (Lindgren & Coursey, 1995), ethical concerns (e.g., Cook, et al., 2011; Gonsiorek, Richards, Pargament, & McMinn, 2009), and a lack of preparedness and training in dealing with religious/spiritual subjects (Durà-Vilà, et al., 2011; Magaldi-Dopman, et al., 2011). These studies point to a gap between awareness of best practice and practitioners’ comfort with implementation. In addition to those just mentioned, there are a number of barriers to considering R/S that are relevant and require attention. These will be discussed next.

IMPEDIMENTS TO CONSIDERING RELIGION AND SPIRITUALITY IN MENTAL HEALTH CARE

Despite the generally positive attitude toward the consideration of religion/spirituality in mental health care, there may be a number of reasons why practitioners report they are less confident to actually consider R/S in practice. Some impediments to practitioners’ comfort and confidence in considering R/S in mental health care will be discussed here, including the religiousness/spirituality of practitioners, the beliefs and attitudes held by practitioners toward R/S in mental health care, concerns around dealing with harmful religious/spiritual beliefs, professional and personal boundary issues, and ontological and value differences between religion/spirituality and psychology. Solutions to these impediments will be discussed, including an ethical decision-making response to religion/spirituality in mental health care (Barnett & Johnson, 2011), and the role of education and training.

The ‘religiosity gap’

Mental health practitioners, particularly psychologists and psychiatrists, tend to hold religious/spiritual beliefs at a lower rate than the general population and the population of clients they serve. A survey of 258 psychologists across the United States (Delaney, et al., 2007) found that psychologists were less likely to believe in God than the general American population (32% vs. 64%) and were more likely to endorse R/S as ‘unimportant’ in their lives (48% vs. 15%). These results were similar to those reported by an earlier survey of U.S. psychologists (Shafranske, 1996). Similarly, a survey of psychiatrists in Canada found that 54% of psychiatrists believed in God, compared with 71% of clients and 81% of the general population (Baetz, Griffin, Bowen, & Marcoux, 2004), while 88% of a group of psychiatric patients in New Zealand stated they believed