Episode 138: Working with Spiritual Struggles in Psychotherapy
Kevin Ing, MD, MDiv, David Puder, MD
In this podcast episode, David Puder, M.D. and Kevin Ing, M.D., M.Div. interview Kenneth I. Pargament, PhD, and Julie J. Exline, PhD about their new book Working with Spiritual Struggles in Psychotherapy: From Research to Practice. Dr. Pargament is a pioneering expert on the role of religion and spirituality in coping with stress and trauma. Dr. Exline is a researcher in the area of spiritual struggles and supernatural attributions. Both clinical psychologists, they are nationally recognized experts in the integration of research on religion and spirituality into clinical practice.
Dr. David Puder, Dr. Kenneth Pargament, Dr. Julie Exline, and Dr. Kevin Ing have no conflicts of interest to report.
Introduction
What are spiritual struggles, how common are they, and why do they matter? Should they be addressed in psychotherapy or left to spiritual and religious leaders? Do atheists and non-religious people have spiritual struggles? In Working with Spiritual Struggles, Dr. Pargament and Dr. Exline answer these questions and highlight the importance of understanding spiritual struggles for clinicians.
What Are Spiritual Struggles?
Pargament and Exline define spiritual struggles as “experiences of tension, conflict, or strain on whatever people view as sacred” (Pargament, 2013). The sacred refers to not only traditional understandings of God or higher powers, but also to any aspect of life that is perceived to hold divine-like qualities, such as transcendence, ultimacy, and boundlessness. Even those who identify as non-religious may perceive aspects of life such as nature, work and vocation, and important loving relationships as sacred. Similarly, the term spirituality is used to describe the general search for the sacred, what one holds as most sacred and ultimately meaningful and valuable in one’s life. When sources of conflict and tension revolve around such questions, spiritual struggles occur. Such sources of strain around religion and spirituality may occur regardless of whether individuals are personally spiritual or religious themselves: on one hand they may have a directly “religious” conflict such as dealing with anger at God or feeling attacked by the devil. On the other hand, they may be angry at religion or feel attacked by or angry towards religious people (interpersonal struggles), or have wrestles with questions and doubts (struggles of doubt), moral struggles about right and wrong, or struggles related to questions of ultimate meaning.
Six Types of Spiritual Struggle
In an effort to examine spiritual struggles more comprehensively, Exline and Pargament delineate six types of spiritual struggles that tap into the supernatural, intrapsychic, and interpersonal domains (Exline, Pargament, Grubbs, & Yali, 2014):
Divine struggles take the form of anger or disappointment with God, and feeling punished, abandoned, or unloved by God.
Demonic struggles involve worries that problems are caused by the devil or evil spirits, and feelings of being attacked or tormented by the devil.
Interpersonal spiritual struggles reflect conflicts with other people and institutions about sacred issues; anger at organized religion and feeling hurt, mistreated, or offended by others in relation to religious or spiritual issues.
Struggles with doubt are marked by feeling confused about religious/ spiritual beliefs and feeling troubled by doubts or questions about religion/spirituality.
Moral struggles take the form of tensions and guilt about not living up to one’s higher standards and wrestling with attempts to follow moral principles.
Struggles of ultimate meaning involve questions about whether one’s life has a deeper meaning and whether life really matters.
Items used to assess the six dimensions:
As Exline notes, spiritual struggles are a mixed bag: growth or distress in one area may or may not lead to similar struggles or resolution of struggles in other areas. For example, one may experience divine struggles of feeling angry towards a punishing God which lead to depression, stress, anxiety and disillusionment. This person may choose to leave this faith tradition, which alleviates this struggle and contributes to reduction of these symptoms. However, this may result in interpersonal struggles as a result of leaving the religious community, as well as contribute to doubt-related struggles and struggles of ultimate meaning as the individual looks to reshape their lives in the absence of belief in God.
Spiritual Struggles Matter
Pargament and Exline argue that even if you are not personally spiritual as a therapist or a clinician, spiritual struggles matter because our patients often describe themselves as spiritual and significant research points to the implications of faith matters to mental health, substance use and physical well-being. According to Pew Research, the vast majority of Americans (90%) believe in God or some kind of higher power. In one national survey of over 1,000 adults, approximately 75% reported some type of spiritual struggle in their lives (Exline, Pargament, & Grubbs, 2014). In a study of over 17,000 adults in the United States, a sizable minority reported a recent experience of a type of spiritual struggle in just the past few weeks: divine struggles (32%), demonic struggles (31%), interpersonal struggles (35%), moral (49%), doubt (35%), and ultimate meaning (43%). Furthermore, spiritual struggles are ubiquitous, reported by men and women, all ages, all ethnicity, and all religious groups that have studied thus far (e.g., Roman Catholic, Protestant, unspecified Christians, Eastern Orthodox, Jewish, Buddhist, Hindu, Muslim, Spiritual not Religious; see (Pargament & Exline, 2021) p. 14. Even if the therapist doesn’t experience spirituality in the same way (a “religiosity gap”), for many people we work with, this is an important area of life that they want to talk about and have incorporated into their psychotherapy and spiritual care. For example, in a study (Pargament & Exline, 2021; Rosmarin, 2018) of 253 patients with psychiatric issues, 58% expressed a desire to integrate spirituality into their psychotherapy, and even 37% of patients with “no religious affiliation” also voiced interest in discussing spirituality in treatment.
Several forces historically have led practitioners to avoid topics of spirituality in psychotherapy. The antireligious bias of founding figures in the field, Freud and Ellis and others, for example, contributes to a lingering antagonism, although this has changed in recent years. Oftentimes, mental health professionals underestimate the importance of spiritual issues, perhaps due to lower levels of religiosity in clinicians (Shafranske & Cummings, 2013). Fears of overstepping professional boundaries and lack of training about spirituality in graduate professional education is also cited (Oxhandler et al., 2015). Contributing to this, some clients may be hesitant to talk about these struggles due to expectations of perceived antireligious bias or because conflicts elicit feelings of guilt, shame and fear of stigmatization (Currier et al., 2018). Some of these tendencies have changed, as spirituality becomes more popularized through mainstream ideas of mindfulness and connectedness or the value of pursuing existential themes as in Victor Frankl’s logotherapy or Irvin Yalom’s existential psychotherapy. Nevertheless, hesitancy may continue regarding issues related to specific religious communities or religious teachings.
Regardless of these challenges, Pargament and Exline remind therapists that to avoid the topic of spiritual struggles is to miss an important opportunity for change. Spiritual struggles are pivotal moments—critical crossroads with long lasting trajectories for an individual’s life. They can lead to decline, fragmentation and brokenness, as well as opportunities to foster wholeness and psychological growth. Therapists are trained to not avoid the uncomfortable, but rather pursue and attend to affect—the aspects of life that generate anxiety, discomfort, fear, exuberant joy as well as deep emotional pain. This instinct ought not be abandoned when the content of therapy veers into the territory of the religious.
A Conceptual Model Of Spiritual Struggles
Pargament and Exline provide a helpful framework for understanding the role of spiritual struggles within the broader framework of an individual’s life.
Spirituality is embedded within a search for significance. This search for significance is guided by an “orienting system”—a system of core beliefs, behavior practices, emotional regulation strategies and relational connectedness that are adopted over the course of one’s life. However, this search for significance is typically neither smooth nor straightforward. As life events occur, spiritual struggles thus grow out of the interplay of how life events interact with one’s search for significance and the orienting system. As these factors interact, spiritual struggles may alter or disrupt aspects of one’s orienting system, or affect their sense of significance by decreasing strength of purpose, rendering purpose as inauthentic, narrow or disintegrated. The outcome of spiritual struggles, whether towards growth or continued/deepening brokenness, depends on an individual’s access to variety and depth of resources and tools for living, ability to see and accept negative circumstances, ability to find a cohesive and authentic guiding vision.
On integration of spirituality and clinical practice
Pargament notes that while a coherent and cohesive life is the goal, clinicians often avoid the spiritual, while they attend to the social, psychological, emotional and biological. The spiritual dimension of life can serve both as a helpful resource as well as a source of problems. While there is enormous benefit to psychotherapy, it may be important to also recognize psychotherapy’s limitations, and help the patient to see and avail themselves of other resources, even spiritual or religious resources, would be more helpful.
Integration of spirituality and clinical practice also draws questions regarding the limitations of what constitutes appropriate boundaries between the professional therapist and religious counselor or spiritual advisor. Exline notes that their book takes a broad psychological stance regarding general psychological principles and phenomena revolving around spiritual struggles. At the same time, they take into mind a broader audience than psychotherapists, and may include a number of other forms of professional religious care, such as therapists within a particular spiritual tradition, clergy, and religious counselors who apply specific faith traditions as well as general psychological principles. These latter religious workers may integrate the toolkit of particular faith traditions (prayers, ritualistic practices, etc.) in addition to the toolkit of concepts of psychotherapy.
Pargament and Exline are quick to raise cautions about crossing the boundary lines of illegitimacy. Integration of spirituality and practice may raise problems when the clinician makes assumptions about a particular faith background, assumptions about a patient’s stated beliefs and the meanings of particular practices and teachings. In the quest for balanced spiritually-integrated psychotherapy, a therapist can err on either side of ignoring/avoiding the spiritual entirely, or crossing illegitimate boundaries. For example, a therapist with an anti-religious bias may recommend leaving a faith tradition outright, or assume that all aspects of a patient’s involvement in a faith community are toxic and psychologically destructive. On the other hand, a therapist may err by inadvertently proselytizing views that are not held by the patient or playing the role of a priest or clergy, drawing theological conclusions or applications not endorsed by the patient.
General Recommendations
Topics of religion and politics can be volatile and affectively-charged territory fraught with emotional power. Pargament and Exline make it clear that self-awareness on the part of the therapist is exceptionally important here. Therapists seeking to improve such skills may consider writing a spiritual biography, exploring issues of spiritual struggles in their own therapy, and assessing their own biases and preconceived notions about religion and spirituality. As with all emotionally charged subjects, spiritual struggles may manifest in emotionally heated moments in transference, that may also serve as grist for important therapeutic change. Both therapist and patient may feel unsafe when there is an explicit or perceived disagreement about a religious or political view. Therapeutic ruptures, unhelpful disclosures, misunderstandings, moments of assuming a shared understanding which turns out to be untrue, may all occur within the therapeutic space. As Exline notes, even if one holds a generally similar religious orientation to the patient, it is not always the case that one’s strategy or method of framing a problem theologically is helpful with any particular individual patient. For example, a broad range of strategies exist within religious traditions to deal with the problem of theodicy (i.e., reconciling the idea of a loving God with a world of suffering), and such strategies differ both across and within particular religious denominations.
Regardless of these difficulties, the alternative of avoiding or neglecting spiritual struggles does not serve therapy. As therapists, we are trained to attend to that content most laden with emotional power, deep joy, sadness, anxiety, and fear. Religion and politics are sources of heat, smoke and conflict that offer great opportunities for psychological growth.
Divine struggles and interpersonal struggles
Exline relates how struggles of anger with God often bleed into interpersonal struggles with religious communities. Feelings of anger, bitterness, and resentment aimed towards God and specific people can be unacceptable and stigmatizing in certain religious and cultural contexts. Some patients may believe “I can’t be angry” or feel that it is morally wrong to be angry with God. For many people, particularly those of Christian and Muslim faith, these emotions may be a sign of disrespect and result in reluctance to disclose such feelings. For Exline, it is therapeutically helpful to allow space for patients to process and express these emotions without judgment and without changing the subject based on the therapist’s own reluctance, ambivalence or strongly held opinions about spiritual beliefs. When space is held to express these angry feelings and still be engaged in a relationship, it can often help to resolve or repair internal conflicts in a patient’s relationship with religious communities, particular people, or relationship with God.
Conclusion
A holistic and integrative psychotherapeutic approach accounts for the spiritual—the life search for a sense of transcendence and sacredness—in addition to the social, psychological, and biological. When the door is opened to discuss questions of spiritual significance, this can deepen and enrich the lives of clients. Such an approach does not require years of additional training, nor a specific expertise on top of other therapeutic modalities. It does not require having a number of techniques and spiritual or theological answers. It requires only a willingness, courage, and curiosity to hold a space open to explore spiritual questions. For the uninitiated, Pargament suggests starting by asking the question: “How are your problems with religious or spiritual communities and ideas affecting your mental health?” Attempt the experiment and see where it goes in therapy.
Bibliography:
Currier, J. M., McDermott, R. C., Hawkins, D. E., Greer, C. L., & Carpenter, R. (2018). Seeking help for religious and spiritual struggles: Exploring the role of mental health literacy. In Professional Psychology: Research and Practice (Vol. 49, Issue 1, pp. 90–97). https://doi.org/10.1037/pro0000151
Exline, J. J., Pargament, K. I., & Grubbs, J. B. (2014). [Longitudinal study of religious/ spiritual
struggles among U.S. adults using Qualtrics panels.] Unpublished raw data.
Oxhandler, H. K., Parrish, D. E., Torres, L. R., & Achenbaum, W. A. (2015). The Integration of Clients’ Religion and Spirituality in Social Work Practice: A National Survey. In Social Work (Vol. 60, Issue 3, pp. 228–237). https://doi.org/10.1093/sw/swv018
Shafranske, E. P., & Cummings, J. P. (2013). Religious and spiritual beliefs, affiliations, and practices of psychologists. In APA handbook of psychology, religion, and spirituality (Vol 2): An applied psychology of religion and spirituality. (pp. 23–41). https://doi.org/10.1037/14046-002