Counseling and Psychotherapy With Religious Persons

A Rational Emotive Behavior Therapy Approach

Stevan L. Nielsen, W. Brad Johnson, Albert Ellis

• Publisher: Routledge
• Year: 2001
• ISBN:
  9781135680695
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Practitioners are increasingly aware that religious persons present unique problems and challenges in therapy. Rational-Emotive Behavior Therapy (REBT) is among the most widely practiced, highly structured and active directive approaches to treating emotional and behavioral problems. Introduced by Albert Ellis in the early 1950s, REBT is the original cognitive-behavioral psychotherapy and its efficacy has been supported by hundreds of treatment outcome studies. A uniquely belief-focused therapy, REBT is usually quite appealing to clients from Christian, Jewish, Muslim, Hindu, and other religious traditions, who respond favorably to REBT's focus on right belief, active engagement in the work of therapy, and reading/practice focused homework. In this practical and user-friendly guide, the authors outline the congruence between the therapeutic approach of REBT and the presenting problems and concerns of religious persons. They describe an approach to reconciling the sacred traditions and beliefs of religious clients with the no nonsense techniques of REBT. They review the essential components of practice with religious clients--including assessment, diagnosis and problem formulation, disputation of irrational beliefs, and other REBT techniques, highlight the primary obstacles facing the therapist when treating religious clients, and offer many case examples from work with this important client population. Mental health professionals from all backgrounds will benefit from the detailed yet manual-focused approach to helping religious clients overcome all forms of emotional distress.

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Practicing REBT With Religious Clients

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Rational Emotive Assessment With Religious Clients

REBT therapists conduct thorough assessments with religious clients for the purpose of determining whether to engage them in treatment, and if so, to determine what set of therapeutic strategies may be most efficacious. During the assessment, it behooves REBT practitioners to consider their ability to ethically offer services to religious clients. For example, the APA Ethics Code (1992) cautioned psychologists to function within their boundaries of competence, to respect human differences (including those based on religious faith), and to identify and respond appropriately to assessment situations with special populations, such as religious persons for whom traditional assessment measures and techniques may not be valid or useful. Similarly, the APA guidelines for providers of psychological services to diverse populations (APA, 1993) emphasized the significance of client religious commitment and spirituality in offering interpersonal and community support, influencing the form of expressions of distress and disturbance, and determining the client’s probable response to treatment. These guidelines and those from related mental health fields underscore the tremendous importance of honoring client religious beliefs and tailoring assessment and intervention practices to accommodate faith commitments.

Assessment with the religiously committed client presents the REBT therapist with a dilemma, particularly if the therapist has little training in treatment of religious clients and is largely unaware of the beliefs and practices common to the religion endorsed by the specific client (Rowan, 1996). Although professional guidelines highly endorse obtaining training and supervision in order to competently treat religious persons, the reality is that the range of religious communities, not to mention the idiosyncratic experiences and expressions of religion, make “expertise” with most religious populations highly unlikely. Furthermore, very little literature exists regarding the unique clinical issues common to specific religious groups.

This chapter recommends a careful and religion-sensitive approach to assessment with REBT clients. It begins with a brief summary of traditional or general REBT assessment and then addresses more focal assessment of both the personal and clinical salience of a client’s religious/spiritual status. It concludes by highlighting the pragmatics and perils of assessing a client’s religious beliefs.

ASSESSMENT IN THE GENERAL REBT TREATMENT SEQUENCE

Although REBT is widely recognized as one of the most efficient approaches to psychotherapy currently available, excellent REBT therapists are careful to conduct detailed assessments of all clients. As an example, here is DiGiuseppe’s (1991) description of the standard intake assessment process for all clients at the Albert Ellis Institute for REBT in New York City. Clients are asked to arrive early for their first appointment in order to complete the assessment materials:

They are asked to complete a four-page biographical information form, the Millon Clinical Multiaxial Inventory II (Millon, 1987), the short form of the Beck Depression Inventory (Beck & Beck, 1972; Beck, Rial, & Rickels, 1974), the General Psychological Well Being Scale (DuPuy, 1984), the General Health Questionnaire (Goldberg, 1972), the Satisfaction with Life Scale (Diener, Emmons, Larsen, & Griffen, 1985), and the Attitudes and Beliefs Scale 2 (DiGiuseppe, Exner, Leaf, & Robin, 1988) … The scales are computer-scored on the premises and are usually available to the therapist by the second session. The brief version of the Beck Depression Inventory, the General Psychological Well Being Scale, the General Health Questionnaire, and the Satisfaction with Life Scale are repeated every four weeks so that therapists and clients can review their progress. (pp. 152–153)

Although there is nothing particularly sacred about the assessment protocol used by the institute, it is wise to collect broad spectrum assessment data on all clients as a prelude to REBT. Such an assessment will typically include information on personality functioning, symptom distress, and relational patterns, as well as detailed biographical material. In addition, utilization of brief symptom-specific measures for depression, anxiety, or anger is recommended and their selection should be tailored to the client’s primary presenting complaint. In selecting measures for use in assessment, parsimony is recommended. Hayes, Nelson, and Jarrett (1987) wisely reminded clinicians to consider the treatment utility of tools selected for clinical assessment. Avoiding redundancy and collection of irrelevant data is critical for maintaining rapport and enhancing the efficiency and effectiveness of the assessment process. For this reason, projective measures and more than one measure of personality and/or global symptom functioning are rarely administered.

Beyond general assessment of psychological functioning, the REBT therapist is interested in rapidly gaining an understanding of the client’s essential beliefs (including those that are evaluative, demanding, and disturbance inducing). REBT therapists begin with the assumption that psychological disturbance is equivalent to the tendency of humans to make extreme, absolutistic evaluations of themselves or perceived events in their lives.

The next chapter outlines the suggested sequence for an REBT therapy session. Certain steps are particularly relevant to the process of assessment with religious clients: specifically, agreeing on a target problem for the session and assessing beliefs, especially irrational, evaluative beliefs (IBs). The remainder of this chapter considers ways the therapist may specifically augment the assessment process in order to address client religiousness. A strategy is presented for both preliminary and advanced assessment of religiousness in REBT clients (W.B.Johnson & Nielsen, 1998). As noted earlier, client religious commitment and belief may become evident and relevant at various stages in the treatment sequence. During the REBT assessment process, a two-step approach for assessing the salience of religiousness to treatment is recommended.

PRELIMINARY ASSESSMENT OF CLIENT RELIGIOUSNESS

The effective REBT therapist is likely to routinely consider the salience of religiousness in the lives of clients. In fact, this may be the most important question to ask in the process of assessing client religiousness: “Is my client’s religion salient and therefore possibly relevant to understanding and treating the presenting problem(s)?” Worthington (1988) emphasized that clients high in religious salience may be either pro- or antireligious. In contrast, a person low in religious salience is unlikely to even consider religion. Those high in religious salience are prone to evaluate their world on at least three important religious value dimensions, including the role of authority of human leaders, scripture or doctrine, and religious group norms. When a client for whom religious faith appears quite salient who is also pro-religious is living a life or engaging in behavior incongruent with religious beliefs, psychological distress and conflict may ensue (Shafranske & Malony, 1996). Further, beliefs that are highly idiosyncratic or at odds with the client’s religious tradition may suggest potentially disturbed or disorganized thinking. Of course, it is important to avoid making assumptions about the client on the basis of religious affiliation alone. Compared to members of their faith or religious community, how committed are they?

After determining that the REBT clients’ religious faith is a significant component of their self and/or community experience (what is referred to as personally salient religion), the clinician must then determine the extent to which religious factors are connected to the essential presenting problem(s). The question here might simply be: “To what extent is the client’s religious involvement relevant to the current disturbance?” When religious beliefs and behaviors are clearly linked to the unique expression of pathology, this is described as clinically salient religion. A religious college student presenting in the midst of an existential “crisis of faith” following several courses that have challenged core religious assumptions, or the middle aged woman who remains in a physically destructive marriage secondary to a belief that God demands this of her, might both be considered clients for whom faith is clinically salient.

A final preliminary assessment question involves determination of the extent to which maximal treatment outcome is likely to hinge on overt work with client religious material. In other words, having determined that religion is salient and connected to this person’s presenting disturbance, the REBT therapist then considers the extent to which achievement of treatment goals requires more concerted assessment of religiousness and, possibly, intentionally religious interventions. Can standard REBT protocols be implemented or does maximal therapeutic gain hinge on a focal assessment of the nature of religious belief and expression? If the latter is indicated, is the therapist competent to conduct such an assessment? When the REBT therapist determines that religion is clinically salient for the client and that treatment will be enhanced by more careful exploration of client religiousness, we recommend some assessment of the following dimensions of religiousness.

ADVANCED ASSESSMENT OF CLIENT RELIGIOUSNESS

Religious Orientation

Allport and Ross (1967) distinguished between the extrinsic and intrinsic religiousness:

Extrinsic values are always instrumental and utilitarian. Persons with this orientation may find religion useful in a variety of ways—to provide security and solace, sociability and distraction, status and self-justification… Persons with this (intrinsic) orientation find their master motive in religion…having embraced a creed the individual endeavors to internalize it and follow it fully. (p. 434)

The Religious Orientation Scale (ROS; Allport & Ross, 1967) is a 20-item measure with intrinsic (9 items) and extrinsic (11 items) scales (Donahue, 1985). The ROS may assist the REBT therapist in determining those clients who tend to “use” their religion (extrinsic) versus those who tend to “live” their religion (intrinsic). In addition, high scores on both scales suggest an indiscriminately proreligious stance, and low scores on both scales suggest a nonreligious approach to life. At present, no instrument in the psychology of religion field has been better constructed or researched.

Spiritual Well-Being

Traditional measures of well-being or satisfaction with life have tended to focus exclusively on material and psychological well-being. For this reason, the spiritual well-being (SWB) scale was developed to incorporate the dimension of spiritual satisfaction or well-being (Bufford, Paloutzian, & Ellison, 1991). The SWB includes 20 items and two subscales. The first assesses religious well-being (tapping the vertical dimension of spirituality or the relationship between person and God). The second is titled existential well-being and evaluates the horizon...