Research has demonstrated the effectiveness of prayer as a medium for cognitive change toward optimism and increased health, at the emotional, social, and physical level (Ai, Peterson, Bolling, & Koenig, 2002; Barrett, 2001; Biggar, Forehand, Devine, Brody, Armistead, Morse, & Simon, 1999; Butler, Stout, & Gardner, 2002; Kennedy, 2002; Ladd & Spilka, 2002; Omartian & Hayford, 2003). Barrett (2001) posited that prayer has a determined effect on psychological states, specifically beliefs, opinions, desires, and emotions, and further found that individuals were more likely to make requests of God to act psychologically, rather than mechanistically in their lives.
Spirituality has progressively turned out to be a consideration for mental health professionals. Consequently, spiritual interventions and integrating prayer are nowadays more often applied in counseling. Nevertheless, no investigation has surveyed Christian patients’ anticipations regarding prayer in counseling (Walker, 2006). Research on client preferences related to prayer when seeking or engaged in Christian-based counselling will broaden the understanding of mental health professionals, and will enhance the effectiveness of treatment efforts by Christian therapists when treating primarily Christian clients. Increased knowledge regarding the integration of prayer as an intervention in Christian counselling will also contribute to the ongoing rapprochement between psychology and religion which many mental health professionals view as desirable (Genia, 2000; Richards & Bergin, 2002; Ripley, Worthington, & Berry, 2001). Because clients are more likely to expect prayer from counsellor who identify themselves as Christians, the current study was undertaken to survey clients in regards to their preferences related to the use of prayer when seeking Christian-based counselling.
This research study then will attempt to explore first-time Christian clients and their counselors or therapists to identify patient hopes and therapist judgments and practices.
Spirituality has been increasingly acknowledged as useful method in mental health tradition. Majority of the mental health practitioners value personal prayer and assert that spirituality is individually significant. Probably as a consequence, numerous mental health practitioners take into account spirituality to be central to people’s health and comfort, including their patients. In reality, prayer is the most often employed spiritual intervention by Christian or religious counselors. Even practitioners serving in secular contexts consistently integrate prayer into their therapy in some manner. For example, such providers judge that praying for a client is suitable, even though most assume that praying with a patient is improper (ibid).
Lots of patients also want spirituality involved within the setting of counseling, probably since around 80% of the population of US believes in God and the influence and power of prayer. Christian patients, specifically, anticipate prayer to be integrated in Christian counseling. Because sympathy to patients’ hopes facilitates the building of therapeutic alliance, which in turn adds to positive results, processes for including prayer in counseling with a number of patients to be examined. Significant to this examination is identifying patient expectations about counseling with prayers. However, there is paucity of research about such expectations (Weld & Eriksen, 2007). This research will attempt to somehow resolve that inadequacy through investigating mainly Christian patients regarding their preferences with respect to prayer in counseling. It additionally surveys their therapists concerning their judgments and opinions about their beliefs and prayer methods so as to identify whether therapists aspects are associated to patient expectations.
Statement of the Problem
Traditionally, spirituality and psychology have been equally independent academic fields, each field depending on conflicting theoretical assumptions. As aforementioned, this condition is shifting, and religious issues have more currently been judged valuable subjects of research within the context of mental health. Religious or Spiritual Problem was attached to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (Weld & Eriksen, 2007, 328), and researches have related people’s spirituality with their mental wellbeing and patients’ spirituality with successful psychotherapy.
Nevertheless, a secondary analysis of available literatures from the past 20 years implies that the practice of spirituality in the counselors’ workplace has been to some extent become controversial. While a number of mental health professionals incorporate spiritual practice into counseling tradition, some professionals refuse to give importance to the value of spirituality; others esteem its essentiality, but do not deem that spiritual concerns should be integrated in psychotherapy; others who consider that spirituality should be provided a haven in the counselor’s headquarters lack the training required to accomplish this successfully (ibid).
Moral, ethical, multicultural and developmental frameworks challenge professionals to correct the controversies. Ethical directives now require tolerance for patients spiritual convictions and principles that have outlined damaging interventions and detrimental faith should facilitate with reinforcement. Moreover, standards associated to knowledge, capabilities, and consciousness that are taken into advantage when dealing with those from diverse racial and ethnic cultures may also be employed to patients with specific spiritual or religious faiths. Further, some courses of action have been designed to assist counselors match interventions with patients spiritual progressive stages (Torre, 2004).
Expertise disciplines have also developed that provide guidance to professionals. For example, within the Christian counseling profession, researches have settled on what spiritual strategies are employed by counselors assessing the patients spiritual background, advising to read particular religious texts, and praying with a patient are among those applied with the highest rate of recurrence (ibid).Therefore, the following hypotheses have been formulated,
Patients are more likely to prefer perceptible prayer in counseling rather than the typical form of counseling.
Patients are more likely to expect that therapists will open up the subject matter of the prayer.
Patients are more likely to have strong hopes that prayer would be integrated in counseling.
Patients will prefer their therapists or counselors praying for them even after or outside the session.
Religious traditionalists have greater expectations of prayer than the freethinking or liberals.
Patients with previous Christian counseling have greater anticipations of prayer than those patients without experience in such counseling.
A large amount of literature is available on the issue of spirituality and counseling. A great deal of literature as well exists on the issue of prayer. The theme of prayer as psychologically valuable or as an intervention in the field of psychotherapy has acquired even a smaller amount of attention (Walker, 2006). Nevertheless, a historical analysis of the literature that is available is also relevant to this research.
A body of literature deals with the prayers association to psychology or psychotherapy. For instance, one research determined that spiritual convictions contributed a positive role in obtaining mental wellbeing and another determined that contemplative prayer was fairly linked to quality of life. Some scholars determined that the integration of prayer among Christian married couples increased a sense of being emotionally confirmed by the spouse and improved partner understanding. Others discovered that survivors of sexual harassment and abuse who obtained Christian counseling that incorporated the power of prayer and scriptures recognized the general conclusion of counseling disapprovingly (ibid).
Rationale of the study
In recent years the lines separating spirituality and psychology have become blurred (Clinton & Ohlschlager, 2002; Koenig & Cohen, 2002; Koenig & Larson, 2001). Drawing upon the extensive literature that recognizes a strong link between religion/spirituality and mental health, practitioners in the field are more open to the exploration of bridges that can span the two disciplines (Chamberlain & Hall, 2000; Koenig, 1998; Larson, Swyers, & McCullough, 1998; Plante & Sherman, 2001). This is not a dabbling in witchery or the dangling of crystal beads in the face of clients, rather a scholarly approach to the integration of psychology and theology toward finding models of effective intervention for clients in personal distress.
With a membership well into the tens of thousands, the American Association of Christian Counselors (AACC) is evidence of the increasing number of qualified clinicians making an effort toward such integration. Their mission statement reads, AACC is committed to assisting Christian counselors and the entire ‘community of care,’ licensed professionals, pastors, and caring church members with little or no formal training. It is our intention to equip clinical, pastoral, and lay caregivers with Biblical truth and psychosocial insights that ministers to hurting persons and helps them move to personal wholeness, interpersonal competence, mental stability, and spiritual maturity. (AACC, 2004)
By blending a religious activity like Christian prayer, demonstrated in the literature to have a positive impact on cognitive outlook consistent with optimism, this study attempts to explore more specifically whether engagement in certain kinds of Christian prayer (Omartian, 2004a, 2004b) can have a significant effect on clients (Ai, Peterson, et al., 2002; Hawkins, et al., 2002).
Praying regularly brings peace to many people and helps them find better ways to cope with the painful parts of their lives (Koenig, 2003). Most hospitals, even non-religiously oriented ones, have a chaplain or even a pastoral department within its personnel to provide care and spiritual support to patients and their families during a time of crisis and suffering. Crises and the distress that usually accompanies such a time of loss, trauma, or tragedy, often bring people to their knees in search of God to help in ways beyond their own capacity. It has been said, “There are no atheists in foxholes!”, a reflection of this truism that the threat of a crisis compels us to search for answers and/or comfort from one who is greater than ourselves.
One of the strong religious dimensions is prayer. Bulbulia (2004) noted that religious teachings such as prayer, faith, spiritual fellowship, and other religious principles are cognitive templates. Ellison (1994) discussed the power of prayer to enhance African Americans’ ability to cope with stressful life events and crisis. Furthermore, Ellison noted that African Americans’ participation in regular prayer contributes significantly to their psychological wellness to decrease the risk of selfharming behaviors, such as substance abuse. Because it is viewed as a direct communication with God, prayer has been credited with bringing on feelings of peace and serenity and a feeling of communion with “One” who is near and willing to help (this is a form of self-affirmation). Although prayer is a behavior, it provides an overall mindset (cognitive template) that can provide individuals a sense of sustenance, strength, and motivation (Ellison). Another religious dimension is fellowship. Fellowship refers to the sense of community, friendship, relationships, and shared interests and concerns found within groups (Adler et al., 2001). Noble (1991) concluded that religious dimension of fellowship with other church members provides African Americans with a sense of empowerment and social change, fostering members to feel a sense of belonging to the congregation. Fellowship provides members a communal sense within the church that is based on the African view of spirituality, in which religious practice permeates every aspect of life. Fellowship allows members to feel a part of and relate to others who have common spiritual and religious views. Fellowship provides support and motivation for members (Noble). Fellowship is a religious practice influenced by religious cognitions; it is not only a behavior, but also a cognitive template of religion (Bulbulia, 2004).
In summary, religion and spirituality are cognitive-based structures. Religiosity is heavily structured so that supernatural conceptual information is acquired, stored, and accessed in ways linked to specific cognitive and behavioral processes (Bulbulia, 2004). Literature supports that religiosity is strongly influenced by cognitive-based structures and can be viewed as a cognitive template (Boyer et al., 2003).
Chapter Two: Review of Related Literature
Introduction
Religion plays a significant role in the lives of Americans, 95% of who express a belief in God (Shafranske, 1996). Of relevance to this study is that 84% of adults believe God can be reached through prayer (Mahoney, Pargament, Jewell, Swank, Scott, Emery, & Rye, 1999). As prayer is the most important pillar of Christianity, it has been used widely by religious scholars, psychotherapists, and counsellors for the purpose, of spiritual healing.
In the domain of multicultural theory, psychologists have carried on to summon for psychological therapies and interventions that are culturally responsive and significant and that incorporate features of patient culture into the counseling method. Moreover, psychologists have progressively acknowledged that spirituality and religion are essential attributes of patient diversity that psychologists should be capable of identifying while treating spiritual patients with sensitivity (Torre, 2004).
Richards and Bergin (2000) have suggested that the involvement of spiritual culture within the context of counseling is theoretically identical to the dynamics of more common multicultural counseling perspectives and skills already promoted by other multicultural scholars. Richard and Bergin (2000) moreover proposed that multicultural experienced outlooks and skills with respect to religion and spirituality take in a number of dimensions.
Among the dimensions of multicultural outlooks and skills most relevant to many of the studies is an awareness of one’s unique cultural tradition, esteem and comfort with other cultures and ideals that varies from one’s own, and an understanding of one’s facilitating approach and how this approach could influence from other cultural contexts. Thus, awareness of religion and spirituality is an essential factor of therapists’ multicultural proficiency (Torre, 2004).
Theological Perspectives on Intercessory Prayer
Though prayer, with its many forms and meanings, it is difficult to understand the exact meaning of prayer as it may be defined as communication between two persons, man and God. The particular form of prayer to be considered in this study is petitionery, or intercessory prayer. Intercessory prayer is a request made of God on behalf of someone else (Schonweiss, 1967; Acts 8:24). It is an asking of God that arises from a concern for others (Lewis, 1975). Jesus valued prayer and practised intercession for others (John 17:9). The apostle Paul expected great results from his intercessory prayers (Phil. 1:19). The certainty of the effect of prayer in the Bible is based on the premise of a loving God who hears requests and responds out of His compassion to meet the needs of those who ask (Brown, 1976).
Yet for the modern thinker intercessory prayer is not easily explained. It is difficult to understand the efficacy of prayer because Scripture does not give a theoretical explanation of why and how it works (McClintock & Strong, 1879). This difficulty lies in the fact that the sovereignty of God seems to render prayer useless. God’s nature of loving man and freely giving him all that is good for him appears to make it unnecessary. Some would settle this difficulty by suggesting that the object of prayer is to produce a consciousness of God’s mercy and protection which fosters an attitude of love in the person praying (McClintock & Strong, 1879). On the other hand,
…the Christian refuses to believe that he can do good only to himself by his prayers. Indeed when this limited view of the efficacy of prayer is accepted, it soon ceases to have any significance at all, and man ceases to pray…When he prays, the Christian is not expecting God to alter His plans for the future; he is bringing to God the factor of his interest and obedience, in the conviction that these will contribute to the way events will develop in the future (Strawson, 1962, p. 108).
Ironside, (n.d.) has said it this way: “It is not that by praying we move God to do but rather that prayer puts us in touch with what God is doing and wants to do.” Being in touch with God is possible because both man and God are spiritual beings. This potential for spiritual communion is what makes healing possible (Pitts, 1961). Merely being in touch with God, however, is not a sufficient explanation of intercessory prayer.
Aside from the subjective effect of prayer, its efficacy, as an actual means of obtaining a blessing from God, is very evident (McClintock & Strong, 1879). The following quote may lend support to the potential of intercessory prayer in the healing process.
As we are bidden to pray for general spiritual blessings–in which instance it might seem as if prayer were simply a means of preparing the heart, and so make it capable of receiving them–so also are we encouraged to ask special blessings, both spiritual and temporal, in hope that thus (and thus only) we may obtain them, and to use intercession for others, equally special and confident, in trust that an effect, which in this case cannot possibly be subjective to ourselves, will be granted to our prayers (McClintock & Strong, 1879, p. 477).
This view is reinforced by numerous examples throughout Scripture (e.g., the results of Jesus’ prayers: John ll: 40-43; Matt. 14:19-21) and direct promises (e.g., Matt. 7: 7-8).
Thiessen (1949) explains the process of prayer and how it fits with the overall working of God.
The facts seem to be this, that God does some things only in answer to prayer; He does some other things without anyone’s praying, and He does some things contrary to the prayers made. If we do not pray for the things that we might get by prayer, we do not get them. If He wants some things done for which no one prays, He will do them without anyone’s praying. If we pray for things contrary to His will, He refuses to grant them. Thus there is a perfect harmony between the foreknowledge, decrees, and providence of God (pp. 187-188).
C.S. Lewis (1959) describes prayer as an action by man that has divine effect. He sees God as having given man the power to act as an agent in the affairs of life. God chooses to allow man an influence in the course of events and it is not inconsistent with His way of influencing life that man and God should have a shared role. God‘s purpose “will be realized in different ways according to the actions, including the prayers, of his creatures” (C.S. Lewis, 1959, p. 8).
De Wolf (1957) cautions us against the two extreme views of the usefulness of prayer.
The first of these views is held by no serious students of the subject but by many superficial and occasional practitioners. This is the belief that prayer is simply and solely the persuading of God to do things which we want done, such as sending rain, curing sick friends or miraculously replacing our sins with virtues.
The second is the doctrine that prayer never changes anything outside the person who is praying, excepting as the experience of prayer induces him to do things he would not otherwise have done or subjectively realigns the forces in his own personality so as to enable him to do what he otherwise could not have done (pp. 144-145).
De Wolf concludes that prayer has both an effect on God‘s action and at the same time, an influence on the person praying. “A careless saying of prayer words which involved no soul-searching act of faith would not offer to God a significantly changed human situation and could not be intelligently thought to affect his acts toward men” (p. 160). Prayer words that are carelessly spoken are not genuine prayers. Effective prayers involve soul-searching faith.
De Wolf balances the extreme theological views of the efficacy of intercessory prayer by concluding that serious prayer has both an influence on God’s action towards the person(s) prayed for and an effect on the person praying.
If the person being prayed for is aware of the intercessory prayer, this could also have a subjective effect on that person. However, if the person is not aware that he or she is being prayed for, the effects could not be attributed to subjective influences. I
The Use of Prayer in Healing and Counseling
Intercessory prayer can be used in a variety of ways in the process of the healing of the emotions. Three groups that have differing prayer emphases are: faith healers who concern themselves with the healing of the emotions pastoral counselors, and professional Christian counselors. The theoretical position of each group will be examined.
Faith Healers of the Emotions
Midura (1981) examined psychological and religious approaches to healing and found them similar in many respects. She investigated such methods as “healing of the memories”, “emotional healing”, and “inner healing”. These approaches are being used widely throughout various religious systems and utilize prayer as a primary part of the healing process. Religious authors address the painful memories or conflicts just as do psychological theorists. The purpose of their intervention is to alleviate the distress. The means by which the resolution comes about varies according to each author (Midura, 1981).
For Agnes Sanford (Sanford, 1947, 1966, 1972), emotional healing comes through the use of specific prayer by the healer. Sincere belief in the effectiveness of prayer on the part of the faith-healer is another important factor, not requiring any particular faith on the part of the client. The specific prayer, prayed in sincere faith, releases God’s power, bringing restoration to the client. Sanford is very clear about the method of healing of memories. It is by use of the prayer of faith that the power of God effects healing. The prayer of faith is a petition of God made with the full assurance that what is asked will be done.
While Sanford’s work (1966) often involved physical healings, the deep healing was considered to be the healing of the memories. This “deep therapy of the Holy Spirit” takes place below the conscious awareness of the soul (psyche) of the person being healed (Sanford, 1966, p. 120). Stapleton (1976, 1977) calls her own work “inner healing”. She also makes use of prayer in her work that is designed to “restore health to the deepest area of our lives by dealing with the root cause of our hurts and pain” (1976, p. 9). For Stapleton, the healing process goes beyond intercessory prayer and evokes the imaginative resources of the recipient. While the unconscious and “deep mind” are terms that are not clearly explained by her, she suggests that negative material must be eliminated from these areas. The painful hurts are apparently distressing memories from the individual‘s past (Stapleton, 1976).
The process of inner healing focuses on recon-structing the memories of past hurtful situations and feelings. This is accomplished primarily through faith-imagination, a capacity available to anyone, to reconstruct the past through creative imagination. One creates or remembers an image. It is concentrated upon until that picture registers on a feeling level. A clear focus of images is significant in reconstructing one’s emotional past (Stapleton, 1977).
Into this faith-imagination Stapleton brings the image of Jesus. With the presence of Christ, healing power is released to change the image and, consequently the damaged emotions (Stapleton, 1977). `
Stapleton maintains that pain and hurt do not continue as the past is emotionally reconstructed. The foundation of the client’s past is healed allowing maturity and growth to emerge (Midura, 1981, p. ll9).
The focus of the work of Sanford and Stapleton is on the prayer of healing. However, one cannot read their works without sensing the caring, listening and attentiveness of these authors. As was previously noted, the concern of the Christian in healing is the wholeness of the person. Healing of the whole person is not only through prayer, but also in listening and relating with others in the body of Christ (Lawrence, 1980). Even so, the main emphasis is on the supernatural activity of God. ‘
Those who practice faith healing of emotions do not necessarily support the use of prayer in the therapy sessions. Edith Drury points out that psychotherapy is a professional contract that is carried out for a fee. She does not believe that a charge should be made for prayer. She further asserts that prayer used openly in the process of therapy will affect the nature of the professional relationship. According to her, prayer for inner healing is not carried out in a professional relationship. She makes a distinction between therapy and the healing of memories. ·
Pastoral Counselors
One of the early uses of prayer in the treatment of nervous disorders was the work of Joseph Pratt, Elwood Worcester and Samuel McComb (Andrick, 1978; Pinney, 1978). In what came to be known as the Emmanuel Movement they had initially conducted a sort of prayer-meeting group treatment for tuberculosis patients. Worcester and Pratt later conducted groups for patients with “functional” nervous disorders, using the methods they had experimented with at the Emmanuel Church. They held “classes” for small groups of people from the local congregation. Treatment consisted of sharing, prayer, and also hypnotism. Pinney (1978) points to this treatment as the beginnings of what is now called group therapy. Contemporary pastoral counselors who suggest the use of prayer in therapy vary widely in their recommended application. Adams (1977) lists the lack of prayer as one of the possible mistakes in counseling that leads to failure. Prayer is included as one of the tools of the counselor, to be used at appropriate junctures (Adams, 1970, p. 7l). Seward Hiltner (1949) has listed 5 general principles for the relevance of prayer in pastoral work and counseling. These guidelines are not for determining the appropriateness of prayer, but for making the prayer relevant when it is used. The first of these principles is that prayer should be addressed to God–not the client. Also, prayer should recognize, before God and the parishioner, the essential spiritual need of the parishioner. Prayer should emphasize the availability of God’s Spirit as a resource of peace, strength, quietness and fellowship. Prayer should be an avenue of expression for the Christian attitude toward suffering. Finally, the form and content of the prayer should be consistent with the parishioner’s experience of Christian life. When people ask for prayer, or obviously expect it, prayer should be offered. In other cases, the pastoral counselor must consider the whole situation and determine the appropriateness of prayer.
Oates (1959) views the whole practice of pastoral counseling as a total experience of prayer, and writes of them both almost interchangeably.
Prayer is the native hue and resolution of the man of God who dedicates hours of time to one person, who listens to that person with fullness of attention and abandon, and who searches with that person for an overall meaning and purpose of his life under God. This spiritual pilgrimage, which is commonly known by the somewhat pedestrian term “pastoral counseling”, is the “soul’s sincere desire, unuttered or expressed” for both counselor and counselee (Oates, 1959, p. 2ll).
Prayer is not an artificial experience to be applied indiscriminately at the client’s request. Prayer for some may be a placebo that can be used to avoid life. For these clients, the counselor may insist that the client pray for himself. Prayer in these instances may be a form of manipulation that does not take seriously the personhood of the counselor or of God. Prayer may be the quest for new meaning. It may express a new and deeper level of personal honesty. Prayer may also be the capping point of resolution that has come out of the struggle for understanding, and therefore, timing is very important. Prayer may be a very supportive way to summarize the experience of a counselee and lend additional encouragement at the end of a session.
Prayer must be understood in the context of relationship. Oates cautions us on its use.
Prayer is a relationship. It is not a tool or a resource or any such means to some other end, however worthy that end may be…Unless the pastoral counselor and his counselee are genuinely convinced of the truth of the relationship of prayer, they may find themselves in the position of attempting to cure one false way of life with another fictitious one. Therefore, it is extremely important that prayer life be considered by the pastoral counselor as being intrinsically real and worthy in its own right apart from any lesser goals it may achieve (Oates, 1959, pp. 217-218).
Prayer, then, becomes part of the relationship and must be compatible with the goals of counseling. In his book Pastoral Care and Counseling Hulme (l98l) describes prayer as a useful resource that has a preventative effect and a follow-up usefulness along with an important part of the ministry of pastoral care and counseling. “While such prayer is not a substitute for counseling, it is an undergirding support for the counseling and for the counselee” (Hulme, 1981, p. 133). “In using prayer as a resource in pastoral care and counseling, we pray for another and at the same time assist the other to pray” (Hulme,1981, p. 134). Just as there are many expressions of intimacy, prayer varies according to the depth of contact with God.
In Hulme’s view, prayer, for a pastoral counselor, is consistent with the symbolic role he or she plays in the church. “This role identification with prayer has been abused by both pastors and those to whom they minister” (Hulme, 1981, p. 137). Although it is often expected that the pastoral counselor will make use of prayer with his or her clients, prayer is just as available to the lay therapist. Prayer requests can be used both constructively and defensively by clients. Some clients expect the pastor to pray with them in every circumstance and feel that their counselors have not done their job unless prayer is part of the counseling. For some, using prayer as a custom in counseling may have the effect of keeping them removed from meaningful human interaction. Prayer, when used defensively, can be a way to avoid real contact. In order to guard against this, some pastors go to the other extreme. Prayer, for these pastors, feels somewhat removed from the common life and they experience it as artificial and uneffective. These pastors are neglecting a powerful resource that is especially suited to their profession. “We need to be emancipated from compulsions either to pray or not to pray so that we can be alert to the Spirit’s guidance in the existential moment” (Hulme, 1981, p. 138). Prayer should not be a matter of course, divorced from the meaning of the client’s experience. Rather than an expected addition to the counseling, prayer should be the natural outgrowth of the counseling dialogue. “As a pastor perceives a person’s needs as these are revealed in the session, he or she is in a position to articulate these needs in intercession to God…Since the activity of prayer grows out of the pastoral dialogue, the dialogue and the prayer are of one piece” (Hulme,1981, p. 145-146).
Prayer during a counseling session has an impact on the dialogue that follows, and this effect may be positive or negative. Prayer may fit well into the process of counseling and act like a good interpretation or an empathic statement–loosening stuck material or bringing some closure to an experience. The negative effect of prayer may be due to poor timing and an insensitivity to the needs of the client. A negative response to prayer may not be destructive, but simply be the stimulus for generating more dialogue, the tenor of which is negative.
For Hulme, prayer in counseling is related to the image one holds of God. If God is understood to be involved in human affairs, then prayer will recognize His presence and the potential of His understanding. If God is viewed as all powerful, then along with His understanding is the limitlessness of His grace. Prayer is not a way to bring God into the counseling process, but rather a recognition that He is there.
When we pray, we are not implying that the resources for our healing are external to us. Although God is the Wholly Other, he is also the one who dwells within us (Hulme, 1981, p. 141).
For Hulme, prayer is used in the counseling relationship when the dynamics of the relationship call for it. Its use is indicated by the combination of a variety of factors, some of which are the client’s attitude toward prayer, the counselor’s attitude toward prayer, the client*s view of God, the purpose of prayer in a particular session, and the dialogue of the session.
Professional Christian Counselors
The Christian counselors reviewed by this author (Collins, 1980, 1977; Crabb, 1975; Hyder, 1971; C. Narramore, 1960; Welter, 1978) do not discuss prayer as an element of therapy in its own right. That is not to say they do not believe in the power of prayer or do not use it in the process of counseling they defend. Collins (1980), for example, in his book Christian Counseling, makes many references to using prayer. Although he does not deal with prayer as a topic for counseling by itself, he frequently includes it as a part of the treatment for many difficulties. It is viewed as one of the additional tools available to psychologists, when psychology is based on the premise of the Christian God (Collins, 1977). Collins points to Jesus as a model of a healer who took time for prayer while preparing for his ministry. Prayer is an appropriate aspect of treatment when dealing with anxiety, marital difficulties, life traumas, and broken relationships.
In his book on psychological research and Christian belief, Myers (1978) does devote a chapter to prayer. He raises the question of “whether superstitious thinking might
penetrate religion, giving people an inflated perception of the manipulative power of their prayers” (p. 269). Myers goes on to say, however, that becoming aware of the possible effects of superstition on intercessory prayer can achieve a healthy purpose. The shattering of illusions can make way for a deeper understanding of the nature of God in the universe. Prayer does not deny God’s sovereignty, but allows God an avenue for action without manipulation. This view of the effect of prayer is like that of the theologians described earlier; prayer has an effect on the one who prays, but it is also somehow causally tied to God’s action.
Farnsworth (1975), in writing about despair, mentions the use of prayer as an adjunct to therapy. He suggests that it is especially appropriate at those points that the client despairs of his/her own resources in life. Prayer at these points gives meaning that cannot be found solely through introspection.
Psychological Literature and Research
Theology understands prayer to have both an objective effect in the affairs of mankind and a subjective effect on the one who prays. The objective effect in the world by the intervention of God has been primarily the concern of religion. Psychology, when it has investigated religion, has usually been concerned with the subjective effect of religious behavior on the individual.
A complete understanding of prayer is beyond scientific account. Religious experience is not limited to discoverable psychological elements. Therefore, the psychological understanding of the elements that are active in prayer is not exhaustive (Stolz, 1923). Nevertheless, there is value in scientifically examining those aspects of prayer that are primarily psychological in nature.
As to the development of a more thorough scientific understanding of how prayer can be used, Laubach (1946) says this:
A large number of the men who have been trained in scientific method and who are experimenting with intercessory prayer, must exchange their findings. Only so can we sift the true from the false, and at last describe the laws of prayer for others with greater accuracy. That this field is too sacred to be subjected to experimentation is untrue. The opposite is the truth. Is prayer as vital as the Bible and the church say it is? If so, then everybody needs to be made sure beyond the shadow of doubt. Prayer is too sacred not to be given to the entire human race (p. 71).
Suggestion has been observed to be a part of the prayers and rituals of Western religions (Gottschall, 1974) and Stolz (1923) sees prayer and suggestion as having common elements. Although genuine religious healing is not merely suggestion, it is not possible to have healing without some degree of suggestion. According to a well known theologian (Tillich, 1957) healing, in the spiritual or genuine religious sense, is that which is mediated by faith. While faith may not be synonymous with suggestion, some expectation on the part of the subject of the healing may be helpful.
The power of suggestion alone is very evident in healing. Rehder (1955) demonstrates the power of suggestion with a case illustration. He reports three women who were hospitalized with physical illnesses requested prayer for their healing from a faith healer. After prayer, each of the women improved markedly. After an ensuing relapse the three patients again requested prayer by the same faith healer. Word was sent to the healer and the next day two of the women improved significantly. It was later discovered, however, that word had never reached the faith healer; hence, the prayer of faith was not offered prior to their second recovery, and in this instance suggestion seems to have been operative. Frank (1961) has made a very sound case for the influence of persuasion as an important and positive element in the process of healing.
Smith (1979) studied prayer and a religious retreat experience. Intrinsic religious orientation was not found to be increased through use of prayer but was positively influenced by the retreat experience. Metz (1980) also studied “prayer for healing” workshops and their effect on the anxiety levels of the participants. Again, prayer could not be singled out as a factor by itself because the focus of the study was broader than prayer alone.
Morgan (1981) found that parents influenced the practice of prayer in their children. He also found prayer to be positively associated with happiness and psychological well-being. These effects seem to be more significant for those subjects under 30 and over 50 years old, which Morgan attributes to the lack of institutional ties for these age groups.
Henning (1981) researched a number of factors in prayer as they related positively or negatively to the desired outcome. He used his subjects’ recall of prayer instances to assess the perceived importance of a number of variables. From his results he states “that faith or trust may be the most significant correlate of successful outcome in prayer.” Behaviors that indicate a healthy relationship with God, related to positive outcome, include thanking in advance and vowing.
It appeared that a weighted combination of acting on the outcome, thanksgiving in advance, prayer for a personal rather than a public object, sensing the will of God, vowing, and claiming a biblical promise would be the most successful foci in prayer for a desired outcome (Henning, 1981, p. 358).
According to Sajwaj and Hedges (1973) prayer may not necessarily have a positive effect. They found that saying a prayer before dinner had some negative effects on the behavior of a six year old mental retardate. Disruptive behaviors increased during the first five minutes of the meal on the days when grace was spoken. Appropriate behaviors were more frequent during those meals that were not preceded by a dinner prayer. It may be that the disruption during grace was caused by requiring a period of quiet with a person who has a short attention span. The child did become less disruptive as the meal progressed, which may suggest that the initial disruption may have been due to factors other than prayer, such as inappropriate expectations for persons with low frustration tolerance.
Lilliston and Brown (19dl) advise caution in the application of religious solutions in clinical practice. They studied undergraduates’ attitudes toward three religious solutions toward problem solving along with an informal remedy. Presenting problems were categorized either as life-threatening, physical problems or psychological/adjustment problems. The religious options were: church attendance, prayer, and involvement with a group that emphasized intense emotional religious experience. The informal approach involved reading about the difficulty and pursuing a non-religious solution. Although religious solutions were seen as more reasonable with a physical, life-threatening problem, the religious solutions were not as highly valued as the informal one, and there was no significant difference between the three religious ones. They conclude that college students are likely to view religious solutions as a “crutch” and not adaptive. They also point out that the use of religious solutions may have a different application where the subject population is interested in religious approaches to problem solving.
Collipp (1969) reports that an experiment was done to test the efficacy of intercessory prayer in the remediation of leukemia. In that study prayer was offered on a regular basis on behalf of a group of leukemic children and their improvement rate was compared with a control group of similar composition. Collipp states that while the data supports the concept of the efficacy of prayer, the “small number of patients in this study precludes definite conclusions about the efficacy of prayer” (p. 202). This study was fashioned after a similar experiment conducted in Great Britain. In the earlier experiment, Joyce and Welldon (1965) studied 48 patients who were “suffering from chronic stationary or progressively deteriorating psychological or rheumatic diseases.” They treated a group of these patients with prayer. As in the Collipp study, the treatment group was subjected to the prayers of prayer groups picked for the experiment. The conclusion of the Joyce and Welldon study was that they were unable to show a significant effect for the treatment group.
Parker and St. Johns (1957) investigated prayer in a study of group therapy. They used three groups to examine “Prayer Therapy.” One group participated in group therapy ’ which included regular prayer. The second group also had group therapy but without prayer. The third group had no group therapy, but was asked to pray for themselves as a form of treatment (called “Random Prayer” group). After a treatment period of nine months they reported a 72% improvement for the Prayer Therapy group. The authors interpret these results to mean that prayer, when properly understood, may be the “most important tool in the reconstruction of man’s personality.” They further suggested that Prayer Therapy provided something additional to psychology. Without it, the healing process was incomplete. The results of their study are interesting, but, as in the above studies, their findings are not conclusive. Their simplification of the statistics makes it difficult to know the significance of their results, and the criterion for improvement is not specifically stated.
Elkins (1977) compared prayer with relaxation training. As a means of tension reduction, one group systematically prayed while the other went through systematic relaxation training. After l0 days, the groups were compared on a number of measures of relaxation. While there seemed to be a certain measure of positive results using prayer, the relaxation training yielded better results. Elkins also found that frequency of prayer, along with the perceived importance and effectiveness of prayer, were predictors of tension reduction for the prayer group.
It should be noted that the author recognizes that this study does not address the objective efficacy of prayer (prayer group was not praying for relaxation), but rather the subjective experience of those who pray.
In a pilot survey of Christian counselors, Lange (l98l) found that most (90%) of those surveyed believed that prayer was an important agent in the therapeutic process. He polled the participants of a national convention of the Christian Association for Psychological Studies. The majority of the population also believed that audible prayers should be permitted in the therapy session and that therapists should pray specifically for their clients on a regular basis. Ninety-four percent disagreed with the statement, “The outcome of therapy will be unaffected by prayer on either the client’s or therapist’s part” and ninety-two percent were opposed to the idea that the effect of prayer was only due to expectation. Although counselors who have theological training seem to value prayer more than their non-theologically trained colleagues, they do not actually pray with any greater frequency.
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Although his research did not concern itself with counseling, Loehr (1959) has done probably the most extensive experimenting with the efficacy of prayer. His long term study of the effects of prayer on the growth of plants provides challenging data that supports the efficacy of prayer. Using carefully controlled conditions, he demonstrated that regular prayer could have a significant positive-effect on the growth of plants.
Religion, Theology, Spirituality and Psychotherapy
Politics and religion are considered topics prone to create controversy in almost any conversation. The typical response is avoidance of these charged matters, yet this question begs the discussion of an apparent relationship between psychology and religion in the literature. That such a relationship exists is evident from a review of the sociological history on how mental health problems have been treated over the centuries (Alexander & Selesnick, 1966; Koenig & Larson, 2001; Zilboorg, 1941). The current relevancy of this discussion is supported by a decade of statistical data indicating that 96% of people living in the United States believe in God, more than 90% pray regularly, 69% are members of a church, and 43% have attended a church, synagogue, or temple within the past 7 days (Gallup, 1995; Princeton Religion Research Center, 1996).
Alexender and Selesnick (1966) point out that one of the first hospital institutions established to care for the mentally ill was part of the religious order of the Church in Jerusalem in AD 490. A Franciscan monk named Bartholomaeus in the 13th century wrote a work depicting the etiology of mental illness from natural, rather than supernatural causes (Kroll, 1973). The Church in Spain further established asylums for the insane in the 15th century that provided better care than their State-based counterparts (Latourette, 1953). Of course, during the 15th century and for the next 200 years, religion entered the dark ages of its practice with mental illness, attributing so much of the symptomatology to demonization, resulting in the torture and execution of thousands of the innocent ill (Zilboorg, 1941). At the turn of the 19th century William Tuke, a Quaker in England, founded the York Retreat for the mentally ill, offering a medical-based approach to treatment and care, called “moral treatment” (Koenig et al., 2001; Taubes, 1998). This has been cited (Taubes, 1998) as the first organized form of psychiatric care in this country. The chaplaincy movement also accompanied the moral treatment of the Quakers in America. Samuel Woodward wrote in the 19th century, “By our whole moral treatment, as well as by our religious services, we try to inculcate all of that which is rational” (as cited in Koenig et al., 2001, p. 68). Interestingly, Woodward would found the Association of Medical Superintendents of American Institutions for the Insane, today known as the American Psychiatric Association. The American Journal of Psychiatry was preceded by the American Journal of Insanity, the official publication of Woodward’s organization (Koenig et al., 2001).
This is the history brought about by Freud’s early views of the religious neuroses associated with mental illness (as cited in Strachey, 1962). The force of that opinion shaped the thinking of the scientific community for decades to come, supported by the foundational work of Albert Ellis (1980, 1988), who “argued that the less religious people are, the more emotionally healthy they will be” (as cited in Koenig et al., 2001, p. 67). Carl Jung (1933), in his own rebuke of religion, wrote:
During the past thirty years, people from all the civilized countries of the earth have consulted me. I have treated many hundreds of patients, the larger number being Protestants, a small number Jews, and not more than five or six believing Catholics. Among all my patients in the second half of life – that is to say, over 35 – there has not been one whose problem in the last resort was not that of finding a religious outlook on life. It is safe to say that every one of them fell ill because he had lost that which the living religions of every age have given to their followers, and none of them has been really healed who did not regain his religious outlook. (p. 229)
The negativism of the early writers has had a dominating influence on philosophical thought in the field of psychology over the past century (Koenig, 1998; Koenig, McCullough, & Larson, 2001).
It is into this cauldron of skepticism that Fuller Theological Seminary founded the first doctoral program with an integrative emphasis, offering a Christocentric training curriculum in psychological training (Maloney, 1995). The Rosemead Graduate School of Professional Psychology, established as the first free-standing Christian doctoral program of its kind, soon thereafter, joined Fuller Seminary in a novel attempt to challenge the prevailing attitude in the academic community of psychology (Maloney, 1995; Pike, McMinn, & Campbell, 1997). However, the climate of the professional world was matched by the skeptical climate of the religious community who feared the secularism of psychology. Fuller and Rosemead found themselves in a high-pressure quandary, as depicted by the following comment: “The faculties of both of these programs were pressed by their secular colleagues with the view that one could not be intelligent (scientific, academically sound) and religious at the same time. They were also pressed by their Christian communities with the view that one could not be Christian and a psychologist (humanist, scientist) at the same time (Pike et al., 1977, p. 279).
Given that over 90% of the American population claims a belief in God, according to Hoge (as cited in Shafranske, 1996), an apparent bias in secular graduate programs in psychology toward overly religious applicants and a growing recognition among Christian churches for better care for the mentally ill and emotionally disturbed, the rationale is set for integrative training programs and a bridging of the gap between the sacred and the secular.
Background Studies on Integration of Religion and Healthcare
Studies conducted between 1950 and 1970 did not produce results conducive to a support of the integration of religion and healthcare (Sanua, 1969). More recent studies, however, have challenged the methodologies of the earlier research that relied on convenience samples of college students and psychiatric patients (Koenig et al., 2001). A number of the older works failed to control for covariates and used college student samples characterized by an immaturity regarding religion. Koenig et al. (2001) offer a different perspective on this period in the literature, “Inverse cross-sectional relationships between religion and mental health may mean that being religious increases mental distress, or it may mean that mental distress increases religiousness as persons seek comfort and solace from these beliefs” (p. 70).
Current reviews of the literature demonstrate a linkage between religion and physical health (Koenig & Cohen, 2002; Thoresen, 1999). Noteworthy is Rayburn’s (2001) use of the term “theobiology” to reflect an interconnection with theology and biology. One meta-analysis of the literature (McCullough, Hoyt, Larson, Koenig, & Thoresen, 2000) found a strong odds ratio of religious involvement and mortality (OR = 1.29), suggestive that the religious has 29% greater odds of survival during a follow-up period than the less religious. Cardiovascular health benefit has been identified in the literature as a significant health outcome in relation to religiosity (Lawler & Younger, 2002; Levin & Vanderpool, 1989).
Powell, Shahabi, and Thoresen (2003) have put forth a critique of the reviews on the linkage of religion to physical health, arguing previous reviews relied on too many studies in which bias and confounding are minimized. Powell et al. (2003) offer a review utilizing a levels of-evidence approach, evaluating 9 hypotheses using only “studies that meet minimally acceptable methodological standards” (p. 36). Although less optimistic about their findings, Powell et al. (2003) conclude that “a relationship between religion or spirituality and physical health does exist” (p. 50).
Integration Models Found in the Literature
A marriage between these two fields is founded on the premise of a revelation from God in the form of nature, referred by theologians as “general revelation”, and in the form of Scripture, referred to as “special revelation” (Brown, 1981; Henry, 1977; McDowell & Stewart, 1983). Although the focus of this paper is on Christian religion, theology, and spirituality, many of the concepts have a broader application to other religions. Islam, for instance, is built on the belief in one God, Allah, and the visions or revelations the prophet Muhammad received from Allah, which are recorded in the Qur’an (McDowell et al., 1983). The practice of integration of psychology with religion is nowhere more developed as systematically and empirically, in more recent years, as is found in the Christian traditions (Clinton & Ohlschlager, 2002; Ripley & Worthington, 1998; Maloney, 1995). This distinctive understanding of divine revelation that includes nature fosters the appreciation among Christian psychotherapists for truths supported in research efforts. Jones (as cited in Clinton et al., 2002) makes a strong case for research found within Scripture in support of current methodologies, citing an intriguing example of how a counselor might incorporate the two sources for illustration.
Research can affirm biblical truth by confirming a biblical principle through general revelation. For example, a client was distraught over his divorce. He had not wanted it, but his wife refused to consider reconciliation. As he struggled with the issues, he discovered a book detailing a longitudinal study on the effects of divorce on children (Wallerstein, 2000). The research confirmed the troubling social effects of divorce on children and identified specific difficulties including such issues as loss, change, conflict, and a sense of betrayal. The client’s counselor used the information to affirm biblical truths and help the client anticipate potential problems that his children might face in the future. (as cited in Clinton et al., 2002, pp. 651-652)
The wise clinician and researcher attempting to bridge faith and psychology will examine all relevant claims with equal measure and rigor, remaining open to new understandings of the world that will enlighten his perspective for the ultimate benefit of the client.
In understanding the rationale behind integrative efforts and Christian based counseling in general, it is normally framed in an attempt to relieve human suffering (Anderson, Zuehlke, & Zuehlke, 2000; McMinn, 1996; Clinton et al., 2002). Compassion is a quality highly esteemed and promoted in Christian communities and applauded among leaders in churches and parachurch organizations (Collins, 1998; Crabb, 1993, 2001; Moon, 1994; Nouwen, 1972). Given the universality of pain and suffering, human service professionals are recognized as instrumental in both the alleviation of the distress and alteration of the client’s perspective of the distressing factors of his life (Anderson et al., 2000; Crabb, 2001).
One additional point regarding this practice of integration bears mention, that being the somewhat artificial seams distinguishing the various sub-disciplines within integrated models. Because no one model of Christian therapy can be found in the literature, it is a challenge to determine how spiritual direction, pastoral counseling, and spiritually-oriented psychotherapy might work out in practice (Worthington, Karusu, McCullough, & Sandage, 1996). This finding, however, is not inconsistent with what is commonly found in the clinical practice of psychotherapy as the theoretical models are applied in clinical contexts (Sprenkle & Moon, 1996). With this introduction to integration theory it will now be worthwhile to explore three particular models for practice application evident in the literature.
Spiritual Direction
Fewer people, even regular attending church members, turn to the institutional church for guidance and counsel during times of personal difficulty and distress (Sperry, 2003; Stairs, 2000; Steere, 1997). This may be a reflection of a loss of confidence in institutional religion and a consumer-oriented culture that prefers to find help in more privatized settings, a need met by the rise of psychotherapy services (Lescher, 1997; Nichols & Schwartz, 2004). Spiritual direction is a form of help drawn from the rich traditions of orthodox Christianity, yet being practiced in more para-church settings by representatives from Catholic, Greek Orthodox, Episcopal, and even Protestant denominations (Sperry, 2003; Ruffing, 2000; Edwards, 2001).
Spiritual direction goes by many names, including spiritual guidance, spiritual companionship, and spiritual friendship. Thornton (1984) gives the practice the simple definition, “the application of theology to life of prayer” (p. 1). While therapy typically revolves around the function of symptom reduction and pain relief, spiritual direction focuses on the individual’s spiritual movement toward a more intimate relationship with God (Stairs, 2000). The relationship between the director and client, usually referred to as the directee, is a collaborative one that incorporates dialogue, narrative, Scripture, prayer, and silence (Ruffing, 2000). Leech (1977) calls the practice “the cure of souls…a seeking after the leading of the Holy Spirit in a given psychological and spiritual situation” (p. 34).
A study of 315 (n = 315) spiritual directors, psychologist members of the Christian Association for Psychological Studies (CAPS), and psychologist members of the American Psychological Association (APA) to ascertain and compare the participants’ mental health and spiritual values Christian psychologists “share many values with spiritual directors” (Howard, McMinn, Bissell, Faries, & VanMeter, 2000, p. 312). Using a randomized sample from the three representative groups, the participants were administered two questionnaires to measure mental health values and the central values and perspectives of the classic figure of spiritual direction from the middle ages, St. John of the Cross. The 315 responses yielded a return rate of 54%, including 134 spiritual directors, 72 from the APA sample, and 109 from the CAPS sample. Chronbach alpha coefficients for the 10 themes from the first questionnaire (Jensen & Bergin, 1988) scale ranged from .72 to .92, a good indicator of item consistency in the survey (Bernard, 2000). A series of one-way analyses of variance (ANOVA) was used in combination with a priori t test contrasts to examine the hypotheses. Howard et al. (2000) found that most psychologists share many of the viewpoints common among spiritual directors and further, that Christian psychologists hold values concerning spirituality similar to those derived from St. John of the Cross. Despite the methodological issue with using a survey developed for this study alone, the St. John of the Cross values survey, this is suggestive of a high level of similarity across the fields of spiritual direction and psychology.
Pastoral Counseling
The second discipline in which integration of psychology and theology or religion is identified is pastoral counseling. Clergy are in a position of leadership that frequently leads to perceptions among their parishioners that they are also a source of wisdom and guidance for dealing with life’s problems (Stone, 1999). Those who present to pastors, ministers, priests, and pastoral counselors raise concerns and issues similar to those of psychological provider clients (Stone, 1999; Wise, 1983).
The rise of the counseling movement in Christian circles led to the establishment of graduate degrees, usually Master of Arts or Master of Science level, in the field of counseling, pastoral counseling, or spiritual psychotherapy (Maloney, 1995) as a way to be better prepared to meet the growing demands in the church for the counseling service. An example of the increasing attention devoted to pastoral counseling at the graduate level, Denver Seminary now offers five graduate degrees in counseling, including a Master of Arts in Counseling that is preparatory for state licensure, a Master of Arts in Counseling Ministries, a Master of Arts in Counseling Ministries/Chaplaincy, a Master of Arts in Youth and Family Ministries/Counseling, and a Doctor of Ministry in Marriage and Family Therapy (Denver Seminary, 2004).
As noted, it is not easy to discern the differences in the professional or licensed professional who earned a degree from such a graduate program and the pastoral counselor who earned a parallel degree from the same or a similar institution, as both are focused on symptom relief and resolution of the presenting problem(s) (Sperry, 2003). Some say the distinctions are artificial and indistinguishable apart from the parameters associated with the setting itself, such as an intake process, session fees, insurance filing, and other professional versus church-oriented practices (J. Craig, personal communication, November 12, 2004).
Pastoral counselors do not generally engage in the psychotherapy of personality disorders and personality change (Sperry, 2003). In most cases where such issues are apparent to the pastoral counselor, a referral to a qualified psychological provider is the course taken, a practice consistent with the Code of Ethics of the American Association of Pastoral Counselors (AAPC, 1994). The AAPC organization has a membership over 3,000 across the nation (AAPC, 1994) with members from church-based, clinic-based, military-based, and school-based settings.
Spiritually Oriented Psychotherapy
Larry Crabb (1975, 1977, 1993, 1997, 2001) has been an outspoken leader in the field of Christian counseling and spiritually oriented psychotherapy over the past 30 years. His contribution to the discipline through his books and lectures has been of considerable influence to spiritual practitioners. Crabb (1977, 1997) emphasizes the theological truth that Christians are endowed with a new heart at conversion that awakens in them a new appetite for God that overwhelms all other passions in life. McMinn (1996) states that “three essential categories…must be considered simultaneously: psychology, theology, and spirituality” (pp. 269-270).
Treatment approaches cover a wide range of secular and spiritual theories (Benner, 2002; Karasu, 1999; Shafranske, 1996). Much like the psychological provider in the secular context, the spiritual psychotherapist selects a treatment modality and intervention based on the presenting problem and need. Spiritual practices range from prayer to involvement of support from pastors and chaplains (Sperry, 2003). It is not certain how many of the 500,000 practicing psychotherapists in the U.S. are operating from a spiritually-based model, but quite likely that the percentage is significant and growing, based on a membership in the American Association of Christian Counselors (AACC) over 100,000 (Clinton, 2004).
One of the apparent distinctive of spiritually oriented psychotherapists is the choice of brief therapy strategies over long-term models (Kollar, 1997; Oliver, Hasz, & Richburg, 1997). The Christian community tends to associate long-term treatment with the psychoanalytic models of psychology and coils at the underlying premises and assumptions (Oliver et al., 1997). This phobic attitude, coupled with the prevailing call for increased accountability in the field from managed care enterprises and the general population may add to the attraction of these models. A theme in the current literature on spiritual psychotherapy is the necessity of maintaining a close link with the church on the part of practitioners in the field (Clinton et al., 2002). This subservient posture in relationship to the role of the church is a key characteristic of many Christian therapists, particularly those in the Protestant Evangelical community.
Clinton and Ohlschlager (2002) identify 10 tasks of the “competent Christian counselor” (p. 69), including: intake/assessment, case formulation/treatment planning, individual counseling, marriage/family interventions, group counseling/discipling, spiritual direction, case evaluation/management, supervision/case consultation, networking/referral, and research translation/technology application (Clinton et al., 2002). The body of knowledge from this professional community is steadily growing and demonstrates an increasing effort to meet the earlier challenges in the field for reliable research in support of the spiritually-oriented theories and models (Clinton, 2004; Karasu, 1999; Koenig & Larson, 2001; Koenig, McCullough et al.,2001).
Implicit and Explicit Integration
It should be understood that not all spiritually-oriented psychotherapists adopt the same style or approach in their clinical work. The actual use of religion in clinical practice covers a continuum from implicit to explicit integration, the former being a more subdued approach in which the counselor embraces a worldview that is Christian-based, but not overtly discussed in the treatment context. Explicit integrationist, on the other hand, will adopt a very overt approach that might involve prayer, Scripture reading, and other spiritual practices for the benefit of problem resolution (Shafranske, 1996).
The current trend in the culture toward spirituality and religion poses challenging opportunities for mental health practitioners, regardless the worldview espoused (Stairs, 2000; Stone, 1999). The integration of psychology and theology requires a careful balance if one is to avoid the assumption of one discipline over the other (Bland, 2003). Tan offers some insightful comments, “Religion in clinical practice is therefore a crucial area for psychologists to develop competence in, both from a professional or clinical point of view, as well as from an ethical perspective (as cited in Shafranske, 1996). With this brief review of the three prominent models for spiritually-oriented treatments as a foundation, a limited discussion of relevant ethical issues and concerns follows.
Techniques of Integrating Spirituality in Counseling
One concern that has been challenging when arguing techniques of integrating spirituality in counseling has been in agreement on precisely what is being integrated. For instance, Pargament (1999) emphasized that psychologists of religion seldom agree on particular meanings of religion and spirituality. Nevertheless, on an expansive level, religion has classically been defined as that which is further organizational, practice and ideological, whereas spirituality has normally been described as that which is further individual, emotional and experiential.
Therapists have recommended a number of various methods of incorporating religious and spiritual means into counseling. As Tan (1996) claims, open integration implies to more overt approach that directly and systematically deals with spiritual or religious issues in therapy, and uses spiritual resources like prayer, Scripture or sacred texts, referrals to church or other religious groups or lay counselors, and other religious practices (368).
Tan (1996) emphasized that this practice to counseling puts importance to both therapist and patient spirituality and involves counseling with a number of form of spiritual direction. Another framework to integrating spirituality in counseling is the implied integration of religion or spirituality. Implied integration is an added concealed approach that does not launch the conversation of religious or spiritual concerns and does not frankly, straightforwardly, or methodically use spiritual resources such as prayer and Scripture or other holy texts, in therapy. An instance of unspoken integration is supporting fundamental therapeutic values on religious codes from an organized religion. Implied integration may be the selected style of integration for therapists who acknowledge a religious conviction or endeavor in spiritual customs but who are not prepared in the open combination of religion and spirituality (ibid).
Shafranske (1996) performed an analysis of training in open and implied integration. His analysis proposed that education and training within the area of psychology and religion appears to be very limited (160) and that mainstream of therapists on no account discuss religious or spiritual concerns in their clinical instruction. Richard and Bergin (1997) emphasized that such therapist provoke the risk of practicing distant to the limitations of professional efficiency or enforcing their personal beliefs and values on religious and spiritual patients. Shafranske (1996) proposed that most therapists framework to the combination of religion and spirituality in psychotherapy was not founded on graduate education in the discipline but focused mainly on the private religious and spiritual experience of the therapist.
Another type of integration is intrapersonal integration, which points to the means in which a therapist employs his or her individual religious or spiritual experience within the context of counseling (Tan, 1987). An instance of intrapersonal integration is wordlessly praying for a patient at some point in the counseling period.
Prayer in Psychotherapy
Prayer is a simple act of turning our mind and heart to the sacred (Ameling, 2000, 42). It is an act of will in which we focus our concentration and open up to our inner depths (Torre, 2004, 2). Perceiving prayer in this manner makes it more convenient to view it as a segment of the therapeutic relations, since suggesting prayer as a self-help mechanism does not automatically mean that people are recommending religion. Rather, applying prayer either inside or outside the therapeutic meeting offers a commanding therapeutic force that lots of people appreciate and feel comfortable with. That appreciation and consolation come initially from the therapist, because it is the comfort and conviction orientation of the therapist that powerfully influences the reality of the interaction (Dossey, 1993). Therapeutic consolation comes from an individual spiritual sentiment and self-consciousness that is detached from religion, in addition to training and education in manners to open up the notion of prayer into the practice. This opening up may assume several forms, depending upon the requirements of the patient, the emphasis of treatment, and the extent of spiritual closeness the therapist is convenient with (Magaletta & Brawer, 1998).
For instance, patients may pray aside from the therapeutic contact either as component of their spiritual custom or abiding by a recommendation from the therapist. This framework permits for the opening up of prayer without essentially integrating it in the actual session. Another alternative is for the therapist to pray aside from the patient either in common or with a particular prayer for a specific patient. In this instance, the therapist can apply prayer if he/she may not be aware of the patients special prayer orientation (ibid). Conclusively, both patient and therapist may pray together in the actual session either with words spoken in a whispered manner or in silence. This is the most intimate among all the methods and requires an apparent understanding of the principle, form and substance of the prayer. This final approach appears to be the least applied by mainstream therapists, since many sense it becomes more spiritually open and their level of awkwardness is greater (Shafranske, 1996). Whatever the preference taken, it is essential for therapists to appropriately recognize their own and their patients beliefs regarding prayer before doing something (Magaletta & Brawer, 1998).
One of the paramount means to approach the integration of prayer in psychotherapy is to create a meticulous spiritual evaluation of both patient and therapist. This may be accomplished formally through the application of particular evaluation tools, or informally as component of the general information acquired on intake. For therapist, this evaluation may entail a personal investigation of prayer beliefs and values, in addition to an understanding of the process he/she be going to pray and for whom (ibid). For the patient, this evaluation may entail putting emphasis on several significant aspects. Some psychologists suggest that any spiritual evaluation should consider the following (Wengert, 2002, 32):
Faith: How can spiritual beliefs help the client cope, and what beliefs give their life meaning?
Importance and influence: How much do faith and belief influence the clients life and important decisions?
Community: Is the client part of a spiritual community, and how is it supportive?
Address: How can this issue of belief be addressed in the therapeutic setting?
Such evaluation allows for the conversation of prayer as a probable method in the therapy session and provides the patient consent to integrate beliefs and values in the communications. The evaluation as well as allows for a successful plan of care that may incorporate prayer as segment of the treatment method. If the therapist and patient settled on the belief that prayer would be a valuable supplementary, a decision can be created as to the process of integration in the session, relying upon the patients requirements and the therapists comfort (ibid).
Ethical Issues and Concerns in Faith-Based Counseling and Research
Over a decade ago Younggren (1993) raised concern that introducing spirituality and religion in psychotherapy may challenge the accepted scientific foundation for psychological theory and treatment. His assumption is that religious therapists are more likely to commit an ethical violation of boundaries in therapy than secular therapists. Data is not available to support or challenge his opinion, but it does speak to the necessity of sound ethics for professional conduct (Tan, 1994).
The AACC (Clinton, 2004) has developed its own Code for ethical conduct of its members, along with the AAPC (1994), both of which, Beck (as cited in Sanders, 1997) found in his analysis, address issues of competence, confidentiality, exploitation, colleague relationships, and deception. Clinical issues specific to spirituality can become quite complicated, as in the case of prayer, the purpose of which might vary significantly (Carmody & Carmody, 1990). Magaletta and Brawer (1998) identify a tripartite model of prayer in psychotherapy, where prayer can be practiced by the client alone, the therapist alone, or as a shared activity in which they both participate. The complexity of the intervention is heightened by the various types of prayer found in religious literature, including colloquial, petitional, ritual, and meditative prayer (Poloma & Pendleton, 1991). The two general principles at issue in the matter of prayer have to do with a restriction of the client’s freedom and practicing beyond the scope of the provider’s competence.
Tan (2003) offers a review of the ethical guidelines for integrating spiritual direction into psychotherapy. While most of these are consistent with professional practice, some are worth noting. A primary guideline is the respect therapists must have for their clients’ right to hold religious beliefs that might differ from theirs (Richards & Bergin, 1997). Religion is diverse in its manifestations and it cannot be assumed that all Christians share similar values, convictions, and practices. This diversity requires the therapist to move sensitively into arenas of spirituality so as not to impose his own preferences on the client or hinder the therapeutic rapport.
Another important ethical principle concerns the therapist’s requirement to determine a client’s comfort level with a particular spiritual intervention prior to its use in the session. The principle of informed consent (APA, 2002) requires the professional to convey treatment intentions in a language and manner that the client can understand and choose to give or deny consent. More frequent interventions are reported by Christian psychologists to include prayer, theological referencing or teaching, and the use of Scripture. Less frequent spiritually-oriented strategies are spiritual relaxation, the healing of traumatic memories through guided imagery that usually involves a visualization of Jesus Christ, forgiveness, and spiritual homework (Clinton et al., 2002; Magaletta et al., 1998; Richards & Potts, 1995).
Ethical violations are a concern in a discussion of theological and religious integration into psychotherapy that must be taken seriously, however, as with most dilemmas of this nature, the final answers are less definable than the guiding principles that govern the practitioner in working with clients. Richards et al. (1995) proposes that those who do not address spiritual perspectives may be in violation of APA (2002) principles around respect for human diversity.
Evidence of bias and prejudice against those who do espouse a religious worldview also requires attention, particularly as spirituality and religion becomes more diverse and prevalent in society (Jones, 1994; Richards et al., 1995; Worthington, 1986, 1990). A mounting body of evidence supports the idea that the expectation of those in psychotherapy is that spiritual and religious issues will be addressed at some point (Sperry, 2003; Westfield, 2001).
Worthington, Kurusu, McCullough, and Sandage (1996) in their 10-year review on religion and psychotherapeutic processes and outcomes offer a strong encouragement for the professional community of psychotherapists:
Religious experience is not only part of multiculturalism but also consistent with the overall direction of postmodern culture. The acceptance of some role of religion in counseling has thus exploded into the mainstream of counseling and clinical psychology over the last decade. (Worthington et al., 1996, p. 448) Before concluding this work on integration, a look at some of the key research available in support of the model will now be explored.
Empirical Research in Support of Integration
Despite considerable empirical literature in support of a link between religion or spirituality and mental health (Koenig, 1998; Koenig et al., 2001; McCullough, Hoyt, Larson, Koenig, & Thoresen, 2000; Plante & Sherman, 2001), theoretically-driven empirical research explaining the relationship remains lacking (Hall, 2004; Hill & Pargament, 2003). Hall (2004) notes the “need to identify the mediating mechanisms underlying RS-mental health associations” (p. 67). Hall (2004) puts forth five central organizing principles integrating religion/spirituality with the basic principles of attachment theory, psychoanalytic theories, and multiple code theory.
It is too early to tell how the field will respond to his paradigm and challenge. Certain biased assumptions have factored into this paucity of research, including the assumption that the construct of religion and spirituality is beyond scientific investigation, and the assumption that the subject does not lend itself to scholarly inquiry (Miller & Thoresen, 2003). The Society for the Scientific Study of Religion has published their quarterly Journal for the Scientific Study of Religion since 1961, building strong support for scholastic efforts in religious research (Miller et al., 2003).
Conceptualization and definition of the constructs poses a threat to research efforts in the field on the variables of religion and spirituality. When found in the literature, too often they have been incorporated as add-on variables without a central focus (Hill et al., 2003). Measures of religion and spirituality have appeared in the literature, lending greater credibility to the constructs and giving promise to future investigations (Bassett, Camplin, Humphrey, & Door, 1991; Ripley, Worthington, & Berry, 2001).
Koenig, McCullough et al. (2001) provided a systematic review of research on religion, mental health, social support and substance abuse in the 20th century (Koenig et al., 2001). Nearly 80% of the studies identified in the meta-analytic review found that religious beliefs consistently correlated to increased satisfaction in life, happiness, positive affect, and higher morale (Koenig et al., 2001). The reviewers also located 101 studies exploring the relationship between religion and depression, two-thirds of which found decreased rates of mood disorders among the more religious of the participants (Propst, 1980; Propst, Ostrom, Watkins, Dean, & Mashburn, 1992). Propst et al. (1992) conducted a clinical trial comparing nonreligious cognitive-behavioral therapy, religious cognitive-behavioral therapy, pastoral counseling treatment, and a waiting-list of clients (n = 11). Other studies suggested decreased anxiety among the religiously active (Miller, Fletcher, & Kabat-Zinn, 1995; Razali, Hasanah, Aminah, & Subramaniam, 1998). The strongest outcome identified in the literature is the decreased likelihood for religious persons to abuse alcohol or take illicit drugs (Koenig et al., 2001).
Worthington et al. (1996) found that nonreligious and religious alike hold similar values about psychotherapy, but differ in their respective valuing of religion. Research on the role of religion in mental health has risen considerably over the past 20 years (Sperry, 2003; Tan, 2003; Worthington et al., 1996). In their 10-year review of the literature, Worthington et al. (1996) chose to delineate between religious and spiritual, using the former category in their study of journal articles between 1984 and 1994. Yet, even with this distinction, the investigators cite the necessity in the field for more research on the effect of integrating religious values and traditions in light of the growing plurality in the world. They conclude with an intriguing comment, “The world has changed dramatically, creating a different climate within which to see the role and future of research on religion and counseling” (Worthington et al., 1996).
Larson and Larson (2003) state that “spirituality/religion emerges in research as an often beneficial source of coping strength in helping in prevention, coping, and at times recovery from physical or emotional illness” (p. 37). In an exploration of the degree to which patients (n = 400) rely upon their religious and spiritual beliefs in dealing with mental illness, it was found that 80% relied upon religious beliefs and activities for coping, 65% found a reduction of symptom severity through such reliance, 48% found religion increasing in importance to them during the episode, and 30% went so far as to cite their religious beliefs and activities as the most important dimension of their wellbeing during the illness (Tepper, Rogers, Coleman, & Maloney, 2001).
Prayer as a Treatment Intervention
The use of prayer as a healing agent or activity is evident in a variety of life contexts, including the physical or medical when we or someone near to us is experiencing a life distressing or life-threatening illness or crisis (Ai et al., 1998; Ai et al, 2002; Biggar, Forehand, Devine, Brody, Armistead, Morse, & Simon, 1999; Kennedy, 2002). Harold Koenig (2003), Associate Professor of Psychiatry and Medicine at Duke University Medical School and the Director at the Center for the Study of Religion/Spirituality and Health at the Duke University Medical Center, has authored nearly 200 scientific articles and dozens of books and chapters on the role of prayer in medical settings. The results of one such study, a three-year research at Duke on intercessory prayer was reported at a meeting of the American College of Cardiology (Koenig, 2003). He comments on the study:
This double-blinded study involved 750 heart patients from throughout the USA and 26 prayer groups from around the world, including Christians in Manchester, Buddhists in Nepal, and Sufi Muslims and Carmelite nuns in America. Half of the patients in the study were prayed for, but nobody involved in the study, nor the participants, knew which half. According to the British Broadcasting Corporation (BBC) news and a special on the Discovery Channel TV program, prayer made no significant difference in the long-term health of the patients studied. (Koenig, 2003, p. 26)
While these kind of outcomes can be discouraging in the field of inquiry on prayer, it is important to point out some of the inherent problems with any scientific study of prayer. The type of research undertaken by Koenig (2003) and others in the medical field is quite difficult for a number of reasons. First, from a methodological standpoint, prayer is very hard to control for in conducting research. Consider the challenge of restraining family members and friends from praying for an ailing loved one or friend. If the control group is not a pure one, the internal validity of the design is at risk (Bernard, 2000; Creswell, 2003). Chibnall, Jeral, and Cerullo (2001) brought light to the problems in identifying the effectiveness of prayer when they discovered that Catholic Christians have weekly prayers for all the sick, presumably establishing a background level of prayer for everyone. Further, the theological implications and expectations around prayer pose several problems, considering that some faith traditions would see physical healing of the body from a diseased condition as answer to intercessory prayer, while others might see death itself as an ultimate form of healing for the patient who is then able to enter into an eternal state of peace. The Duke study (Koenig, 2003) does not have to weaken confidence in prayer as an intervention in any context, whether medical or psychological, but it does raise relevant questions about how far research can go in lending credibility to any metaphysical outcomes from intercessory prayer.
Prayer as a Cognitive Psychological Intervention
Given the elusive nature of prayer it is necessary to delineate how intercessory prayer is identified in this research as an intervention aimed to alter clients ‘thoughts, feelings, and sentiments toward their sufferings. Richard Foster (1992) offers the most useful way of distinguishing between the various types of prayers found in Christian circles. He contends that prayer essentially connects the one praying to some specific reality, using factor analytic terms, he advocates a general prayer factor out of which three specific types of prayer emerge, including inward, outward, and upward prayers (Foster, 1992). The focus of inward prayers is self-examination, while outward prayers are aimed at improving human-to-human relationships and upward prayers are focused on the human-divine relationship. Cognitive theorists in the field of psychology have argued that apart from the theological and metaphysical properties or benefits of prayer, the activity of praying informs and influences cognition (Barrett, 2001; Lawson & McCauley, 1990).
Observations from research suggest improvement in health and even life expectancy for those who are engaged in the activity of praying (Powell et al., 2003). Dossey (1993) views prayer as one of the best kept secrets in modern medicine. His work in the field of medicine on the health benefits of prayer have been heralded by a wide range of religious traditions. Despite criticism from his colleagues in the medical community he optimistically promotes prayer as an alternative medical treatment in the future of healthcare in the United States (Dossey, 1993).
It is unclear precisely how prayer works to promote physiological or psychological health in the life of the individual. The very act of contemplative introspection in the midst of a stressful lifestyle and culture may offer respite for the devout person given to consistent rituals of prayer. Some suggest it is the optimism and hope that comes from a foundation of faith behind the prayers offered (Ai et al., 1998, 2002).
By altering that perception in a positive way, the prayers constitute an intervention targeted at the cognitive dimension (Barrett, 2001; Baucom et al., 1989, 1990, 1996; Beach et al., 1995; Hawkins et al., 2002). Butler, Stout, and Gardner (2002) examined the use of prayer as a conflict resolution ritual in their study of religious couples and families (n = 217), building on an earlier study (Butler, Gardner, & Bird, 1998) that investigated religious’ couples use of prayer to invoke God’s involvement in marital process with a primary focus on conflict. The later study (Butler et al., 2002) used a mail survey, posing some concerns to internal validity of the design (Bernard, 2000), to gain responses to a Prayer-Conflict Questionnaire (Butler et al., 1998) from a sample of 53% Latter-day Saint, 28% Protestant, and 19% Catholic participants. The researchers reported:
Religious couples reported statistically significant effects associated with their practice of prayer. Specifically, couples noted that prayer invoked phenomenological interaction with a meaningfully personified Deity (t = 26.64, p = .000). Characterization of their metaphysical experience with Deity as an interactional “relationship” (Butler & Harper, 1994) thus appears reasonable. Spouses’ interactional experience included feeling emotionally validated (t = 14.22, p = .000). Spouses also noted that prayer increased feelings of mindfulness and accountability toward Deity (t = 30.05, p = .000). Prayer decreased negativity, contempt, and hostility (t = 19.81, p = .000), as well as emotional reactivity toward their partner (t = 27.88, p = .000). Associated with this experience of de-escalation were an increase in their relationship and partner orientation (t = 25.29, p = .000), increase of an unbiased/systemic perspective and partner empathy (t = 16.64, p = .000), and an increase in self-change as compared to a partner-change focus (t = 28.40, p = .000). Finally, spouses reported an increased experience of couple responsibility for reconciliation and problem-solving in consequence of prayer (t = 25.85, p = .000), together with an experience of incremental coaching or help from Deity, as opposed to outright problem solving on their behalf (t = 10.39, p = .000). (Butler et al., 2002, p. 30) This type of research holds promise for the present study, particularly the benefit for the participating couples in the domain of marital sentiment as indicated in the decreased negativity, contempt, and hostility, as well as the increase in partner empathy (Butler et al., 2002). The implementation of prayer in psychotherapy has been recognized as a means for building therapeutic rapport with clients, inducing relaxation, establishing ritualistic structure within a family, and increasing client reflection (Denton, 1990; Loewenberg, 1988; Margaletta & Brawer, 1998). Ethical principles specific to prayer as an intervention in treatment, can be grouped into two categories. The first concern relates to the therapist’s requirement to respect the freedom of the client in choosing to voluntarily participate in the treatment process (AACC, 2004; AAMFT, 2002; APA, 2002). This principle necessitates an awareness on the part of the clinician of his own biases and prejudices around religiosity and spiritual beliefs. The second principle at stake in the use of prayer as a treatment intervention with couples is the expertise and training required of the therapist with the intervention (AACC, 2004; AAMFT, 2002; APA, 2002). The practitioner’s experience with prayer may be quite narrow, given the diversity in the culture regarding religious and spiritual beliefs and practice. This must be taken into consideration and caution should be exercised so as to discern properly whether this or any faith based intervention is appropriate for the client(s). A thorough assessment of this aspect should be part of the comprehensive assessment undertaken by the therapist early in the treatment, facilitating the means to determine the potential efficacy and problems associated with utilizing such an intervention with the couple.
Conclusion
People who participate in the religious activity of prayer on a regular basis often demonstrate attitudes of optimism that promote physical and emotional health (Ai et al., 1998, 2002; Chibnal et al., 2001; Dossey, 1993). A body of literature deals with the prayer’s association to psychology or psychotherapy. For instance, one research determined that spiritual convictions contributed a positive role in obtaining mental wellbeing and another determined that contemplative prayer was fairly linked to quality of life. Some scholar determined that the integration of prayer among Christian married couples increased a sense of being emotionally confirmed by the spouse and improved partner understanding. Others discovered that survivors of sexual harassment and abuse who obtained Christian counseling that incorporated the power of prayer and scriptures recognized the general conclusion of counseling disapprovingly. As with any intervention in psychotherapy, the model will require testing and modification in order to find the right combination of prayers, format for reciting the prayers, and the optimum period of time for the intervention to produce the best results, however, this blend of cognitive research with religious/spiritual activity as a means to protect against life distress and deterioration and even remediate against the same is promising.
Chapter III – Research Design
Overview of Research Questions
The following three research questions guided the study:
How does the religious experience of attending church or other places of worship in the community influence the patients?
What and how do different dimensions of prayer influence the paitents in staying healthy?
This research study used a qualitative research design, specifically a phenomenological method. The phenomenological research design included in-depth, open-ended, audiotaped interviews for data collection. The aim of qualitative research is to help in the understanding of social phenomena in a natural rather than experimental setting, with an emphasis on the meanings, experiences, and views of the participants rather than on providing quantified answers to a research question (Meadows, 2003).
Rationale for Research Design
Qualitative, interpretive research methodologies focus primarily on understanding and accounting for the meaning of human experiences and actions. The qualitative research approach is also referred to as interpretivist research. Interpretivist research is primarily exploratory and descriptive, designed to discover what can be learned about the area or topic of interest. The interpretivist researcher views the world as a sociopsychological construct, where multiple realities form an interconnected whole that only can be understood as these multiple realities form (Bernard, 2000). Interpretivist research is typically used to answer questions about the complex nature of phenomena, often with the goal of describing and understanding the phenomena from the participants’ point of view (Leedy & Ormrod, 2001).
Bernard (2000) noted that phenomenology is a philosophy of knowledge that emphasizes direct observation of a phenomenon. Phenomenology seeks to describe the phenomena and social realities in words, rather than in numbers and figures. It emphasizes the common experience of all human beings and the phenomenologist’s ability to relate to the feelings of others. One major goal of phenomenological research is to produce convincing descriptions of what the people studied experience in order to understand how the people who were studied think and feel about their lives. Leedy and Ormrod (2001) defined a primary objective of a phenomenological study as attempting to understand people’s perceptions, perspectives, and understandings of a particular situation or experience. A phenomenological study tries to answer the following question: “What is it like to experience this phenomenon?” (Leedy & Ormrod, 2001, p. 153).
Sampling Design
This study used a nonprobability sampling design, specifically, convenience sampling of Christian males based on a snowball sampling technique. The study used this technique due to using a convenience sample of individuals who were readily available and willing to participate in the study. Meadows (2003) noted that convenience sampling simply takes people who are readily available and accessible to be involved in a research study.
Participants in the study were 20 adults who are members of a conservative Christian denomination. To guarantee that participants did possess a conventional Christian orientation, they were asked to answer two questions pertaining to conservative religious beliefs that were extracted from the General Social Survey (Davis & Smith, 1986) and used as a spiritual measure by other researchers.
Before contact with participants, an informant who is either a pastor or a church leader, from the denominations signed an informed consent to allow data gathering at the chosen site. The surveys were administered in religious studies in classes, and other religious sessions. Individuals who agreed to become participants were randomly assigned to various treatment conditions that would be formulated and will complete all instruments at one time. The four criteria to participate in the study were as follows:
Participants must be Christian males aged 18 and over.
Participants must adhere to the conservative Christian denomination
Participants must identify religion as their primary influence to stay healthy
Study Sample Size
Theoretical sampling and theoretical saturation (Strauss & Corbin, 1998) were utilized to determine and select the sample size of 20 participants. The use of theoretical sampling provides a general rule that when building theory, data should be collected until each category is saturated. The final number of participants in the sample is then determined when the outcome of the interviews becomes repetitive and no new themes emerge.
One of the goals of theoretical sampling is interviewing participants who are versed in the phenomena under investigation, thus providing higher quality data (Glaser & Strauss, 1967; Strauss & Corbin 1998). The flexibility of theoretical sampling allows the researcher to follow directions highlighted by the data. By allowing the gathered data to dictate the choice of participants, the researcher may be able to reduce the anticipated sample size.
Interviews
The initial interviews were proposed to last 60–90 minutes, but lasted 43–60 minutes. The interviews were shorter yet rich with data and were guided by the research questions, which were very clear and focused on obtaining responses that would address the research questions. Initially, arrangements were made to interview research candidates selected in a church at comfortable and private office of the church. An interview guide was developed and utilized for the study. The interview guide is a written list of questions and topics related to the topic under investigation that needs to be covered in a particular order. The interview guide served as a reminder of the specific types and focus of questions that needed to be explored. All questions on the interview guide were asked of all participants.
Data Collection Procedures
Initial screening contact with potential participants occurred by telephone contact and e-mail correspondence. Participants for the study were recruited via flyers posted in the church, pastor referral, and snowball sampling methods. Potential participants were contacted by telephone or e-mail and screened to assess their appropriateness to be invited as a candidate for the study. Prospective participants who were screened and meet the study criteria and who expressed interest to participate in the study were scheduled for follow-up, face-to-face interviews. During the phone and e-mail contact to schedule appointments for interviews, participants were provided a basic orientation on the process of informed consent.
During the initial face-to-face interview, the informed consent forms were signed by participants and collected; all candidates for the study received two original informed consent forms to sign, with the candidate submitting one original signed informed consent form to the investigator and keeping the other for his records. At the initial interview candidates selected fictitious names to safeguard their anonymity and confidentiality.
The study utilized the method of in-depth, open-ended interviews. In-depth, open-ended interviews were used as a foundation and are considered preferable in view of the study goal of capturing the voices of the experiences of the influence of religion on African American males’ staying sober from crack cocaine. In fact, in-depth, open-ended interviews are strongly encouraged when one is working with phenomena to redefine or build theory (Denzin & Lincoln, 2000; Strauss & Corbin, 1998; S. J. Taylor & Bogdan, 1998). S. J. Taylor and Bogdan noted that structured interviews are not considered in phenomenological studies, because they may limit and compromise participants’ self-disclosure and thereby affect the overall analytic process. In-depth interviewing provides a deeper appreciation and understanding of the informants’ perspectives on their lives, experiences, or situations as expressed in their own words (S. J. Taylor & Bogdan).
The interviews were recorded on audiotape and later transcribed. As mentioned, the interviews were scheduled to last 60–90 minutes but lasted 43–60 minutes. Meadows (2003) noted the optimal length of an in-depth interview is dependent on a number of factors, which include the resources and time available to carry out the interviews. Interviews over 90– 120 minutes are likely to be approaching the limit when fatigue sets in for both the interviewer and interviewee. As noted by Leedy and Ormrod (2001), the researcher must listen closely as participants describe their everyday experiences with the phenomenon and must stay alert for recognizing common phrases, patterns, and themes. Although the study incorporated the use of audiotapes as a major tool, field notes were charted during the interviews as needed (writing down important data and observations in a note pad to review later). This ensured that important phrases, patterns, and themes were captured and not missed.
Data Analysis
Data analysis focused on the questions that guided this research study. Leedy and Ormrod (2001) stated that the research questions always must guide the research design. Holding to the principles that guide qualitative research methods, the researcher is not interested in whether the research findings are statistically and empirically correct, valid, reliable, or even universal. What is more critical in qualitative research is to describe accurately what was being heard, seen, and felt from the participants and to express their voices in a way that can be understood both from analytical and theoretical frameworks, without in any way minimizing their internal and external realities (Strauss & Corbin, 1998; S. J. Taylor & Bogdan, 1998).
The interview audiotapes were filed with other data and kept secure in a locked cabinet to protect the confidentiality rights of the participants. The researcher was careful to be supportive, gentle, and empathetic to participants, showing genuine concern to encourage openness of communication and self-disclosure.
The researcher utilized a triangulation method during data collection. In triangulation, different approaches are combined to strengthen a concept or theory (Leedy & Ormrod, 2001). First, participants were interviewed and their audiotaped interviews were than transcribed. Second, interview transcripts were mailed to all participants for their review and approval. All participants than signed off approval on the transcripts and returned the transcripts by mail to the researcher. This method strengthened the trustworthiness and credibility of the transcripts as the meaning units or statements of the participants. Meaning units are words, sentences, or paragraphs containing aspects related to each other through their content and context (Graneheim & Lundman, 2003). Lastly, the researcher collaborated with an outside evaluator educated in qualitative research methods to support disassociating self from personal bias and to minimize preconceptions. The evaluator corroborated that the data from the research (codes, categories, subcategories, and themes) were accurate and approved the coding of meaning units or statements of the participants into themes.
Data Analysis Software
Qualitative researchers must decide whether to use computer-assisted, qualitative, data-analysis software or a hand-coding process (Barry, 1998). Considering the number of interviews as well as the length of the interviews the researcher did not make the use of a computer program necessary, as these programs are more useful with larger sets of data with a variety of data inputs. The length and number of the transcribed interviews used in this study were more suited to a traditional approach to analysis. Software also does not allow for context analysis; it takes the human mind to analyze. Creswell (2003) noted that qualitative computer software programs are useful to assist in data analysis when the database analysis is large (more than 500 pages of transcription). Since the data transcription was smaller, the researcher decided to use a hand-coding process, allowing for a more personal, hands-on approach to the analysis. Hand-coding also allowed having the transcribed interviews side by side to allow for more comparison between the different interviews and what the participants had to say than would have been possible in an electronic analysis (Creswell).
This study employed a grounded theory and content analysis approach for data analysis of the interviews collected from the 20 study participants. Content analysis concepts and categories provide exploration of data serving to explain the who, what, where, when, and why of the phenomena of interest (Graneheim & Lundman, 2003). A grounded theory approach to the analysis implies the development of categories of data serving to explain the who, what, where, when, and why of the phenomena of interest. This approach is geared towards developing an explanatory theory rather than testing a theory. The theory is developed from the data or grounded in the data and proposes to describe as well as explain the findings about a theory that strives for objectivity through the use of a systematic set of steps throughout the analysis (Strauss & Corbin, 1998). Grounded theory and content analysis approaches are often used in data collection and analysis of qualitative studies (Graneheim & Lundman, 2003; Strauss & Corbin).
The analysis of this dataset of interviews with the Christian males began with a microanalysis of the interviews (Strauss & Corbin, 1998). Microanalysis involved audiotaped interviews of the participants’ stories and transcribing the interviews into narratives. This involved a line-by-line, word-by-word, careful reading of the interview data for each participant and coding of the data into small units (word, phrase, or sentence into meaning units). The analysis led to open coding, described by Strauss and Corbin as the process used to define the properties and dimensions of the phenomenon or category from the data. The microanalysis was accomplished prior to the conceptualization of any categories or themes. During the process of microanalysis, categories began to emerge, along with their dimensions and properties as well as possible relationships between categories.
Theoretical sampling of the data was used as the categories and concepts emerged for the purpose of defining and expanding or contracting the conditions or continuum of the concepts or phenomena. Theoretical sampling assisted in defining the concepts and categories, whereas theoretical saturation assisted in the development of the categories when no new relationships or facets of the category emerged from the data (Strauss & Corbin, 1998).
As mentioned, theoretical sampling is the process of reinterviewing participants as new themes, concepts, and incongruent information emerge (Strauss & Corbin, 1998; S. J. Taylor & Bogdan, 1998). Axial coding (Strauss & Corbin) was used to relate categories of phenomena or categories to their supporting codes or subcategories. This relationship was examined by linking the codes to the established properties and dimensions of the category. The comparative process of analysis was a central feature of the grounded theory approach to analysis; making systematic but creative theoretical comparisons helped raise questions and discover properties and dimensions from the data. Such theoretical comparisons enable the researcher to identify patterns as well as variations in patterns in the data and phenomena.
Analytical Process
During the data analysis process the research must be diligent to follow an analytical process. The analytical process has three major steps:
The researcher must listen attentively to the audiotaped interviews to record initial impressions.
The audiotapes then must be transcribed by the researcher (or a professional transcriber, preserving confidentiality).
The researcher must read, reread, analyze, and reanalyze using a procedure known as open coding.
Coding is simply the act of identifying themes that assist with theory building and involves naming the incidences of phenomena; creating concepts and categories; determining their properties and dimensions; and, as necessary, creating subcategories to explain inconsistent and conflicting information. Subcategories are specifying features of a category that give it precision (Glasser & Strauss, 1967; Strauss & Corbin, 1998; S. J. Taylor & Bogdan, 1998).
The term phenomena refers to major themes in the data that become represented as concepts. Concepts of the study produced categories that were useful to connect very specific parts of the data as well as the general trends of the data (Glasser & Strauss, 1967; Strauss & Corbin, 1998; S. J. Taylor & Bogdan, 1998). Examples of categories that developed from the study include history of drug use patterns prior to getting sober through the influence of religion, history of substance abuse treatments, family religious history, environmental history and influence on mental health and religious practice, and socioeconomic history. The categories contributed to data used in the narrative of the study.
It is important to remember that the findings of qualitative research are based on the analysis of the narrative of individual experiences. The study participants for qualitative research have not been selected to be statistically representative of the population under study, but to provide variations in the nature of their views and experiences (Fenton & Karlson, 2002).
Iterative analysis of the collected interviews throughout the data collection process allowed the researcher to see emerging patterns, categories, and dimensions. Iterative analysis is a process whereby the researcher moves back and forth through the data in order to find, compare, and verify the patterns, concepts, categories, properties and dimensions of the phenomena. Having gained the insight of the emerging patterns, categories, and dimensions, the following interviews could be focused on filling those patterns, categories, and dimensions to the point of saturation (Strauss & Corbin, 1998). Strauss and Corbin (1998) noted that the use of theoretical sampling provides a general rule that data should be collected until no additional themes and concepts emerge to build categories. The final number of participants in the sample is then determined when the outcome of the research becomes saturated with information. Twelve participants were interviewed for the study, and 10 participants who provided the richest responses related to the phenomena under investigation were selected as the sample group utilizing methods of theoretical sampling and theoretical saturation. As noted earlier, triangulation was also used to strengthen findings.
Ethical Standards
This research study utilized the four ethical principles recommended by Rest (1982): (a) awareness of moral sensitivity to participants’ cultural and special needs; (b) moral reasoning, the ability of the researcher to identify moral dilemmas and problems during the research process and determine appropriate ethical resolution; (c) moral reasoning, or the process of thinking about proper actions to perform when facing ethical dilemmas during research and the ability to address these dilemmas appropriately and utilize consultation as needed; and (d) moral commitment, the process that allows the person to choose moral actions, characterized by the strength and tenacity of the person conducting research to hold onto ethical decisions. Honesty is also an integral quality of a good researcher.
Confidentiality
The research conducted for this study maintained ethical standards and confidentiality in accordance with the Institutional Review Board (IRB) of the institution. Procedures were developed for ensuring confidentiality of the study, and informed consent was obtained from participants. To assure confidentiality and right of privacy, the researcher provided each participant a code number and labeled any written documents with that number rather than with the person’s name. Also, all participants in the research study were given a pseudonym to assure anonymity.
In qualitative research, breach of confidentiality and the resultant invasion of privacy are usually the greatest risks of harm to participants. It is usually impossible to assure complete confidentiality of data in qualitative research, especially in narrative and phenomenological, in-depth studies. The convention of using pseudonyms for writing and reporting such information does not completely hide the person’s identity. In qualitative design, privacy may not be respected through the data collection process that mainly consists of observing or interviewing the participants in their natural environment, where participants are easily identifiable and their confidentiality cannot be protected.
CHAPTER 4: RESULTS
Introduction
The purpose of this qualitative study was to explore the Christian clients and their counselors or therapists to identify patient hopes and therapist judgments and practices. The study contributes to the psychotherapy literature so other mental health providers can expand their clinical and theoretical knowledge base when providing services to this population. The study sought to address the overarching question of how prayer based counseling influences Christian clients. This section presents the study results, utilizing the living narratives of the participants’ lived experiences taken from participant’s tape-recorded interview transcripts. Participants’ stories and interview quotes are presented using alias names to safeguard their identity and protect their confidentiality. Themes and categories are
Research QuestionsThis study addressed the following three research questions:
How does the religious experience of attending church or other places of worship in the community influence the patients?
What and how do different dimensions of prayer influence the paitents in staying healthy?
Interview Participants
Each of the 20 Christian males interviewed for the study provided descriptive information about himself on a personal level. This information and the researcher’s observations were incorporated into the personal stories of the participants. Five participants of this study were married; 3 of the unmarried participants had been divorced. The educational level ranged from eighth grade to achieving a master’s degree. The participants were employed in a variety of fields. The initial interviews were proposed to last 1.0–1.5 hours, but lasted 40 minutes to 1 hour. The interviews’ average duration was 50 minutes. The interviews were shorter yet rich with data due to the fact that the preciseness of the interview was guided by the research questions which were clear and focused on obtaining responses that would address the research objectives.
Data Analysis
This study employed a grounded theory and content analysis approach for data analysis of the interviews collected from the 210 study participants. Content analysis concepts and categories provide exploration of data serving to explain the who, what, where, when, and why of the phenomena of interest (Graneheim & Lundman, 2003). A grounded theory approach to the analysis implies the development of categories of data serving to explain the who, what, where, when, and why of the phenomena of interest. This approach is geared towards developing an explanatory theory rather than testing a theory. The theory is developed from the data; grounded in the data, the theory is proposed to describe as well as explain the findings about a phenomenon. Grounded theorists strive for objectivity through the use of a systematic set of steps throughout the analysis (Strauss & Corbin, 1998). Grounded theory and content analysis approaches are often used in data collection and analysis of qualitative studies (Strauss & Corbin; Graneheim & Lundman, 2003).
Findings for Question: How Prayer Affects christen clients
This research question was covered the following: What and how do the different dimensions of prayer influence Christian clients to stay healthy in the context of (a) prayer, (b) God, and (c) spirituality emerging from the words of the
participants. Religion and spirituality can be viewed as cognitive structures, and cognitive theories of religion aim to explain religion and the religious experience in terms of the development of religious beliefs and behaviors. Boyer (2001) noted dimensions of religion include prayer, faith, and religious outlook and practice. Religious dimensions can provide inner strength to individuals as well as bolster their self-worth and self-efficacy (Dilulio, 1998)
The use of prayer, a perceived personal relationship with and faith in God, and spirituality for these participants were quite important and emerged as the data were analyzed. Faith reflected the participants’ at times intense faith in God and the reliance they placed in God in their personal and professional lives. Faith was how the participants articulated their faith in God and their very personalized relationship with God. The prayer category described and defined the dimensions of prayer as meaning of prayer, why pray, and the relation of prayer to life. The participants discussed the immense power of prayer to them, how their prayers were answered to get healthy, their regular practice of prayer, and the strength prayer instilled in them. The participants also described and defined dimensions of spirituality and how they utilized spirituality in their lives. Some of the spiritual experiences and beliefs expressed by the participants about spirituality were beliefs that spirituality allowed the Holy Spirit into one’s life, spirituality is being born again, spirituality changes one’s morals and values, spirituality is a dimension of God, and spiritual principles are the essence of religion.
The participants all promoted the positive effect of prayer, faith and God, and spirituality had on changing their self-centered behavior and thinking to God-centered behavior and thinking. The participant males portrayed true examples of the positive influence of prayer, faith in God, and spirituality to create life changes.
Brown, one of the participant, stated,
I believe in the body of Christ. The group of believers is not an organization, but it’s a living moving, breathing organism. I know that God loves me personally, and my faith allows me to trust in God’s absolute power. (Brown)
The participants commented they did not always trust themselves but did trust in God. They felt they had to surrender themselves to God or their lives would not work, and they likely would be back on drugs and doing things they should not. Their faith in God was “foundational, believing that there is a creator and that He is involved in my everyday experience and that He cares about me personally and by faith I believe in Him.” They believed in God and that God made the earth and world and formed their lives around these beliefs.
The theme of prayer was supported by four subcategories emerging from the data:
(a) how the participant defined prayer, (b) the relationship of prayer to life, (c) why pray, and (d) the meaning of prayer. These components encompassed the participants’ use of prayer in their lives. The participants talked about different dimensions of their prayer experience, and all agreed prayer was very important to them in their religious life. The participants all reported a strong belief of the power of prayer to change their lives and provide them strength bestowed from God to get through trying times. The participants talked about prayer being a vital aspect of their religious life as well as essential to their refraining from drugs. Because the participants’ responses to defining prayer and meaning of prayer were similar, they are reported as combined findings under the defining prayer component. Defining prayer examined the participants’ understanding and perception of the meaning of prayer and the function it serves in the participants’ lives. The participants were able to express their understanding of what prayer is and what did prayer fulfill in their lives.
The main aim of this study and the research question was how do the different dimensions of prayer influence Christian clients to stay mentally healthy through the use of prayer in their counseling sessions. The importance of prayer in the lives of these participants was very apparent. The participants’ responses to this question highlighted that the participants used prayer as a way to stay away from ailments by praying and felt God was listening to them, watching over them, and guiding their lives at all times. Religion and God kept them feeling cared for and protected from thoughts of ailment and focused them on living their idea of a Christian life. They prayed frequently and intensely, using prayer and their answers to those prayers as guidance. The participants perceived they had a direct, personal relationship and communication with God and used this communication often in the course of their daily lives. Prayer appeared to be personalized to the person rather than commonalities in prayer across the participants. Each used prayer in his life in a personalized manner.
The participants were very committed to practicing prayer in their religious lives and had no reservations that their prayers were heard and answered by God. They reported that God will answer, and he hears, because no prayer goes unanswered. Prayer was important to these participants. Overall, they defined prayer as the opportunity to talk to or communicate with God, which they did regularly and frequently. The participants’ hearts were certainly inspired by their practice of prayer, and it was essential to their religious experience.
The participants also mentioned a difference between spirituality and religion. The participants talked about how they found God through their spirituality. The participants all emphasized the importance of spirituality in their lives and recovery from mental ailment and how spirituality played an important part in their lives daily if not hourly, providing the participants with a way to live healthier lives. Defining spirituality. The participants defined the illusive concept of spirituality in a variety of ways. Although the participants had variations of their concept of spirituality, they all felt a connection between God and spirituality.
Summary
This chapter has presented the findings of this qualitative study on the perception of Christian clients about the impact of prayer on their lives. As the participants came from conservative Christian denomination they developed a very personal and intense relationship with their perception of God and how God was there to communicate personally with and guide the participants in their lives. The participants developed strength to restrain from mental ailment through prayers. Each man had a strong belief in prayer. They prayed regularly; 2 of the participants had rooms in their home for prayer, and all of the participants depended upon prayer and God to keep them free from mental ailment. The last section, chapter 5, provides a summary of the overall study. The implications of the findings are reviewed for additional research and recommendations for related disciplines in the human service field. It is also hoped that the general public will find interest in the findings of this study.
CHAPTER 5: RESULTS, CONCLUSIONS, AND RECOMMENDATIONS
The purpose of this study was to explore the perception and impact of prayer on Christian clients. The literature review indicated religion has been identified as a possible influence on relieving people from many mental sufferings. The study used a qualitative research design, with a phenomenological methodology or lens for examining the data. The study produced data supporting the literature review’s indications that prayer has a positive impact of mental health in Christianity.
The researcher explored the relationship between the dimensions of prayer and the participants’ mental health. Boyer (2001) noted dimensions of religion include prayer, faith, and religious outlook and practice. Religious dimensions of prayer have been identified to provide inner strength to individuals as well as bolster their self-worth and support healthier lifestyles (Dilulio, 1998). As discussed in the previous chapter, prayer was a powerful influence for the participants’ mental health and all participants in the study practiced daily prayer. All the participants expressed that when they prayed they believed God answered their prayers. The participants identified the practice of prayer as a key factor of strength that allows them to live productive Christian lives (Boyer, 2001).
Spirituality was essentially important to these participants, and they expressed different perceptions of spirituality. Yet, the participants all believed spirituality involved honesty, integrity, love, and belief in God (Sulmasy, 1999). The participants had developed new standards of life that included making positive choices and practicing positive morals that exemplified Christian values. The participants made strong efforts to set positive examples of Christian lives to others and worked hard to be positive role models in their communities for others. These participants had strong commitments to reach out to others, to introduce them to religion, and to help others and change their lives. The participants also realized that they must continue to practice Christian lives in order to be mentally healthier (Carter, 1999; J. W. Jones, 2004).
Conclusions
The conclusions that emerged from the study overall supported the research literature indicating a strong relationship between religion (from a Christian framework) mental health. The participants in this study all mentioned that, as a result of their church attendance and religious experience, they now prayed daily. The participants stated reading and studying the Bible and attending Bible study was inspiring and motivating as a religious activity. The participants mentioned the importance of fellowship with other church members and how their fellowship experience provided them support for their sobriety. The participants in this study embraced attending church and participating in interpersonal relationships with church members as an important ingredient of their recovery from addiction.
The participants felt a personal relationship with God was of prominent importance for their recovery to be successful. Nine of the participants specifically talked about having a personal relationship with God and praying daily as their personal route of communication with God. The participants credited their spiritual growth and inspiration for living healthy, productive lives directly to their relationships with God. All of the participants agreed that God was an important force in their religious life and recovery from mental health.
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