Psychiatry & Psychotherapy Podcast - Working with Spiritual Struggles in Psychotherapy

Episode Date: February 4, 2022

In this podcast episode, David Puder, M.D. and Kevin Ing, M.D., M.Div. interview Kenneth I. Pargament, PhD, and Julie J. Exline, PhD about their new book Working with Spiritual Struggles in Psychotherapy: From Research to Practice. Dr. Pargament is a pioneering expert on the role of religion and spirituality in coping with stress and trauma. Dr. Exline is a researcher in the area of spiritual struggles and supernatural attributions. Both clinical psychologists, they are nationally recognized experts in the integration of research on religion and spirituality into clinical practice.  By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. Welcome back to the podcast. I am joined today with Kevin Ng. He is a resident at UC Irvine, who is helping out with this episode. And this is an episode on a recent book that Ken Pargament and Julie Exline wrote. They're both with us. They're both professors. And this book is called Working with Spiritual Struggles in Psychotherapy. I have become aware of Dr. Pargament. through multiple of his things that he's written over the years, and I've read other books of his. And so when I saw this new book coming out, I was like, I got to get Kevin Ng on this book with me and see what we can, what pearls of wisdom we can pull out.

So I think what would be good to start, and either of you can answer these questions, is maybe define what do we mean by spiritual struggles? Well, we tend to think about spiritual struggles as being sources of conflict or tension or strain that people might have around religion and spirituality, regardless of whether they are personally religious or spiritual themselves. So for some people, these might involve feeling angry at God or feeling punished by God or maybe something like feeling attacked by the devil. so they might involve these supernatural beings, but they might also involve things like just being angry at religion or feeling mistreated by religious people. We call those interpersonal struggles around religion. People might have questions and doubts about their beliefs.

They might have moral struggles trying to do what's right and feeling a lot of guilt when they don't. And ultimate meaning struggles, which is this striving to find a sense of meaning or purpose, purpose in one's life and maybe having trouble doing that. Okay. And how would you define spirituality, just so we're all on the same page? Well, we think of spirituality really as a process. It's a lifelong process. To put it most simply, we think about spirituality is what people do to seek out something sacred in their lives.

By sacred, we're referring not only to notions of God and higher powers, but also other aspects of life that can take on divine attributes, such as nature, loving relationships, work can be seen as sacred. So spirituality has to do with the relationships we form with those parts of life that we hold sacred. Okay. So let's say you're a therapist. listening to this and you're like, I'm not a spiritual person, how would you sort of introduce this topic to them and why it might be important? Well, just kind of, by piggybacking on that last comment I made, that if you think about spirituality broadly involving whatever we may hold sacred, then even people who may not be theists, believers in God, may still hold some kind of spiritual beliefs or

or express it in some ways in their lives. So we think when you talk about spirituality in a broader sense, the umbrella of spirituality, I think, grows larger. That's not to say there aren't people who don't see themselves as religious or spiritual. But the reality is that many of the clients and patients that we see in practice are, in fact, believers and gods. You know, the surveys suggest 90% or more of people

in the United States, believe in God. And there's, I think, significant research to say that people's faith, questions about faith, all have important implications for their health and well-being. So even though therapists themselves may not experience religion and spirituality in the same way as clients, there may be, in fact, what we call a religiosity gap in that way. The fact is that for the people we work with every day. It's an important part of their lives. And many of them would, in fact, like to be able to talk about it and integrate their faith into their treatment. Yeah, I was going to say, and I suppose, and I have a bias because I feel like spirituality is incredibly important to talk about in the context of psychotherapy. But I have talked to many of my colleagues and trainees throughout my training career who haven't had any training in it whatsoever. or any discussion about how to do a spiritual assessment or inventory in the context of therapy or treatment.

So I'd love to hear, what do you think are some of, I guess, the reasons why it's difficult or it's hard or why is this gap exist in psychotherapy for someone who's on the opposite side of that spectrum of expectation? Well, you're not alone, Kevin, about not having had the training in this area. at least within psychology and social work and counseling and marital and family therapy, the majority of people receive, majority of graduate students receive no training at all in topic of religion and spirituality. So I think for many of them, when the topic may come up in treatment,

the therapists just don't know what to do. They're just kind of left clueless. and so may shy away from the topic, try to change the subject to more comfortable territory. So if a client is talking about God, the therapist may say, well, you know, that sounds similar to the way you talk about your father. And then all of a sudden the field has shifted to more familiar turf. I think there's still some lingering antagonism to or bias against religion and spirituality among some mental health practitioners.

You know, the founding figures in our field from Freud to Ellis to, you know, others as well, have been really sometimes antagonistic to religion and spirituality. And I think some of that has continues to be present in the field, even though I think we're making progress in that way. I think there's often a distinction, too, where therapists are more comfortable these days with discussions that they might perceive focusing on spirituality as opposed to religion. There's often, I believe, a stronger negative reaction to the word religion than there is to these forms of spirituality that have become more popular in mainstream psychology today. You know, things having to do with mindfulness or awe or connectedness,

those might be more familiar or comfortable territory for therapists than anything that seems like it's getting into religious communities, specific religious teachings, et cetera. I was thinking about just like Logotherapy, kind of like something that I've talked about on some of the episodes, talked about Man Search for Meaning, you know, kind of this idea of looking for the meaning and purpose in life. How does that relate or where does that overlap with this book in your work here? Well, I think that the logotherapy clearly has important religious and spiritual implications. In fact, Frankl himself in writing about logotherapy, really, I think, understood the search for meaning not in secular terms as much as in a kind of spiritual sense. He said we discover meaning.

We don't create meaning. He believed that there was a meaning out there for each and every one of us that was in some. ways to be to be found, not to be created by ourselves, which has quite a spiritual connotation to it. So the search for meaning in itself has some, you know, a spiritual flavor to it. In our book, Julie and I talk about one aspect of that closely related to it is the struggles that people experience in trying to find meaning. So, and Frankel talks about that as well. And I think he would probably be quite comfortable with what we've written in talking about therapy at times is really helping people find meaning, but work through the challenges in that process and the struggles people have experienced in their search for meaning. And other existentialists have also written to this, such as Irving Yalom talks about this in his own really classic book on existential psychotherapy and talks about the challenges people run into. And the symptoms they can develop when the search for meaning becomes very difficult.

And so people may run into some problems and pitfalls as they try to find meaning in lives. Yeah, and I think you both do quite a great job in your conceptual model of spiritual struggles in this book. And it does make sense once you brought in the questions of ultimate significance of meaning. of ultimacy of transcendence, then that's certainly an area that almost anyone would be interested in talking about in therapy, whether that space is filled by a particular religious content or tradition or more of a general search. So I thought that was a great way to lay out how to think about struggles or spiritual struggles in the contents of therapy. Yeah, I think there's a spiritual struggles we think about is in-between phenomena. They're kind of hidden in the cracks and crevices of

human experience and in psychotherapy as well. And so they're really in-between belief and unbelief between meaningfulness and meaninglessness, between good and evil, between connection and disconnection. They're that place in between where people are really trying to figure things out and experiencing some challenges and emotional. discomfort in doing that. And we think that's just really part and parcel of life. They're a natural part of life, but they're also a natural part of psychotherapy. So you talked about in one study that you actually were part of in 2014, both of you actually, that spiritual struggles are pretty common. 75% of 1,000 people reported having some spiritual struggles. You guys created this measure

on spiritual struggles based off of these six domains. And I'm wondering if you can speak to that a little bit like what you found in that study, specifically the commonness of this, maybe more common than most of the audience would assume. Yeah, one of the things that we find to be maybe the most important part of our mission is just to let people know that spiritual struggles are incredibly common. So, as you said, around 75% of people are endorsing some level of spiritual struggle. Often will focus on something like during the past month. And struggles having to do with things like doubts, interpersonal issues around religion, struggling with morality, tend to be more common than people coming right out and saying

that they're struggling with God or with the devil, those more supernatural struggles. But all of these different types of struggles show really consistent connections with emotional distress, things like anxiety, depression, stress, and some connections to physical health symptoms too. So one thing we really want to convey to people is that even though they might feel reluctant to disclose that they're having struggles around religion or spirituality, that these are incredibly common. And I might be able to describe more later some of the earlier work that we had done on anger at God. But the basic take-home point being that people are often afraid to be angry at religion or to be angry at God or to admit that they're having doubts. There can be like a stigma around it. And they might, religious people in particular, might be afraid to disclose it. But the more that we're able to normalize the experience for people, it seems to really help give them a safe space to be able to process it.

to accept that they're having this struggle, which is the first step toward moving through it effectively. Yeah, you talk about how it's not a bad thing. It's not a thing that you should feel any shame about to have this spiritual struggle, to not see it as a sign of weak faith or pathology or immaturity. Yes, that's an absolutely key point from all the writing that we have tried to do on this. is this focus on struggles as being painful, and they might make us feel, as Ken has often said,

shaken to the core. But these are challenging things that we're facing, often around very deep parts of our existence. And if we're able to take them on, acknowledge that we have them, these can really be ways to press us toward growth, toward examining our beliefs, examining our relationships and our emotions, and trying to find solutions that are going to actually help us grow as people. And that may or may not mean

becoming more engaged with our religious tradition, for example. Some people might choose to disengage, but still feel that they've really grown from this experience and other people are going to stay engaged. But the message of growth coming through struggle is one that is not guaranteed. The empirical research on it is a little spotty, but it's a definite possibility. And the last thing we would want is for people to feel like struggles or anything that they would need to be ashamed of, whether they're just a symptom that something is wrong. And we just need to, you know, get over these and fix them. I think that's a really important point that Julie is making. We've talked about struggles

is we've tried to find the right metaphor for thinking about struggles. And one of them that we've used is that they're forks in the road that are their pivotal times in life that can lead towards growth and positive transformation at best or decline and even brokenness at worst.

The limitation of that metaphor is that it oversimplifies things because sometimes that growth, in decline can both take place and there can be both pain and gain from struggles. So they're not mutually exclusive. I think the reality is maybe a little bit messier that as we try to grapple with these powerful struggles in our lives, at times we make some progress and at times we need to take two steps, we take two steps back and three steps forward.

So they are pivotal times, but the trajectory of, of, um, movement through struggles isn't always simply up or simply down. Yeah, my sense was this book was quite optimistic or at least hopeful in the sense of these spiritual struggles are an opt-thin-missed but important point for potential psychological growth in a number of people and most people, in fact. And it's kind of a refrain throughout the book of how every single one of these struggles can be an area that leads to either decline or confusion or disorientation or be part of the opposite side of the fork in the road, which is a path towards growth.

And so I thought that was very helpful to frame it in that sense. And it seems as if even if maybe a majority of the evidence points towards decline and in many cases that this hopefully could be an area that future clinicians can make some, do some changing about some of those statistics, hopefully. Yeah, and I wouldn't, I wouldn't say that we have any kind of definitive evidence that struggles usually lead to decline, you know, to spiritual decline. I think as, as Ken was mentioning, this mixed profile is something that's likely to be common. So let's say that you have somebody who had a, was part of a church community that believed in a really angry punishing God.

Somebody might decide to eventually, after a lot of struggle and soul searching, they might decide to pull away from that community and stop believing in this angry God, but maybe they stopped believing in God altogether. So they could reduce some of these interpersonal struggles around religion by leaving, but then they have all these issues about having left a community. So there's still going to be all kinds of different struggles there. They're no longer believing in this angry God, but now they maybe don't believe in God. And that could create struggles around doubt and ultimate meaning. So sometimes I feel like it's kind of a, you know, you have this energy that you're working with. And it has to go somewhere, kind of like this whack-a-mole game. You know, you deal with one thing and then stress can come up somewhere else.

And I think as people are going through these. processes and trying to integrate all of this, these different ideas and emotions and kind of weave them into a coherent story. There are these happy and sad things that are often occurring at the same time. You know, you lose something, you gain something else. And that's all going on as part of the same picture. Yeah. It's like in this journey, they may maybe moving towards something that's a more sort of authentic spirituality for them, despite, you know, the community being like you're leaving us, right? And that may be hard. It's like, it's hard to sometimes unwind the various narratives that they start to sort of combine.

For example, that maybe that angry preacher person, right? Like, and sort of like his personality, you know, how do you unwind that from like some more of the healthy things that they got, the good things? You know, and it's often a mixed bag, like, I got these good things from this community, but then there were some parts that were not so good. You know, how do you help someone make sense of that? Yeah, I think that's a great point, but isn't that life as a whole? I mean, it certainly applies to the religious and spiritual domain, but I think in psychotherapy, that's just what we help our clients and patients do, grapple with the mixed character of life,

the fact that it's the multiple dimensions, the multiple threads that run through it, and the kind of ambiguity and at times the paradox that we can find in life, and being able to kind of encompass that and hold on to it without necessarily having to find simple and easy answers. I think part of the tremendous value of psychotherapy is to help people come to terms with that mixed nature of our lives in trying to move forward to fulfilling lives in spite of the fact that life is a puzzle, that life is filled with ambiguity and sometimes paradox and hard choices. But that certainly comes to life when we're talking about religious and spiritual issues. Yeah. Okay. I have a quote for you. you guys from Kernberg, all observations of clinical phenomena depend upon theories. And when we think

that we are forgetting about theory, it only means that we have a theory of which we are not aware. Why do you think I read that? It's interesting because I think that you can take a, in looking into this area of religion and spirituality, you can try to apply theory, where you can work more from kind of the grassroots up. And I think in my own approach to this has been much more working from the grassroots. This work on struggles, for instance, kind of grew out of conversations with clients that I had, initially on how they look to their faith for help and coping with their problems.

but then learning that for at least some clients, their faith was really a source more of stress and strain than resolution, which led to this, for me, focusing more and more on spiritual struggles as a really important part of what we do. And I didn't so much have a theory in mind, at least not initially, as just being kind of really kind of perplexed and wondering about what was going on here. And that, so it built on the experience of regular people coming in and that I might not

have identified myself if I had just been reading theory. Although I do think, Ken, in the work that you've done conceptually in preparing for the book and in conversations that we've had leading into that, I know that this focus on wholeness and integration and ways for people to find wholeness despite the struggles. that they're having and the different ways to get there has been kind of an overarching theme that you've also brought in a little more top down as well. Yeah. Well, bottom up, top down, they start to work together.

But it didn't, you know, I don't think there was a wholeness theory that really was out there to build on. It's more, again, that just accumulating the bits and pieces of people's experience and then the bits and pieces from research findings. And it all becomes like a puzzle that we're starting to put. the pieces together and trying to solve to make sense of this incredible human experience. So yeah, there's theory now and some of it I have helped to create and some we've built on as well, theory out there that we brought into this work.

But certainly I think there's one of the things I like about our work is it is really so rooted in basic human experience. And it just grows out of experience, including the measures of spiritual, or struggle, the items on the measure are very simple and straightforward and it are complicated. And people can relate to those questions about whether or not they've had a struggle. Because I think in some ways it does come out of their lived experience. I think another challenge too about having a specific theory underlying all of this is that the different struggles are quite different conceptually.

There's overlap. But feeling as though you're being attacked by the devil or some supernatural adversary is pretty different from having this process of wondering whether or not your core beliefs are true. And that's different from having interpersonal conflicts with people around religious issues or their political views associated with those. They're different things going on psychologically. So I guess when I think about spiritual struggles, I think about a whole life domain, like struggles at work, struggles and relationships, spiritual struggles. It's a whole big domain, rather than something where I'd say, well, this is, this is the whole core of what

spiritual struggle is about. I would say that for me, this both and idea that religion and spirituality have benefits, but also have this shadow side, it has been kind of an orienting idea. But when you start getting the specific struggles, there are very different things going on psychologically with people. Yeah, I think how... Go ahead. Kevin. Well, I was trying to think of a good time to ask this question, and this might be as good as any on this question of integration and top down versus bottom up. But, you know, I think one potential, for those who are opposed to the idea or have some questions about the idea of integration, some might say that the goals, values, and ultimate aims of psychotherapy versus a particular religious or spiritual aim are maybe overlapping, but sometimes different. And so one question I had was, it is a perfect integration possible,

and perhaps specifically, do you have any thoughts about the relationship between the therapist and the religious counselors or religious leaders, if that happens to be the case for the client? Because one thought that came up to me throughout this book was that as the individual psychotherapist, you are beholden to your client only and their particular story, their particular narrative,

whatever idiosyncrasy is of belief and how that interfaces with their life and their and and so forth. And the religious counselor, whether it's a priest or an imam or a rab or so forth, it's maybe perhaps divided or somewhat more like a couple's therapist. Like they have to worry about the individual, but they also have to worry about whatever it looks like to have faithful adherence to that particular faith tradition. And so there can be attention a little bit between how you as a therapist are situated when it comes to that one person. So do you have any general thoughts about that conflict? I mean, you said quite a lot about looking internally to somebody's particular resources, whether it's the religious resources or other resources

to help them to navigate that conflict. There's a bunch of questions rolled in there. That's a great question, Kevin, and like all great questions, they're really hard to grapple with, and there's certainly no easy answers. I would say that we think of wholeness is also a process and a journey that no one ever becomes fully whole

because we're frail, finite beings, and wholeness has to do not only with just ourselves, but being part of a larger community as well. So it's really, it has to do with virtually every aspect of life, of pulling your life together to make a meaningful, coherent, cohesive orientation to life. It's a journey, and it's part of, I think, what therapists and clergy are very much concerned about. But as psychotherapists, I think, we've generally focused on wholeness in terms of the social, psychological, emotional, biological side and have relatively neglected the spiritual side.

And I think that's really unfortunate because that's a part of being whole as well. I think as therapists, we certainly should not ignore that dimension. and we have a part to play in helping people talk about their spirituality and their faith, as Julie notes, is either a resource or is a source of problems. But having said that, there's limits to what we can do as therapists. And it's important at times also to bring in other resources, including clergy. For instance, I worked with a client who was feeling she had been raped years earlier, and she was feeling that the rape was a punishment for unforgivable sins that she had committed earlier in life.

And even though I talked with her about self-compassion and forgiveness for self, it's clear that her feelings of unforgiveness were also tied to her faith tradition, which she interpreted as placing her beyond the pale of forgiveness. And eventually I worked with her priest. and helped to involve him in the treatment, who was a wonderful man, and he could begin to talk with her about no, that wasn't quite an accurate view of her tradition. And she could find forgiveness and she could participate in a sacrament of reconciliation. Now, I couldn't offer that. I was a psychologist.

I don't, that would be malpractice to go and try to act as if I have that kind of religious authority and legitimacy. But he could. and she found tremendous value, I think, in experiencing that sense of reconciliation and communion with her church. So we worked together. And to me, that's therapy at its best, where you help people draw on their resources and to find greater wholeness in their lives. And I really agree with that, Ken. I just wanted to respond to something else that Kevin mentioned about integration. where it sounds like you might have been talking about it in terms of integrating faith with practice.

So I think that when we were getting ready to write this book and in most of our papers, we're taking more of a, I would call it a broad psychological stance, but we know that a lot of the people who would be interested in this work are people who are working within faith tradition. So maybe people who are in pastoral counseling in a specific tradition, or you might have psychologists, counselors, social workers who are affiliated with a particular religious tradition or maybe people who are trying to blend therapy and something like spiritual direction. And there, some of the options that you have might be different. You might be in a setting where it would be seen as appropriate to pray with a client or a patient, for example,

or to assign scripture readings or something like that. There's all kinds of different ways that the general principles that we've talked about could be applied in different settings. We had to make a choice to be more general and not tie things to a particular faith tradition. And when you start getting into specific faith traditions, there's always these questions about some of the boundaries around if I'm going to start praying with clients, for example, or a, trying to help them hear from God, I'm kind of crossing into a different line of a relationship

from what a therapist would typically do. And you just have to be thoughtful about what those changes in boundaries might mean for your client or your patient and make sure that you're on the same page about that. Because let's say that you were praying and you felt like you got a message from God for your patient. And they didn't agree with that or they felt like they had to take it as God's word because you said it. You could see how tricky boundary violations could sometimes come up when the therapists start going outside of their usual lane and going more into this supernatural lane. So we do raise a few cautions about that in the book and some of our other writings. But I know that for a portion of the audience, that that could really be a valuable part of their toolkit. And what they

can offer is this ability to do both the therapy work and the work within the faith tradition. So lots of great things there. Sorry we couldn't get into all of that in the book. There's just too many traditions and we didn't want to go outside our expertise. Yeah, I almost think a therapist could err on either side, right? So I think an atheist therapist could hear that story, for example, of that client of yours who, you know,

felt like God was judging them. And they could almost be like, yeah, this is why you need to leave that spirituality. it's toxic, you know, this is, so they could kind of like push their own agenda, their own theories, right? Or you could be, or you could go the opposite way and be like, no, your spirituality. I don't even know what that would look like. You're like, your spirituality is not saying that, you know, and, you know, it could be, they could feel both the boundary violations from both sides. You know what I'm talking about? Like, there's this kind of like line that we walk.

in the middle? Yeah, I think there are, I think it's an excellent, making an excellent point. The bottom line is that part of spiritually competent care is being respectful of your client's orientation to spiritual, in religion one way or another, and there are different ways of being disrespectful. One is to simply voice antagonism to someone's personal belief. and expressions, and the other is to try to impose or proselytize to a religious point of view. And both are in some ways not respectful of the client's own faith orientation and tradition.

And both are in dangers that we can run into as we try to move to more spiritually competent care. I think the same could be said about politics, which is, you know, a lot of my patients have no idea where I'm coming from politically. They could be the complete opposite of me and not know. One of my mentors, it's like, he's like, you know, he has various things that he believes that are very strongly believed. They're very different than myself, but he has no idea that I have different views. So I think it's like politics is kind of that another one of those examples of Whereas we need to understand our biases where we come from and maybe not have it play out. But when people have such strong emotions, it's like, how do you not let that bias seep through?

I mean, everyone is, like, charged up with what they believe nowadays, right? Like, how do you realize that you're even biased, you know? Self-awareness is every bit as important in the spiritual domain as in the other domain. I know when I've taught seminars in spiritually integrated psychotherapy, one of the most, I think, useful things we've done in the class is everyone writes a spiritual autobiography. So they have to tell their spiritual journey and share it with each other. And it's a way of just increasing awareness of one's own biases,

and we all have them, so that we are in a better position to, and see how they may play out and affect the nature of the therapeutic process. But I do know that sometimes it can seem really unsafe in therapy or other settings when people bring up a religious or political view where there's sharp disagreement. Or maybe they bring up a minority view or they just assume that the other person would be on the same page. There can certainly be a lot of conflict and even therapeutic ruptures can occur when those assumptions are made or when therapists disclose too much about their beliefs on interesting things that can come up.

If you believe that you're on the same page as a client, let's say, in terms of religion, I know that in the past, when I was working with some clients who were from a tradition that was similar to mine, I had made some assumptions about their theological beliefs or about types of strategies of framing things theologically that would be helpful to them. And often they weren't at all. And that's a problem that can come up with this integration perspective. As you can say, oh, we're both Episcopalians,

or we both go to the assemblies of God, or we're Catholics, or we're both Jews. I can assume something about what this person believes. And then sometimes that can lead to misunderstandings and ruptures as well. So these are really delicate topics. And certainly as politics and religion have gotten mixed more, the amount of energy around those things in the therapy room can be really intense. And I couldn't agree more that that can be very hard to navigate. I think the alternative to neglect it just doesn't work. You know, we've been, you know, I think all mental health professionals are taught to go where there's emotional power in clients' lives.

We listen hard for those signs of tension, joy, deep sadness. We look for the tears. And I think you're right, David, that religion, like politics, is tremendously powerful. Very few people are neutral when it comes to matters of faith. If you want to disrupt a boring party or dinner party, just talk about religion. and it's guaranteed to create some discomfort or some tension or some open conflict. It's not. And so, you know, and that says something for therapists that if we are taught to go with the emotion,

then sidestepping religion just doesn't work. Okay, I want to jump into the six types of spiritual struggles that you guys address in the book. And I kind of want to find out which one for you guys is the one that you get most excited about. And maybe like, like which one. just kind of jumps to your mind as like, yeah, that's the one, if I had to, if I had to help a patient with one of those, what it would be. So the six are defined struggles, demonic struggles, interpersonal, spiritual struggles, struggles with doubt, moral struggles, struggles with ultimate meeting. So Julie, do you want to start? That's a great question. It's actually a challenging one.

I would say in the past, my own focus was mostly on things around people, being angry at God, which often bleeds into being angry at religious communities. So I think that for me, giving people a safe place to express complaints, anger, frustration, their fears of being judged by expressing disagreement, I really find that to be rewarding to try to let people know that a lot of people feel anger around religion. They're annoyed with members of religious communities, whether they're their own or somebody else's. People might be feeling like they have trouble trusting God. So those things where people are having what they might see as unacceptable emotions or are afraid that they're going to be stigmatized in some way for being angry at God or for questioning their face, I really like to give people a space to process those things and to see what could be good about their anger.

and their disagreements and how they could grow from that. That was probably my favorite. Okay. Is God big enough for people to be angry at him? I mean, is that like, isn't that like, isn't there something like just inherently in a lot of spiritual people where they're like, I can't be angry at God or I can't be angry at all? Like, how do you help people with that?

I have to be careful here not to monologue too much, but briefly. So a lot of people are afraid that angry. at God is morally wrong. You know, I can't come in as a researcher and say if it's morally wrong or not. You know, that's everybody's own decision. But certainly within the U.S., people who are more devout and Christian or Muslim tend to be more nervous about anger at God. So because people often see it as morally wrong, and they might see it as being some kind of sign of disrespect, there's often real reluctance to disclose it. And when people do choose to tell somebody that they're angry, at God, the good news is that most of the time they get a supportive response where people will

say something like, you know, I felt that way myself too. But in the studies that we've looked at, about half people also said that they told somebody and they got at least a little bit of a judging response, a feeling that maybe you shouldn't be feeling that way or maybe that's not okay. And what we found was that if people are able to express complaint or ask tough questions, of God. This is, you know, for believers who want a relationship with God. If they're able to express those negative emotions but still stay engaged in a relationship, these are the people who tend to report that they've come out with this sense of a relationship with God being stronger. And having the affirmation of another person helps with that. So if I tell you that I'm angry at

God and you're like, you know, a lot of people feel that way, that will actually help me to feel safer going to God and working through it. But if people have even a little bit of that sense of judgment coming across, they're more likely to try to suppress their anger at God, and they're more likely to stay angry. They're also more likely to exit the relationship with God, and they're more likely to use substances. So a big take-home point is that anger toward God is something that a lot of people experience and that letting people know that it's normal, that it's common, and not having them feel any shame about it

might actually help them to go to God to work through it. Whereas if people feel any shame or rejection around that, like that God's can't handle it or that their religious community can't handle it, they're more likely to use these avoidance strategies that ultimately can end up being like, like imagine yourself trying to pray and it's like there's an elephant in the room because you're not telling God that you're angry.

Well, you know, certainly in the monotheistic traditions, the idea is that God already knows, right? So you're not really hiding anything, but people feel like, well, I'm just not going to bring this up, this thing that I'm angry about. So I would say for people to be able to tolerate the struggles that they're having, be able to be okay with the fact that they're having the struggle and to maybe just express their concerns in a respectful way to God that can take them a long way. Yeah, I do some research on medical education. That's my sort of where I've done some work.

And psychological safety is one of those things we look at, like, how safe do you feel like telling your boss, like, hey, I disagree with you. I think you're missing something. And what we found is that if, you know, people are higher in psychological safety, you report more heirs to them, better care is done. but it takes a lot of different things to create psychological safety. And so when you say there's people that when you share your anger, they shame you or it's like not okay or you shouldn't be angry or, you know, it breaks down.

It decreases that psychological safety. Whereas, you know, I think even like in therapy, it's like, hey, if a patient feels angry at something I did, it's like, how can I meet that with gratitude and sort of curiosity? and I see that as kind of the ideal of like how a good therapist is, right? They kind of like are, you know, it's not too much to be angry at the therapist because that's part of therapy. That's transference. I mean, how can you grow past, you know, some of the internalized early experiences of

disavowed anger if you don't feel some anger at your therapist? And, you know, I see that in a very similar light with like anger towards a higher being. You know, it's like it's part of the process. Yeah, two points I wanted to just mention as you were talking, Dave, and speaking to what Julie was saying too, I think one point is that Julie had mentioned this earlier, but I think it's important to stress, you know, you're talking about which struggle do you find most interesting. That's kind of like asking to pick among the favorite of your six children, you know, there. And so that's a difficult thing to do.

But the other thing is, even though these are different struggles, they are connected to each other. And so people who struggle in one domain are more likely to struggle than another domain, too. Julie was talking about struggles with God and then anger towards people in the congregation. And that's not uncommon at all. I recall working with a Muslim student who was coming in because he was having religious doubts. He was a physics major. And what he was learning in physics wasn't consistent with what he'd been taught in growing up about Islam. And at the same time, coupled with the religious doubts were real fear and anxiety about what it would mean for him if he were to share some of these doubts with his family and his tight,

Muslim community and would he be divorcing himself from the people that he loved? So doubt-related struggles and interpersonal struggles just went hand in hand. They're very difficult to disentangle. The other point I want to make, which is related to what you were saying, David, about the importance of the safe relationship. In my therapy experience, people don't usually come in with a spiritual struggle. They're certainly not their presenting problem. Because these these conflicts are often very sensitive, sometimes hidden to the point of people themselves being unaware of them. They may not come out till well into therapy and until after the therapeutic, the therapist has established some trust and the clients feel it's a safe place to talk about

these matters. So you need a relationship. You need to work on building the relationship and sometimes what may seem to be a client who is not experiencing struggles at all, we can be surprised by that, that down the road struggles emerge. Yeah, I think also like, thinking about my own sort of journey, I've had a bunch of different therapists in my journey, and one of them was spiritual, and it's like I didn't want to share my spiritual struggles with her for some reason, because it didn't feel safe. And then one was kind of anti-spiritual, and I felt like when I would bring stuff up, it got such a secular bent that it was almost like it shut up. It's me down, you know? And then also like there's the projecting that I've noticed of my own sort of

reflections of their critique upon my process, you know, which is inherently there because I am, I might imagine they be, they may be more secular or more secular minded, you know, or more, more full of secular theories. So I'm wondering as like, how do you, how do you navigate this sort of with clients and how do you, you know, that first time they bring up that spiritual struggle, how do you meet them in that so that they feel safe, kind of continuing to tell their story? I think it's important to be authentic. And in this area, it's first of all, important to meet, when the topic arises, to meet it with interest and curiosity and to basically say, I'd like to hear more about that. I'm not familiar with that. Could you tell me more? What's that experience

like for you? And so part of it is, just we communicate our interest verbally and non-verbally too. We don't try to change the subject. We don't shift in our seats. We don't look uncomfortable. And that's part of it. And at times, I think it's important to be really transparent with the patients and clients we work with if we want to know where we're coming from. And I don't think we can be completely neutral about this. and to be, you know, as Freud would say, you know, tabular rosas, people like you're talking about, David, our patients and clients will read into us. And sometimes I think some self-disclosure in very appropriate ways is important. So the people we're working with do have a sense of

where we're coming from. And having said that, being careful then not to impose and not to try to convert or parasitize to either a secular or a particular religious tradition. I'm curious, like, what you think, are there definitive evidence-based positive spiritual things, which despite maybe, you know, that we could look outside of, like, a specific spiritual framework, and we could say, that's absolutely good. You know what I mean? Like, it's absolutely good. Forgiveness always works, or forgiveness, you know, always leads to mental. mental health benefits, are there those things that are like, despite having very spiritual backgrounds, the research continues again and again to say, this is a positive thing or this is a

negative thing? I would venture to say, based on some research, it's certainly consistent with what you were just saying, David, that being able to provide that sense of safety. and as you were saying, Ken, that sense of interest and acceptance. So this curiosity and a safe environment for the client to talk about what's going on with them is going to be good no matter what. And to be able to normalize the idea that a lot of people are having these struggles, that this is very, very common and that it could lead to growth. I think that those ideas could be conveyed by,

any mental health professional in a way that would be respectful and would help to provide at least kind of a stage setting maneuver to make it safe for the person to talk through this with you. I think that's absolutely the case. I think part of it is simply, in effective therapy here, is creating a safe space for people to talk about what they've not been able to talk about. And when people have that safe space, many people just respond with a, oh, I can talk about that here. We did one program several years ago now. We developed it for spiritual struggles in college called Winding Road. And in just a short period of time, we found that the students who were experiencing

struggles, they described a number of positive gains in just an eight-week program. And I think a big part of it was just the normalization of the struggles and to see other students struggling with the same spiritual issues they were dealing with and to feel like it's okay. It's okay to struggle. It's not a symptom. It's a part of my growth and my evolution as a person. So, you know, there's lots of ways that, you know, I often tell, I often tell therapists and workshops that we're not talking about the development of a whole new therapeutic orientation here. Being sensitive to spiritual issues and therapy as both resources and sources of struggles and problems is something that can be simply integrated in any therapeutic orientation. And it's not rocket science. We can apply some of the same basic clinical

skills, listening, caring, appreciation of differences into the religious and spiritual realm. And when we do, I think it really just magnifies the potential power of therapy to create transformation in people's lives. Yeah. Can I jump in with one one related thing in terms of, so I do agree very much with Ken that these are a lot of therapy 101 skills. As you were talking about David, I think a problematic thing is having a therapist be visibly uncomfortable or kind of steer away from these topics in conversation. That's kind of an obvious thing. But I think on the other side, something you might run into in some of the more faith integrated settings is that the therapist might feel pressured to come up with a theological solution for the client. You know, I've got to find the right Bible verse.

I've got to find the right prayer. I've got to find the right spiritual exercise. or the right philosophical or theological argument that's going to help this client not be angry at God anymore, or that's going to help them work through these issues with their faith. So I think that's a risk sometimes of people trying to wear both hats of being pastoral and being a therapist, is that there might be a little bit more of a tendency to go in with that fix-it strategy. And one thing that we have definitely found from our research on anger at God is that there's not any one theological, answer that people find uniformly satisfying. For some people, the idea that God doesn't exist

seems to be the thing that works for them. For other people, it's the idea that God's not to blame. God didn't cause these things. For other people, it's the idea that God has some higher purpose or that God's ways are mysterious or that God is suffering with us. There are all, or that I need to work through my issues with my parents, and then the God stuff is going to get better. there's all these different modes. And I think sometimes people might have kind of a pet idea. I know that I had a pet way of dealing with anger at God, having to do with God being loving but mysterious.

And when I tried it with clients a couple of times, it really backfired. Because what they didn't need was a theological solution and me to come up with that for them. They just needed the gift of my presence. And that goes back to basic therapy training, chaplaincy training, that ministry of presence and letting people know that we are there with them when they're suffering is typically much more valuable, especially when they're in an acute crisis, much more valuable than us coming up with the right theological bullet or pill that's going to put everything in line for them. So I think having therapists take that pressure off themselves and realize that it might

actually be damaging, especially when people are in crisis, to try to give people theological fixes and start tinkering with their theology, it just might not be the most helpful thing. Well, to add to that, if we have a client who's coming in or a patient, who's coming in, and the client is having a conflict with a mother, and it's really bothering them very much,

and the client asks the therapist, what should I do? Tell me what to do. Well, therapists wouldn't, you know, any therapist worked with his or her assault, would not say, okay, you need to do X, Y, or Z. The therapist would probably say, well, let's talk about it. Let's talk about it.

Let's try to sort it out. So tell me more about the conflicts you're experiencing and your feelings. And that's no different, I think, than the way that you can approach anger to God or feeling punished by God or feeling abandoned by God. Tell me about it. What's that like for you? What are you experiencing? How have we been feeling this way?

Let's try to sort it out. And again, so some of the basic clinical skills can be, you know, applicable to the spiritual and religious realm. Yeah. And in the book, you also talk about, like, how general attachment styles with parents, secure, avoidant, ambivalent, disorganized, influence our relationship with God. You know, can you talk a little bit about that, what the research has shown? Sure. Well, there's lots of research out there that we did not initiate. There's been research for years showing that people's images of their parents tend to relate to their images of God.

And it's not surprising because with our parents being our first authority figures and then we learn about God, it's not surprising if we kind of project the things about our parents onto God. A few things that end up being important here are that in terms of how we envision God, that actually the images of both parents are important. I know Freud was very focused on the idea of God as this father figure. And certainly in the monotheistic traditions, we tend to hear about God in male terms. But a lot of the attachment stuff, do I feel safe as an infant, are people responding to my needs? A lot of that ends up coming from moms or other female caregivers as well. So there's both this this male and this female dimension that can end up getting projected onto God. And sometimes people aren't aware of the ways that, you know, like maybe they've been taught that God is unconditionally loving.

But because their mother or father tended to be more, you know, disapproving and you had to do everything right to please them, they'll project that onto God or maybe focus on the scriptures or the teachings that, emphasize that more conditional aspect of God's love. So I think with the parental things, sometimes healing the relationship or the memories about the parent, which sometimes can happen even through the therapeutic relationship in part, can help to, can help people to be more open to different images of God. But we also don't want to go to this extreme that psychologists are sometimes tempted to say, oh, it's all just about your parents and then end up not having a a conversation about the person's actual image of God, which might have been very much shaped by religious teachings and other life experiences as well.

Yeah, the research also shows that for some people, they're able to look to God in some ways is a compensation for problems with their parents. So God becomes the kind of idealized parent that they wish they had had. So it's also a very rich and interesting area. of how, how does our understanding of God develop and how our relationships with parents and other figures in the community, how does it shape who we come to worship? Along that related note there,

I'm wondering if, you know, this distinction between having a relationship or an attachment style from your parents and, but also sort of a God object, a God-object relationship as well. Does that also apply? to polytheistic or atheistic or secular people as well who may not believe in God, but have some still sort of relationship to a personified sense of the transcendent meaning or something like that, shouting angrily at the universe.

Does that also apply in that sense? Our research hasn't looked at that question really directly, but what I would speculate would be that a more secure sense of attachment in general, is going to enable people to feel safer in most of their relationships and in different life situations. You kind of have that inner foundation of security. So I would speculate that even in a tradition that's not this kind of one-on-one relationship with God, that having a secure attachment foundation would help to give people a certain amount of psychological security and strength to help them face spiritual struggles? Well, that was a question that came up for me in the

moral struggles chapter, because one thing I think that came up for me was, to use Karen Hornay's phrase, the tyranny of the shoulds, sometimes an overly punitive inner critic, I should do this, I should do not that. An overly rigid moral superstructure can impede the ability to look honestly and authentically at, for example, our anger towards God or emotions or impulses that we have that go against a particular moral code. And so I think that's where that question came up. Well, we did kind of try to address that issue of the shoulds. And, you know, it's I think another example of the, what we're called to do as therapists is to balance and weave together competing sometimes demands on us. On the one hand, we try to avoid problems of moral over-control,

which sounds like Hornay and Freud, we're emphasizing oftentimes in their work, you know, the demands of the superego. On the other hand, there's the problem of impulse under control, which is maybe the id gone wild. I think we get better than Freudian terms. And you can air and direction. Sounds like a new TV show. It gone wild. Yeah. And so the moral struggle is

how do you negotiate these two extremes? And sometimes people actually go back and forth, a yo-yo back and forth between moral over-control, trying to control their impulses to the point that they get no satisfaction of life or go to impulse out of control.

and so they lose control and they may engage in addictive behaviors and so they go back and forth between that and the moral struggle is how do you find a way to reconcile these these natural aspects of who we are our impulses and our moral codes yeah that's good i see a lot of spirituality as like how do we balance these two these two facets you know the the out of control younger stuff son versus the kind of restrictive, over-controlled, judgmental older son, right? I think we all kind of like. Yeah, I worked with a pastor, actually, more than one who were there wrestling with use of pornography, and they were pastors, and they just couldn't, they had such a terrible time reconciling their use of pornography with what they were preaching on Sundays. And so, you know, that was quite a moral struggle. I kind of want to bring this, bring some summary sort of summative comments from you guys and bring this to a close.

From your research, what are the things that you would most like to communicate to, like, the audience of psychotherapists, psychiatrists, you know, mental health professionals that are listening to this? Like, what are some things that you definitely want them to walk away with? Maybe we'll start with you, Julie. I would say for me, key messages for therapists would be just having the courage and the openness to allow people to talk about these spiritual struggles and showing that curiosity that Ken talked about and not let yourself be frightened into thinking that you have to have the answers or that you need to have the referrals, just to be able to provide that safe place and to be able to normalize for your clients or patients that so many people have these struggles and that they're a normal

part of human experience. Being able to provide those things, I think, is a wonderful service that any mental health provider can give. Very good. Ken, what do you think? Summative takeaways you would want people to have? Well, we're spiritual as well as psychological, social, physical beings. and when we open the door to a spiritual conversation in therapy, I think we have the potential to deepen and enrich the therapeutic process and to enrich the lives of our clients. Again, this doesn't involve a whole new therapeutic orientation or necessarily needing years of training. I remember at a workshop of two physicians.

one physician said to me, after us, oh, great. So now I have to become expert in spirituality and religion on top of everything else that I'm dealing with. Just great. And I said to him, I said, look, you don't have to do that. This isn't rocket science. But try this as an experiment.

Just ask your next patient one question about their religion or spirituality. One question, like, how are your problems affecting you, religiously or spiritually. And see where it takes you. It may open the door to a deeper conversation, and they'll lead the way.

They'll take you there, and you might find that it really does deepen and enrich your own work with your patience. Very good. Very good. Kevin, anything that you'd like to put out there, things that you took away from reading this book? I overall really enjoy.

the book and I think maybe a final comment was thinking about this wanting to work to help patients move from brokenness to wholeness as a particular thing that shapes the outcome of spiritual struggles was a big takeaway from me and trying to and trying to help them have a more expansive, broader, deeper, flexible approach at times to help find ways to affirm life, find ways to have a more cohesive, more integrated sense of their spiritual life and how that relates to other aspects of their life. Those were big takeaways for me and how to get as much of the gold out of this spiritual struggle as possible. Very good. Well, thank you guys so much for coming on. I really appreciate it. Thank you. And for my audience, if you have a chance,

go check out their book. I think it will be a good deep dive into into this topic and give you some comfort in addressing spiritual concerns, even if you're not a spiritual person, or if you are a spiritual person, maybe how to do it in a way with some nuance and to do it in a way that would be most helpful to clients. If you have any questions, you can always reach out to me and my website, Psychiatrypodcast.com, and we'll leave it there.