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Older adults' and mental health professionals' attitudes toward religion-spirituality in psychotherapy

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Older adults' and mental health professionals' attitudes toward religion-spirituality in psychotherapy
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Joules, Shaalon
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English
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91 leaves : ; 28 cm

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Subjects / Keywords:
Psychotherapy -- Religious aspects ( lcsh )
Older people -- Attitudes ( lcsh )
Mental health personnel -- Attitudes ( lcsh )
Psychoanalysis and religion ( lcsh )
Mental health personnel -- Attitudes ( fast )
Older people -- Attitudes ( fast )
Psychoanalysis and religion ( fast )
Psychotherapy -- Religious aspects ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Includes bibliographical references (leaves 83-91).
General Note:
Department of Psychology
Statement of Responsibility:
by Shaalon Joules.

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ocm48713479
Classification:
LD1190.L645 2001m .J68 ( lcc )

Full Text
OLDER ADULTS AND MENTAL HEALTH PROFESSIONALS
ATTITUDES TOWARD RELIGION-SPIRITUALITY IN PSYCHOTHERAPY
by
Shaalon Joules
B.A., University of Colorado at Denver, 1998
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Clinical Psychology
2001
n
J'
V*


2001 by Shaalon Joules
All rights reserved.


This thesis for the Master of Arts
degree by
Shaalon Joules
has been approved
by
Shawn C. Worthy


Joules, Shaalon (M.A., Clinical Psychology)
Older Adults and Mental Health Professionals Attitudes Toward Religion-
Spirituality in Psychotherapy
Thesis directed by Professor Mitchell M. Handelsman
ABSTRACT
This study assessed older adults and mental health professionals attitudes
toward various religious-spiritual issues and behaviors in therapy. Older adults and
professionals answered 37 items on an exploratory questionnaire regarding how
religious-spiritual issues may play a role in therapy with older adults. They also
responded to items on the Spiritual Involvement and Beliefs Scale, which examined a
persons spiritual beliefs and actions. A total of 124 psychologists, 109 older adults
from churches, and 106 older adults in the community participated in the study. Five
factors emerged from analysis of the 37 items: general acceptance of beliefs in
therapy, therapists role, clients perspective, general judgments, and
negativity/skepticism. In general, both professionals and older adults agreed that
religious-spiritual beliefs should be given the same importance as age, race, or gender
in therapy. However, a discrepancy does exist between professionals and older
adults attitudes toward integrating religion-spirituality into therapy. Professionals
tended to be more hesitant to initiate certain spiritual interventions. In addition, more
experienced professionals were less willing to discuss religion-spirituality in therapy.
Also, older adults tended to expect religion-spirituality to be addressed in therapy,
relatively more so if they were affiliated with a church, female, unmarried, or
Christian. The results of this study show the need for professionals and older adults
to understand how variables such as spiritual background, gender, or marital status
can affect each groups attitude toward involving religion-spirituality in therapy.
Mutual understanding can help begin a respectful dialogue about to how to address
this issue in therapy with older adults.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
IV


DEDICATION
I dedicate this thesis to my parents and sister for their continuous understanding,
support, and inspiration.


ACKNOWLEDGEMENT
My thanks to my advisor, Dr. Handelsman, for his guidance during the writing of this
thesis. I also wish to thank all those who helped me collect data for their support.


CONTENTS
Tables...........................................................ix
CHAPTER
1. INTRODUCTION...................................................1
Religion in Therapy.........................................3
Appropriateness of Addressing Religion in Therapy.....3
How to Address Religion in Therapy....................7
Educating Therapists in Religious Issues.............15
Therapists Beliefs and Approach to Treatment........17
Consulting with Clergy...............................20
Older Adults and Religion..................................22
Older Adults and Therapy...................................25
Conclusions................................................28
2. THE PRESENT STUDY.............................................32
Method.....................................................33
Participants.........................................33
Materials............................................33
Procedure............................................34
vii


Results
35
Spiritual Involvement and Beliefs Scale Scoring.38
Personal Spiritual StatusSIBS..................39
Attitudes toward Religious-Spiritual Issues in Therapy.42
Analyses of RITQ................................53
Discussion...........................................58
APPENDIX
A. ROLE OF RELIGIOUS-SPIRITUAL ISSUES IN THERAPY
QUESTIONNAIRE...........................................70
B. THE SPIRITUAL INVOLVEMENT AND BELIEFS
SCALE...................................................73
C. DEMOGRAPHIC INFORMATION FORM C.........................76
D. DEMOGRAPHIC INFORMATION FORM P.........................78
E. RESEARCH INFORMATION...................................80
F. COVER LETTER...........................................81
G. COVER LETTER...........................................82
REFERENCES.............................................................83
viii


TABLES
Table
1.1 Levels of Integrating Spirituality into Therapy................10
2.2 Demographic Profile of Respondents.............................36
2.3 Demographic Profile of Professionals...........................38
2.4 Spiritual Status Profile of Respondents........................39
2.5 Percentages of Responses to Items on RITQ......................43
IX


CHAPTER 1
INTRODUCTION
As of 1994, there were 33.2 million older adults (age 65 and older) in the
United States (U.S. Census Bureau, 1995). This number is expected to increase
rapidly as the baby boomers enter their senior years. According to a report by the
United States Department of Health and Human Services (1999), at present 19.8% of
older adults (age 55 and older) experience mental illness in a given year. Moreover,
Jeste et al. (1999) stated that aging baby boomers have a higher risk of depression,
anxiety disorders, and substance abuse than the current cohort of older adults. Thus,
the researchers predict the prevalence of mental illness in older adults will rise to
21.6%.
Many older adults consider religion a reliable coping mechanism (Koenig,
Larson, & Matthews, 1996); e.g., religious traditions, rituals, and scripture tend to
remain static for long periods of time. Older adults commonly express that God helps
them cope with their problems (Bower, 1996). Stronger religious beliefs may be
found in older adults as they are more likely to have experienced situations that have
tested their faith or out of which faith was bom (Koenig, 1994). Religion provides a
framework for understanding the human experience and the nature of the universe.
In addition, as baby boomers enter into late life, they appear to be turning
1


more to religious-spiritual beliefs (Clark, 1999). This is parallel to the trend that an
increasing number of clients voice spiritual issues in therapy. A 1992 Gallup poll
showed that 81% of respondents would prefer a counselor who integrates their beliefs
into the counseling process (Kelly, 1998). Thus, the role of religion in psychotherapy
with older adults needs to be studied because the American population values
religious beliefs, and as the new generation of older adults is more willing to seek
psychiatric care, this issue is increasingly pertinent to mental health professionals
providing optimal treatment to clients.
I will divide the remainder of this introduction into three sections: role of
religion in therapy, the relationship between older adults and religion, and working
with older adults in therapy. Each section will cover what is currently known in the
area. I will conclude by describing what is unknown in the area of religion in therapy
with older adults and the specific research questions I will address in my thesis.
Some general research questions I explore in the introduction are: In what way can
religious beliefs be integrated into therapy? How significant are spiritual beliefs for
older adults?
Before continuing, I will clarify some terms. The literature regarding this area
describes both religion and spirituality. Religion is generally considered to be the
beliefs, practices, and rituals related to a specific established religious tradition
(Koenig & Larson, 1998, p. 381) in order to worship a higher being or power.
Spirituality is a sense of relatedness to a transcendent dimension or to something
2


greater than the local self (Koenig & Larson, 1998, p. 381). Both involve the notion
of a higher being, but spirituality does not emphasize rules or rituals. Thus, the two
terms do overlap with each other, and much of the literature uses the two terms
interchangeably (Josephson, Larson, & Juthani, 2000; Meador & Koenig, 2000;
Standard, Sandhu, & Painter, 2000). I will also use the two interchangeably in this
paper.
Religion in Therapy
In this section I discuss the following issues from the literature: the
appropriateness of addressing religion/spirituality in therapy, how to address religion
in therapy, the role of religious beliefs as a coping mechanism, educating therapists in
spiritual issues, therapists beliefs and approaches to treatment, and consulting with
clergy.
Appropriateness of Addressing Religion in Therapy
The concept of therapy has changed over the years, from that of patient and
distant therapist, to that of a dynamic, cooperative patient-therapist relationship
(Heilman, 1999). In such a relationship, therapists should examine all variables that
may pertain to clients background, which includes religion. Some clients may view
or understand mental illness to be a religious/spiritual problem. Appropriate
treatment for such clients might involve addressing spiritual concerns (Ruiz, 1998).
3


For years, many therapists have ignored or pathologized religious/spiritual issues in
treatment (Turner, Lukoff, Bamhouse, & Lu, 1995). This seems ironic considering
both religion and therapy make assumptions about what is unhealthy (e.g., neurotic
anxiety), and what is healthy (e.g., ability to love) (Jones, 1994). The diagnostic
category of religious or spiritual problem in the DSM-IV demonstrates that the old
attitude toward religion is changing. This category allows therapists to address
problems of a spiritual nature that are the focus of clinical attention and not
attributable to a mental disorder (Turner et al., 1995). Many professionals in the area
of mental health are moving to integrate spiritual issues into therapy (Miller, 1999).
The goal of this integration is to understand better how religious/spiritual beliefs
affect clients worldview and problems they are experiencing. Thus, if clients wish to
have their religious beliefs taken into consideration, therapists should acknowledge
these beliefs and discuss their role in clients problems.
Many clients not only seek relief from psychiatric symptoms, but also desire
spiritual wholeness and moral guidance in their lives, and believe therapy can help
with these issues (Jones, 1994; Sperry, 2000). Ignoring religious beliefs when clients
raise them as relevant to their problem or treatment may be unethical. It could lead
clients to terminate therapy (Richards & Bergin, 2000), thereby causing them to
endure continued suffering. Also, disregarding beliefs that are an integral part of
clients lives means that therapists are discounting clients roles as active participants
in therapy (Sollod, 1993). In essence, therapists are telling clients, We hear you
4


saying that religion/spirituality is important to you, but we do not think it is legitimate
or valuable in helping you deal with your problem. Therapists may be preventing
clients from making choices about treatment that directly affect their well-being.
Addressing religion in therapy is helpful in identifying healthy religious
resources that bring comfort and support (Koenig, 1998), and can aid clients in
complying with treatment. Research shows that people who attend church are
happier than those who do not, which is most likely due to social support of a church
community and the feeling of being close to God (Argyle, 2000). Prayer and
meditation can also be beneficial to clients. British psychologists Maltby, Lewis, and
Day examined the relationship between prayer and mental health (Praying, 1999).
These psychologists studied 251 men and 223 women, ages 18 to 29. They measured
the subjects reasons for having a religious belief, the frequency with which they
attended church and their tendency to depression. The researchers found that people
who pray frequently are less likely to suffer from depression and anxiety. Similarly,
other studies have shown that frequent prayer appears to act as a stress deterrent and
stress buffer (Miller, 1999).
Meditation has been found to result in greater relaxation, alertness, awareness,
empathy, and sensitivity (Sollod, 1993). Kabat-Zinn et al. (1992) studied the
effectiveness of a group stress reduction program based on mindfulness meditation
for patients with anxiety disorders. Twenty of the 22 participants reduced their
anxiety and the frequency of panic attacks to minimal levels following the meditation
5


treatment. Despite this finding, the benefits/results of meditation seem to be the same
as those incurred from relaxation exercises (Worthington, Kurusu, McCullough, &
Sandage, 1996). However, for clients who are spiritually inclined, meditation may be
a more comfortable method of assisting them to better comprehend the self.
Therapists should also address religion in therapy to be aware of unhealthy
religious coping. Clients may use religious beliefs to avoid underlying issues or to
resist therapy (Bamhouse, 1986). For example, they might employ religious beliefs
to justify and perpetuate feelings of guilt. Also, feelings of anger toward God or
believing negative events are Gods punishment tend to lead to unsuccessful
adjustment (Argyle, 2000). Indeed, a study soon after the Oklahoma City bombing
revealed that subjects who used negative religious coping (e.g., God abandoned them,
they turned away from God, or expressed anger at God) tended to report greater
callousness toward others (Koenig, 1998). Thus, research has shown the relevance,
utility, and harm of religious beliefs for clients in treatment, and the resulting need for
therapists to give attention to spiritual beliefs. Knowing the impact religious beliefs
can have on people, I will ask in my study whether older adults and therapists
perceive religion to be compatible with therapy.
6


How to Address Religion in Therapy
Procedure. Having established the appropriateness of religious issues in
therapy, the first step in addressing religion/spirituality in therapy is to do an
assessment on this factor (Meador & Koenig, 2000). Reasons for conducting a
religious/spiritual assessment are to assure clients that their religious life is pertinent
to treatment, to understand the nature of clients thinking patterns, and to make the
overall assessment of clients comprehensive (Schultz-Ross & Gutheil, 1997).
Therapists can begin by simply asking if religious faith is an important part of clients
lives (Koenig, 1998). If clients desire to talk about their faith, therapists should
incorporate the information into the rest of the history obtained. If clients prefer not
to talk about their faith, this request should be honored (Meador & Koenig, 2000).
Once therapists have discerned that religious issues are important to clients or
related to the presenting problem, a more detailed religious assessment is necessary
(Josephson et al., 2000). The following questions elicit germane information about
clients religious background:
1. What is your faith or belief? (Puchalski, 2000) What is your concept of a
supreme being?
2. How has your faith influenced your life in the past and at present? (Koenig,
1998, p. 327)
3. Are you part of a religious or spiritual community? Is this of support to you and
7


how? (Koenig, 1998, p. 327; Puchalski, 2000)
4. Are there spiritual issues you would like me to address? (Koenig, 1998, p. 327;
Puchalski, 2000)
In addition, therapists should ask clients to describe specific values and beliefs they
hold as well as rituals related to their religious tradition. Moreover, therapists can ask
clients for their sense of the role religious beliefs play in their presenting problem.
Therapists may also inquire about the influence of religion during clients
developmental years, who taught the client religious precepts, and the type of
relationship with this person(s) (Josephson et al., 2000). Boehnlin (2000) suggested
therapists note any positive or negative experiences clients have had with religion.
Finally, therapists should ask if clients have changed their religious affiliation from
that into which they were bom and what lead them to do so (Shultz-Ross & Gutheil,
1997). Following the viewpoint that taking a spiritual history makes an assessment of
clients more comprehensive, I will ask in my study whether older adults and
therapists think spiritual beliefs should be discussed in therapy.
Diagnostic Issues. Upon obtaining a religious history, therapists can then use
it to help with diagnostic issues. I will discuss three scenarios therapists may be
likely to encounter. In the first, therapists may have to differentiate a psychotic
episode from a religious experience. In this case, a common diagnostic consideration
is visions and voices (Sperry, 2000). The voices and/or visions a client experiences
must be put into a cultural context. In some cultures, visual or auditory hallucinations
8


with religious content may be part of a normal religious experience (Lukoff & Lu,
1999). However, sometimes religion may be a direct indicator of psychosis. Clients
with schizophrenia may feel they are God or Jesus or have a special relationship with
a supreme being. Thus, it is best to ask clients how they would respond to the voices
and visions and analyze those answers in conjunction with their religious history.
Psychotic responses are highly idiosyncratic, usually having to do with the self,
others being involved only in a paranoid way. Normal responses are in the direction
of healthier self-understanding, better relations with others or constructive actions of
some sort (Bamhouse, 1986, p. 102).
A second scenario may involve focusing clinical attention on clients distress
due to loss of faith, questioning of spiritual values, or conversion to a new faith
(American Psychiatric Association, 1994). For example, therapists may see clients
who have just had a near-death experience. The sole clinical problem could revolve
around them doubting their mental stability (Lukoff & Lu, 1999) or how this
experience has changed their lives and their relationships with others. Information
gained from a history of clients religious backgrounds will help therapists better
understand the nature of clients problems and how to treat them.
The third scenario includes the possibility that clients may simultaneously
experience a religious/spiritual problem and a mental disorder.. The mental disorder
could be related or unrelated to the spiritual problem, but the problem is severe
enough to warrant clinical attention (Lukoff & Lu, 1999). For instance, clients with
9


major depression may believe they must suffer depressive feelings because God is
punishing them for some sin they committed. Therapists need to treat both the
depression and the religious problem. Substance abuse and dependence, obsessive-
compulsive disorder, and psychotic disorders are other disorders in which spiritual
issues often arise (Koenig, 1998; Koenig & Larson, 1998; Lukoff & Lu, 1999).
Methods of Treatment. Once therapists have clarified diagnostic issues,
various methods can be used to approach treatment with a religious-minded client.
According to Sperry (2000) therapists can incorporate religion into therapy at three
levels. Using Sperrys ideas, I have summarized his levels into Table 1.1, which
shows how these three levels are broken down in the therapeutic setting. Sperry
commented that the first level is the most spiritually involved type of therapy; at level
two, therapists may or may not be personally spiritual, but could employ spiritual
interventions. The least spiritually involved level in therapy is level three.
Table 1.1
Levels of Integrating Spirituality into Therapy
Level I Level II Level HI
Conduct spiritual assessment Yes Yes Yes
Discuss spiritual issues in therapy Yes Yes Maybe
Use spiritual interventions with clients Yes Yes Maybe
Process spiritual issues in therapy and use spiritual interventions with clients Yes Yes Maybe
10


Table 1.1 (Cont.)
Level I Level II Level III
Spiritual in personal life Yes Maybe No
Practice spiritual based therapy Yes Maybe No
The first level routinely incorporates a spiritual assessment of clients.
Therapists believe in therapeutic processing of clients religious issues, discussion of
psychospiritual concerns. Furthermore, therapy is spiritually based and therapists
actively seek to employ their personal spiritual beliefs/interventions in professional
practice. Consequently, it appears this level is best suited for therapists and clients of
the same religious background.
The second level of incorporating spirituality into therapy involves a spiritual
assessment, processing clients spiritual issues, and using spiritual interventions if
necessary (Sperry, 2000). Unlike the first level, therapists in this level exercise a
degree of latitude in their approach to religious matters. For example, therapists
method of treatment may reflect their personal beliefs. Or, therapists may believe it is
appropriate to work only through clients religious viewpoints. Also, therapists (like
those in the first level) think it is important to work not only with relevant spiritual
issues, but in the process strengthen clients relationship with God or a higher power.
The third level includes spiritual assessment as a regular part of practice
(Sperry, 2000). This is based on ethical guidelines of practice. Spiritual interventions
such as prayer can be used, but the therapists role is passive. Essentially in this
11


level, therapists are concerned about spiritual history to the extent they would be
concerned about developmental history in completing a psychological evaluation.
The therapists main role is to respect and address religious issues, if relevant, just as
with any other variable. This can be done even if therapists and clients religious
views differ.
In addition to incorporating spirituality into therapy at various levels, different
types of therapies may include religious beliefs as a mode of treatment. Little
research has been done on the different types of therapies and their effectiveness
regarding religious-oriented clients (Worthington et al., 1996). However, one study
conducted by Propst (as cited in Koenig, 1998), examined the effects of Christian
beliefs in cognitive-behavioral therapy with religious clients. Results showed
religious cognitive-behavioral therapy to be equally but more rapidly effective
compared to nonreligious cognitive-behavioral therapy in treating mild to moderate
depression in religious clients. This result may stem from cognitive-behavioral
therapys emphasis on the importance of personal beliefs influencing behavior and
that errors in thinking occur, but can be modified. Accordingly, many religious
persons find the cognitive-behavioral approach to be flexible and compatible with the
desire to address their values (Shafranske, 1996).
Therapists can also adapt treatment in such a way that they may employ
spiritual interventions, such as spiritual journal writing and meditation (Taggart,
1994), religious scripture or prayer, consultation with clergy, or referral to clergy
12


(Koenig, 1998). Consulting with clergy will be discussed in further detail later in this
paper. In this study, I will ask older adults and therapists which of these spiritual
interventions they find appropriate to use in therapy.
Journal writing is a technique familiar to and used by therapists. This
technique can also be tailored to a spiritual focus. Clients write down spiritual
feelings, conflicts, and topics of prayer (Taggart, 1994) for therapeutic analysis.
Using religious scripture to place religious teachings in context may help
clients correct an erroneous belief or misperception. Reading certain passages
regularly or when needed can bring relief to clients (Cloud & Townsend, 1992).
Praying, either silently or aloud, in a therapeutic session must be done with caution.
Obviously, therapists should do so only with the consent of clients, and it is best for
clients to do the praying. This way, clients can directly express themselves and they
are in control of their treatment. Prayer may be most useful when clients are
experiencing a discrete stressor, such as the death of a loved one or upcoming surgery
(Koenig, 1998). All of these techniques may be included more freely when there is a
match in religious beliefs or background between therapists and clients (Meador &
Koenig, 2000).
Regardless of the type of therapy or level of spirituality in which therapists
choose to operate their practice, it is imperative that the method and goals of
treatment are discussed with clients. Therapists and clients should consider whether
religious beliefs will help or hinder treatment goals (Northcut, 2000). Religious
13


coping strategies that have been helpful previously to clients might be applicable to
the current problem. The decision to use such strategies must ultimately come from
clients. If clients believe religious beliefs would hinder treatment, therapists can
discuss with clients why this may be so (Northcut, 2000). If clients decide not to use
a religious coping mechanism, therapists should respect this choice.
Coping Mechanism. Clients religious beliefs may be a beneficial coping
device. Argyle (2000) reported that 130 studies have been done which examined the
effectiveness of religious coping on mental health. Analysis showed the relationship
between religious coping and mental health to be 34% positive, 4% negative, and
62% nonsignificant in all of these cases. In the majority of the cases it appears that
religious coping did not help or hurt an individuals adjustment to stressful events.
Initially, the results seem to indicate that religious coping is not any better than a
nonreligious coping at helping one adjust to crisis. Upon closer examination,
however, the reason for this finding appears to be a failure in asking about specific
types of religious coping (Miller, 1999). Specific spiritual strategies might have more
direct impact on positive or negative adjustment rather than general religious coping.
Along this line, some initial research has been done looking at what
constitutes helpful versus harmful religious coping. It seems spiritual support and
collaborative religious coping (partnership and guidance from God), congregational
support, and benevolent religious reframing (consider a negative event as Gods will)
are forms of helpful religious coping. Discontent with congregation and God (feeling
14


abandoned by church and God) and negative religious reframing (a negative event is
punishment from God) are harmful coping strategies (Koenig, 1998). According to
Ellison and Levin (as cited in Faith and Health, 1998) who have reviewed studies
examining religious beliefs and its effects on health, religious involvement is
generally associated with better health status. The benefit of religious beliefs seems
to lie in its strength in promoting healthy behaviors, social support, self-esteem,
coping skills, and positive emotions. Of course, therapists must remember that a rigid
or inflexible religious system can undermine a healthy sense of self (Koenig &
Larson, 1998). Thus, therapists need to address religious coping that may be used in
a defensive, avoidant, or other negative manner (Meador & Koenig, 1998). Religious
coping mechanisms can be used to change clients cognitions in a positive direction.
Based upon this research, I will ask whether older adults and therapists view religious
coping as helpful or harmful and under what circumstances they use spiritual coping.
Educating Therapists in Religious Issues
Noting all the issues involved in addressing religion in therapy, it is not
surprising to find research and discussion stressing the importance of educating
mental health professionals in the role of spirituality in mental health. A study by
Shafranske (2000) showed that 49% of therapists reported that spiritual issues were
involved in treatment often or a great deal of the time, 43% sometimes, and 8%
rarely. These numbers point to the need for therapists to be knowledgeable in dealing
15


with religious issues. Unfortunately, many clinical training programs omit or
minimize training about religion and spirituality (Koenig, 1998). This seems to be
supported by research that showed that 85% of clinical psychologists reported
receiving little or no training in the area of religion in psychology, while 65% of
psychiatrists reported that religious and spiritual issues were rarely or never presented
in training (Shafranske, 1996,2000).
Most mental health professionals will encounter growing religious diversity in
their practices (Richards & Bergin, 2000). Of the 91% of Americans who state a
religious preference, 93% are Christian, 2% are Jewish, and the remaining 5% are
Muslim, Hindu, Buddhist or belong to other religious groups (Boehnlein, 2000). It is
irresponsible for therapists to believe they would not encounter religious-minded
clients or simply refer such clients. Accordingly, in 1994, the Accreditation Council
for Graduate Medical Education published new Special Requirements for Residency
Training in Psychiatry, recognizing the significance of addressing spiritual issues in
psychiatry residency training programs (Koenig, 1998). The Council now mandates
that all psychiatry residency programs address religious factors and educate residents
about this factors relevance to understanding clients (Puchalski, Larson, & Lu,
2000). The curriculum must cover religion/spirituality and mental healthan
overview of findings regarding clients need and published research, how to assess
clients religious/spiritual practices, beliefs and attitudes, and religion/spirituality in
human life cycle development. Considering the growing number of spiritually
16


diverse people and the requirements for psychiatry residents, I will ask older adults
and therapists if they believe religion should be given the same standing as other
psychosocial variables in therapy.
Therapists Beliefs and Approach to Treatment
Training therapists about how to discuss religious issues in therapy should
also include therapists self-awareness about their own spiritual beliefs and practices
(Northcut, 2000). Therapists should know how their beliefs may influence treatment
with clients. A study by Bilgrave and Deluty (1998) looked at the relationship
between religious beliefs and psychotherapeutic orientations among clinical and
counseling psychologists. They mailed questionnaires to 501 psychologists; 237
completed the survey properly. They found that 66% of the psychologists who
responded believed in the transcendent. Seventy-two percent claimed their religious
beliefs influenced their practice of psychotherapy. These psychologists tended to rate
religion as personally important and to experience high levels of spiritual support.
Also, 66% claimed their practice of therapy influenced their religious beliefs. These
psychologists deemed their religious values as important and supportive, and they
held mystical spiritual beliefs. The researchers found that psychologists who
followed Eastern and mystical beliefs tended to endorse the humanistic and
existential perspectives, while those who held orthodox Christian beliefs tended to
subscribe to the cognitive-behavioral perspective. The researchers concluded that
17


most psychologists blend together what they have learned from psychology and their
exposure to religion, which leads them to intentionally choose specific
psychotherapeutic orientations.
Shafranske and Malony (1990) examined the nature of clinical psychologists
religiousness and spirituality, their attitudes toward religiousness, and their utilization
of religious interventions in therapy. The researchers sent questionnaires to 1,000
psychologists; 409 were completed. The results showed that 70% of psychologists
believed in a personal God or a transcendent dimension in nature; 74% believed
spiritual and religious issues were relevant to their work; 64% reported that the
religious background of clients influenced the course and outcome of therapy. The
researchers concluded that psychologists respected religious aspects of their clients
experiences. The psychologists attitudes differed, however, in regard to the degree
in which they addressed religious aspects in therapy. For example, 87% thought it
was appropriate to know clients religious background and 59% supported the use of
religious concepts in therapy. However, 68% believed it was inappropriate to pray
with clients. The researchers found that psychologists personal orientation toward
religiousness was the primary factor in how they approached religious issues in
therapy and the type of spiritual interventions they used.
A study by Allman, De la Rocha, Elkins, and Weathers (1992) examined
therapists attitudes towards clients who report mystical experiences. A survey was
sent to 650 American Psychological Association members. The response rate was
18


44%. The findings suggested that humanistic/existential therapists were least likely
to consider such clients pathological, while behavioral therapists were most likely to
consider these clients pathological. Also, therapists who reported having personal
mystical experiences or ascribed to personal spirituality were less likely to attribute
psychopathology to clients reporting mystical experiences. The researchers
concluded that psychotherapists are interested in mystical and spiritual matters,
contrary to widespread belief.
Shafranske (2000) compared 253 psychologists and 111 psychiatrists
religious attitudes to those of the general public. Results showed that psychologists
and psychiatrists are less religious than the public. For example, 73% of psychiatrists
and 72% of psychologists believe in God or a Universal Spirit, in contrast to 96% of
the American public. However, the number of mental health professionals who are
religious is not as low as one may think. Moreover, many of them seem accepting of
the role religious beliefs play in therapy. The findings also implied that therapists
may be biased when determining whether or not clients religious expressions are
pathological due to their own religious background. Hence, when working with
clients, therapists should be aware of their biases and that countertransference could
occur.
The research shows that therapists personal spiritual views influence how
therapists conduct their practice and diagnose clients. Based upon this conclusion, I
will assess whether therapists and older adults report that therapists spiritual beliefs
19


influence their practices with older adult clients.
Consulting with Clergy
Therapists should educate themselves regarding how to treat clients of
different religions (Richards & Bergin, 2000), and of course, asking clients specific
questions about their religious background. However, sometimes this is not enough.
Even through education, therapists may not be familiar with certain nuances. Or
clients could misunderstand or distort their religious beliefs and practices. In such
circumstances, therapists may need to consider a consultation with clergy.
Very little research has been done on the role of clergy in mental health.
However, research has shown that 40% of Americans turn to clergy as their initial or
primary mental health resource (Boehnlein, 2000). The reason for this appears to be
that spirituality gives meaning and purpose to ones life and this can be the dominant
issue, especially during times of suffering due to physical or psychiatric illness
(Puchalski et al., 2000). Hence, a person would feel more comfortable turning to
his/her clergy first. Consequently, therapists who utilize this fact can better
understand and treat clients (Ruiz, 1998). Indeed, collaboration between clergy and
therapists can be beneficial for these two parties, as well as the clients. The available
research shows that although clergy see people with serious mental illness, they are
not prepared to provide adequate treatment (Boehnlein, 2000). Mental health
therapists can gain access to individuals suffering from mental illness through clergy,
20


thereby providing quality treatment. Likewise, clergy will be well-equipped to focus
on spiritual issues and assist clients in connecting to social support systems through
the faith community (Koenig, 1998).
Unfortunately, a study by McMinn, Chaddock, Edwards, Lim, and Campbell
(1998) shows that only a moderate amount of collaboration is occurring between
psychologists and clergy. The researchers sent a questionnaire to 200 clergy, 200
psychologists interested in religious issues (APA Division 36 Psychology of
Religion), and 200 psychologists who were chosen without regard to religious
interests (APA Division 12 Clinical Psychology). The researchers received 245
completed questionnaires. Of the 245 participants, 56 were clergy, 113 were
psychologists of Division 36, and 76 were psychologists of Division 12. Apparently,
referral patterns between clergy and psychologists tend to be unidirectional.
Specifically, both groups of psychologists tended to make fewer referrals to clergy
than clergy made to psychologists. The researchers used a Likert Scale to measure
participants responses, ranging from 1 (never) to 5 (always). On the average, both
groups of psychologists considered the frequency at which they referred clients to
clergy as rarely (Division 36 M= 2.4, Division 12 M-2.3). On the other hand,
clergy rated the frequency at which they referred people to psychologists as
sometimes occurring (M = 3.1). The moderate collaboration between clergy and
psychologists may be attributable to perceived obstacles to collaboration. The biggest
obstacles perceived by all three groups were that psychologists do not need clergy
21


and lack awareness of available resources. The researchers concluded that one way to
overcome these obstacles is to enhance trust between clergy and psychologists, which
can be done by increasing the familiarity between the two groups. Familiarity can be
reached by attending training sessions together. Based on the research that
collaboration with clergy can be beneficial, but that psychologists do not do so often,
I will ask whether older adults and therapists think it is appropriate to consult with
clergy.
Older Adults and Religion
In the previous section, I discussed the various aspects and importance of
integrating religion and therapy. In this section, I will focus on how significant the
role of religious beliefs is in the lives of older adults.
Research appears to be sparse regarding the question of whether or not people
become more spiritual as they grow older. Bower (1996) suggested that the available
research is equivocal. Markides (1983) conducted a four-year longitudinal study,
examining the relationships between church attendance, self-rated religiosity, and
private prayer with aging. Mexican-Americans and whites, aged 60 and older made
up the participant population. The first interviews included 510 people, but follow-up
interviews included only 338 people. Results based on this sample indicated that
among Mexican Americans, church attendance declined slightly, self-rated religiosity
showed a small increase, and practice of private prayer did not change. Among
22


whites, no significant change occurred in frequency of church attendance or private
prayer, but there was a small increase in self-rated religiosity.
Markides, Levin, & Ray (1987) followed up on the previous study, using the
same participant population of Mexican-Americans and whites. This study was an
eight-year longitudinal study, again examining church attendance, self-rated
religiosity, and private prayer. The results were based on 230 of the 510 original
respondents. The findings did not show that the elderly turned increasingly toward
religion. In fact, self-rated religiosity remained fairly stable over time. Church
attendance is the only variable that decreases with age, probably due to a decline in
health.
In contrast, a 1999 Gallup poll indicated that religion becomes an increasingly
important part of Americans daily lives as they get older (Ehmann, 1999). Among
adults aged 65 or older, membership in a church or synagogue is 79% compared to
66% of 30-to 49-year-olds. Organized religion is the most common form of
voluntary social participation by older adults (Koenig, Larson, & Matthews, 1996).
The difference in organized religion or church involvement between those in the 30-
49 age group and those who are 65 and older may be due to a cohort effect. Clark
(1999) argued that baby boomers break with institutions, including religious
institutions, led them to on a more personal spiritual journey, whereas those bom
before World War II remain more loyal to institutions and doctrinal beliefs.
The interest in religiousness in later life appears to be related to one
23


questioning the meaning of ones existence or purpose in life. For some older adults,
religion can furnish an orderly view of the world, meaning in life, and a framework
where past misdeeds can be forgiven, allowing for salvation (Koenig, 1994). Thus,
some older adults may have a more benign view of life after death than others
(Thomas & Eisenhandler, 1999). However, for some older adults religious beliefs
can cause anxiety or depression rather than provide comfort, as they believe they
must suffer eternal damnation for sins (Burgess, Schmeeckle, & Bengtson, 1998).
Overall, research seems to indicate that more often than not, older adults
benefit from religious/spiritual practices, regardless of gender or race. A study by
Pincharoen (1997) focused on spirituality and health in elderly Thai persons. She
found that these persons utilized religious resources to achieve peace of mind and
harmony. Likewise, research with older adults in India, England, and the United
States consistently shows the importance of religious beliefs in how they handle
losses associated with old age (Thomas & Eisenhandler, 1999). A sense of
transcendence helped many individuals make meaning of their lives and cope with the
prospect of death. Ramsey and Blieszner (1999) conducted in-depth interviews with
eight women from the United States and Germany and found their spiritual beliefs
gave them strength to adjust positively to difficult times. Koenig (1994) studied the
outcome of religious coping in 1,000 hospitalized older adult males and found that
56% reported religion was the most important factor that enabled them to cope with
their situation. Older adults may find that faith and trust in God is one of the few
24


ways left to them to help cope with difficulties in life (Bower, 1996).
Based upon the research that shows older adults tend to be spiritual and use
religious beliefs to cope with stressors, in my study I will ask older adults and
therapists whether spiritual beliefs are important in life and assess the extent to which
spirituality exists in older adults and therapists lives.
Older Adults and Therapy
I concluded the previous section with a research question about using spiritual
coping strategies in therapy with older adults. This raises the issue of the variables
relevant to older adults in therapy. One such variable to be aware of when working
with older adults in therapy is sensory deficits, such as impaired hearing or vision,
which could negatively impact the therapeutic process if therapists do not address
these issues (Pachana, 1999). Also, therapists must work to alleviate any shame older
adults may feel over receiving mental health care. In addition, therapists need to be
prepared to deal with multiple concurrent mental disorders and medical problems,
such as depression, dementia, substance abuse, and diabetes (Cooley et al., 1998).
The research on therapy with older adults is primarily concerned with types of
therapy best for older adults, and therapy in different settings. Koenig (1994) stated
that although psychodynamic therapy can be effective in older adults, most often it is
best not to use it. He believed as it is insight-oriented, older adults would come to
recognize neurotic impulses, but then feel depressed because they think it is too late
25


in life to change. However, according to Pachana (1999) and Nordhus, Nielsen, and
Kvale (1998), comprehensive reviews of studies comparing the effectiveness of
different types of therapies with older adults revealed that all therapies were about
equal in effectiveness. Cooley et al. (1998) have also found no single psychological
intervention to be preferred for older adults. Rather, selection of therapy should be
guided by the nature of the problem and client preference as with other populations.
The second area of research examines therapy in nursing home settings,
assisted living facilities, and outpatient settings. Older adults face grief and loss
issues, and physical and/or mental decline. However, the nursing home population in
particular is vulnerable to a constant deterioration of a sense of independence and
competency. The rules and regulations of nursing homes curtail residents decision-
making opportunities, freedom, and privacy (Conn & Kaye, 1992). In addition,
nursing home residents feel disconnected from their family and friends; some feel
they have been abandoned. Thus, compared to older adults in the other two settings,
those in nursing homes are facing multiple losses or adjustments simultaneously
(Sadavoy, 1992), which could easily lead to a major depression. Moreover, as
nursing home residents conditions are typically chronic and unlikely to improve,
therapy might best be centered around emotion-focused coping which aims to
regulate distressful emotions, rather than problem-focused coping which seeks to
effect change (Bower, 1996).
According to Kaas and Lewis (1999) the prevalence of depression in assisted
26


living facilities is at 10% to 20%. Cognitive-behavioral group therapy has been
especially effective in treating depression in older adults. Kaas and Lewis developed
such a therapy program and studied its outcome with 11 older adults (10 females, one
male) in an assisted living facility. Nine participants were mildly depressed or had no
depression; two participants were severely depressed. All of the participants
completed eight one-hour weekly sessions, consisting of a cognitive-behavioral
psychoeducational component, as well as therapy. The older adults found the therapy
beneficial and all of the participants stated they would participate in another group.
Independent living older adults, like those in nursing homes and assisted
living, most often suffer depression compared to other disorders (Brody & Semel,
1993; Nordhus et al., 1998). Nordhus et al. found that depression among outpatients
at a clinic in Norway was due to conflicts in close, current relationships. The most
frequent disputes were found with children, followed by spouses, and siblings. Brody
and Semel studied outpatient group therapy in older adults at a Rhode Island clinic.
They found that depressed older adults require a longer period of education in the
therapeutic process. Although the groups were intelligent, they were unaware of how
to express feelings and doubted the utility of talk therapy. However, eventually they
were able to express themselves and share feelings.
Therapy with older adults is unique. Some older adults feel their physical or
mental conditions are unlikely to improve and they find it difficult to express their
emotions directly. Considering such circumstances, and that many older adults are
27


religious, they may find that their spiritual beliefs provide emotion-focused coping
and it is easier to describe their feelings in spiritual terms. Hence, I will ask in my
study whether older adults and therapists are comfortable discussing religious issues
in therapy with one another and if spiritual beliefs influence whether or not older
adult clients seek therapy.
Conclusions
The review of the literature in these three areas leads to several conclusions.
First, religion can no longer be ignored as a factor in therapy. Assessing religious
beliefs creates a more complete picture of the client. Moreover, it can clarify
diagnostic issues. Also, guidelines are already in place to train psychiatry residents in
how to ethically address religious issues or concerns.
Second, religious beliefs appear to be an important source of strength for older
adults, regardless of gender or race. They influence the way people react to and cope
with negative events. Older adults find religious beliefs to be a steady cognitive
framework through which they can make sense of the world. In addition, attending
worship services allows for social interaction and support, which is important as older
adults face many losses at this time of their lives.
Third, when conducting therapy with older adults, therapists need to be
sensitive to physical and cognitive loss. Also, therapists should realize that todays
older adults come from a generation in which mental illness was stigmatized, and
28


they are not familiar with discussing feelings and sharing personal, negative
experiences with others. Moreover, depression is the most common mental illness.
older adults face. However, this can co-occur with multiple mental and/or physical
problems, making an accurate diagnosis difficult. Determining a diagnosis with older
adults may also be affected by medical illnesses mimicking mental illnesses and older
adults expressing feelings or symptoms in spiritual terms.
The literature review has also revealed a gap in an integration of all these
areas. For example, the literature states that the number of older adults in therapy is
increasing. It also asserts that religion is an effective coping mechanism used by older
adults to deal with stress or changes in their lives. Furthermore, the literature
concludes that religion should be addressed in therapy. However, it appears that no
research has been done that examines what kind of religious/spiritual behaviors
should be performed in the therapeutic relationship when working with older adults.
The only studies I found focused on older adults and medical doctors
attitudes toward discussing spiritual issues in a medical context. A study by Koenig,
Bearon, and Dayringer (1989) of 160 family physicians and general practitioners
found that the majority of doctors believed that religion has a positive effect on the
mental health of older patients. Many doctors (87.7%) also believed that it is
appropriate for them to address spiritual issues when a patient makes a direct request.
In addition, the researchers discovered that doctors who believed religion is the most
important influence in the lives of older adults thought it was appropriate for them to
29


address religious issues. Another interesting finding was that physicians who thought
patients would like their doctors to pray with them were more likely than others to
accept dealing with religion in the medical setting. The researchers concluded that
physicians who understood the importance of religion in the lives of older adults, and
were aware that patients might want to pray with them, were likely to believe it is
appropriate to address religion in a medical setting.
Another study by Oyama and Koenig (1998) compared family medicine
outpatients and their doctors religious beliefs and behaviors. The researchers also
looked at whether patients religiousness affected their expectations of their doctors
regarding religious matters. The researchers determined that patients are more
involved in religious beliefs and practices than their doctors. Physicians were less
likely to pray privately and hold intrinsic religious attitudes. The more religious the
patients, the more they wanted to know their doctors beliefs, share their beliefs with
their doctor, and have their doctor pray with them.
These studies provided information on when doctors might discuss spiritual
issues with patients and how each groups personal beliefs influence how they react
to addressing spirituality in a medical setting. Unfortunately, similar research among
mental health professionals and older adults is lacking. Some studies examine
therapists views toward spirituality in therapy, but I cannot find any research that
looks at older adults attitude on this subject. Furthermore, there is no study that
directly compares the two groups opinions. Do older adults and therapists think
30


religious beliefs are relevant to therapy? In what capacity?
31


CHAPTER 2
THE PRESENT STUDY
This research will look at both older adults and therapists attitudes toward
addressing religious-spiritual issues in therapy and compare how each party differs in
their attitudes on this subject. The results of this study can help begin a dialogue
between these two sides to create a clearer understanding on what each party believes
is appropriate to practice in therapy.
Older adults and therapists enter the therapeutic relationship with an existing
set of attitudes regarding their personal religious/spiritual beliefs. Both groups also
hold certain attitudes about the extent to which religious beliefs should be addressed
in therapy. In this study, I propose to measure older adults and therapists attitudes
toward various religious-spiritual issues and behaviors in therapy. I will also examine
the nature of religious-spiritual beliefs in the personal lives of these two groups. The
purpose of this study is to determine what, if any, differences exist between older
adults and therapists attitudes toward integrating religion-spirituality into therapy
and to what extent those differences are influenced by each groups personal
religious-spiritual beliefs.
32


Method
Participants
Older adults (age 55 and older) from two mental health centers, a college, as
well as four senior centers, three retirement homes, and eight churches in the Denver
Metro area participated in this study. In addition, I mailed questionnaires to a group
of 300 randomly chosen licensed psychologists across Colorado and therapists at
three mental health facilities. I categorized the participants into three groups:
professionals, community older adults, and older adults affiliated with churches.
Materials
Religion in Therapy Questionnaire (RITOV For this study, I developed an
instrument specifically for the research question regarding therapists and older
adults attitudes toward religion-spirituality in therapy. The questionnaire consists of
37 items on a five-point Likert scale. I based the items of the survey upon the
information and research gathered from the literature review. I wrote the items to
measure the following:
1. Discussing clients religious-spiritual issues in therapy.
2. Use of religious-spiritual beliefs as a coping device in therapy.
3. Engaging in various religious-spiritual interventions in therapy.
33


4. Consulting with clergy.
5. Influence of religious-spiritual beliefs on older adults compliance with treatment.
6. Compatibility of religious-spiritual beliefs with therapy.
7. Importance of religious-spiritual background or beliefs in therapists and older
adults lives.
8. Influence of religious-spiritual beliefs on therapists practice of therapy.
9. Giving religious-spiritual beliefs the same consideration as other psychosocial
variables (e.g., age, gender).
The Spiritual Beliefs and Involvement Scale (SIBSV Developed by Hatch, Burg,
Naberhaus, and Hellmich (1998), this scale measures spiritual actions and beliefs.
The scale consists of 26 items in a modified Likert-type format. The scale reliability
and validity are very good, with high internal consistency (Cronbachs alpha = .92);
strong test-retest reliability (r = .92); and a high correlation (r = .80) with an
established measure of spirituality, the Spiritual Well-Being Scale (Paloutzian &
Ellison, 1982).
Procedure
I mailed a cover letter, the questionnaires, and a stamped return envelope to
older adults, therapists at three mental health facilities, and 300 licensed
psychologists. Also, I handed out the cover letter and questionnaires to older adults at
various senior centers, retirement homes, and churches across the Denver Metro area.
34


Participants first read the cover letter. Those who agreed to participate completed the
Role of Religious-Spiritual Issues in Therapy Questionnaire, then the Spiritual
Involvement and Beliefs Scale, and finally, the demographics sheet.
Results
I mailed three hundred thirty-nine questionnaires to mental health
professionals across Colorado. Six were returned as undeliverable. Of the 333
delivered surveys, 130 were returned, for a 39% response rate. Six professionals
returned blank questionnaires; thus, a total of 124 professional surveys were included
for analysis. In addition, I gave surveys to 106 older adults recruited in the
community and 109 older adults recruited from churches. Hence, a total of 339
questionnaires were collected for this study.
Respondents had the option to omit items, and not all of the participants chose
to answer every item of the demographic profile or the questionnaires. Hence, the
data analyses are based on those who disclosed the information for a particular item.
For those who left seven questions or less unanswered on the SIBS, I took the average
of their available score and replaced the missing items with the average score. I did
not include the 10 SIBS with more than seven questions missing in the analysis.
A total of 106 men and 218 women participated in this study. The mean age
of respondents was 63.8 years with a range of 25 to 93. Fifty-two percent of
participants identified their religious affiliation as Christian, 13.6% Catholic, 15.8%
35


reported other religious affiliations, and 1.2% reported no religious affiliation. The
majority of respondents (95.4%) were white. Many professionals (63.9%) rated their
work experience with older adults at 25%. Also, 72.3% of professionals identified
their practice as not religious-spiritually based. Characteristics of the participants are
summarized in Tables 2.2 and 2.3. Table 2.2 contains characteristics of all three
populations and Table 2.3 includes demographics relating only to professionals.
Table 2.2
Demographic Profile of Respondents
Overall Professional Community Church
Characteristic % N % N % N % N
Age (N = 317)
25-39 7.9 25 20.7 25 - - - -
40-54 19.9 63 52.1 63 - - - -
55-69 32.8 104 24.8 30 31.9 30 43.1 44
70-84 33.8 107 2.5 3 53.2 50 52.9 54
85 and over 5.7 18 - - 14.9 14 3.9 4
Mean 63.8 49.9 73.6 71.3
Range 25-93 25-80 55-91 55-93
Standard Deviation 14.47 10.40 8.97 8.58
Gender (N = 324)
Male 32.7 106 40.5 49 22.2 22 33.7 35
Female 67.3 218 59.5 72 77.8 77 66.3 69
Marital Status (N = 324)
Married 51.9 168 75.8 91 24 24 51 53
Widowed 24.4 79 1.7 2 47 47 28.8 30
Divorced 16.4 53 11.7 14 22 22 16.3 17
Separated .9 3 .8 1 1 1 1 1
Single 6.5 21 10 12 6 6 2.9 3
36


Table 2.2 (Cont.)
Overall Professional Community Church
Characteristic % N % N % N % N
Ethnic background
(N = 323)
White 95.4 308 95 114 94.9 94 96.2 100
African American .9 3 .8 1 1 1 1 1
Hispanic 1.9 6 1.7 2 2 2 1.9 2
Asian/Pacific .3 1 .8 1 - - - -
Islander
Native American .3 1 - - 1 1 - -
Other 1.2 4 1.7 2 1 1 1 1
Religious affiliation
(N = 322)
Christian (Protestant 52 168 33.9 40 64 64 61.5 64
& Orthodox)
Catholic 13.6 44 12.7 15 17 17 11.5 12
Jewish 4 13 9.3 11 2 2 - -
Buddhist .9 3 2.5 3 - - - -
Native American .6 2 .8 1 1 1 - -
Religions
Spiritualist 3.7 12 5.1 6 1 1 4.8 5
Atheist 2;5 8 5.9 7 - - - -
Agnostic 5.6 18 10.2 12 6 6 - -
Other 15.8 51 16.1 19 9 9 22.1 23
None 1.2 4 3.4 4 - - - -
Location (N = 322)
City or 82.6 266 72.6 85 82.2 83 94.2 98
metropolitan
area
Medium-sized 12.4 40 17.1 20 14.9 15 4.8 5
town
Rural or small 5 16 10.3 12 3 3 1 1
Town
Living situation
(N = 203)
Independent N/A N/A N/A N/A 92.1 93 98 100
Assisted-living N/A N/A N/A N/A 7.9 8 2 2
37


Table 2.3
Demographic Profile of Professionals
Characteristic % N
Degree type (N 122)
Masters 7.4 9
Ph.D 66.4 81
Psy.D 20.5 25
Other 5.7 7
Years Licensed (N = 121)
0-10 47.1 57
11-21 29.8 36
22-32 19.8 24
33-43 3.3 4
Mean 13.6
Range 0-40
Standard Deviation 9.27
Older adult experience (N = 122)
0% 19.7 24
25% 63.9 78
50% 10.7 13
75% 4.1 5
100% 1.6 2
Practice type (N = 119)
Religious-Spiritual 3.4 4
Partly Religious-Spiritual 24.4 29
Not Religious-Spiritual 72.3 86
Spiritual Involvement and Beliefs Scale Scoring
I totaled participants responses to each item on the Spiritual Involvement and
Beliefs Scale, resulting in a spiritual status score. The minimum score possible is 26
(low spiritual status) and the maximum score possible is 130. In this study, the mean
spiritual status score was 96.6 with a range of 41 to 130. Based on the overall range
38


of scores, I conducted a three-way split to create categories of spiritual status of
approximately equal number. The range of scores was divided into three categories:
low (41-92), medium (93-105), and high (106-130) spiritual status. The SIBS results
are summarized in Table 2.4.
Table 2.4
Spiritual Status Profile of Respondents
Overall Professional Community Church
Characteristic % N % N % N % N
Spiritual Status
(N = 329)
41-92 35.0 115 48.8 60 40 40 14.2 15
93-105 34.7 114 36.6 45 26 26 40.6 43
106-130 30.4 100 14.6 18 34 34 45.3 48
Mean 96.6 89 .7 97.2 104 1.0
Range 41- 130 41-122 64- 126 74-130
Standard Deviation 16 12 17. 00 15 73 11.44
Personal Spiritual StatusSIBS
Population and Gender. A 3 x 2 ANOVA revealed no significant interaction
between population (professionals, community older adults, church older adults) and
gender on spiritual status. However, there were significant main effects for both
population and gender.
The analysis showed amain effect for population, F(2, 317) = 21.9 ,p < .05.
Subsequent Bonferroni tests (all reported Bonferroni results are significant at p < .05)
revealed that professionals reported lower spiritual status (M = 89.7, SD = 17.12, N=
121) than both the community (M = 97.56, SD = 15.65, N= 98) and church groups
39


(M = 103.9, SD = 11.49, N = 104). Also, the community group reported significantly
lower spiritual status than the church group. Females had higher spiritual status (M=
98.5, SD = 14.70, N= 217) than males (M= 92.9, SD = 18.24, N= 106), F( 1, 317) =
6.46, p .011.
Practice and Gender. I combined the completely religious-spiritual based
practices and the partial religious-spiritual based practice types of the professionals
into one group (spiritual) and compared this group to the non-spiritual based practice
group. A 2 x 2 ANOVA showed only one effect, a significant main effect for practice
type. The spiritual practice group reported higher spiritual status (M= 102.1, SD =
11.67, N = 32) than the non-spiritual practice group (M= 84.9, SD = 16.77, N = 86),
F(l, 114) = 28.5,/? <.001.
Marital Status and Gender. I combined the widowed, divorced, separated, and
single people into one category (unmarried, N 154) and compared this to the
married category (N= 168). I tested for an interaction between marital status and
gender, but the 2 x 2 ANOVA revealed only one effect, a significant main effect for
gender, which mirrored the results described previously.
Religious Affiliation and Gender. I combined Catholics, Buddhists, Jews,
Spiritualists, Native American Religions, Atheists, Agnostics, and those who marked
other or none into one group labeled non-Christian and compared this group to
Christians. A 2 x 2 ANOVA revealed significant main effects for religious affiliation
and gender. Christians reported higher spiritual status (M= 101.9, SD = 11.86, N=
40


167) than non-Christians (M= 91.1, SD = 18.27, N= 153), F( 1, 316) 43.5,p < .001.
The gender main effect mirrored results mentioned previously.
Population and Religious Affiliation. A 3 x 2 ANOVA uncovered a
significant interaction between population (professionals, community, church) and
religious affiliation (Christians, non-Christians) on spiritual status, F(2, 315) = 3.9,p
= .020. Subsequent Bonferroni tests revealed no significant difference in spiritual
status among Christian professionals (M = 96.9, SD = 10.95, N = 40), the Christian
community group (M= 102.2, SD = 12.65, N= 63) and Christian church group {M-
104.7, SD 10.70, N= 64). Among the non-Christians, the church group (M= 102.5,
SD = 12.68, N = 40) reported a significantly higher spiritual status than both the
professionals (M = 86.1, SD = 18.77, N = 78) and the community group (M= 88.7,
SD = 17.02, N= 36).
Religious Affiliation and Marital Status. A 2 x 2 ANOVA showed significant
main effects for marital status and religious affiliation. Unmarried people reported
higher spiritual status (M 99.3, SD = 15.29, N = 155) than married people (M=
94.2, SD = 16.68, N= 165), F(l, 316) = 5.29,p = .022. The religious affiliation main
effect mirrored results mentioned previously.
Population and Marital Status. I tested for an interaction between population
and marital status, but the 3 x 2 ANOVA uncovered only one effect, a significant
effect for population, which mirrored results described above.
41


Attitudes toward Religious-Spiritual Issues in Therapy
The Role of Religious-Spiritual Issues in Therapy Questionnaire (RITQ)
consisted of 37 items asking how various religious-spiritual issues may play a role in
therapy with older adults. Table 2.5 lists the frequency of each response to each item
on this questionnaire. For the purposes of data reduction, I conducted a factor
analysis of the 37 items using a prinicipal components factor analysis with promax
rotation. This test revealed that nine factors had eigenvalues greater than 1.0. A
scree test to examine eigenvalues indicated that five factors accounted for 46.4% of
the variance in ratings. Thus, five factors were extracted, with a loading criteria of
.30. A Cronbachs alpha reliability coefficient performed on the five factors
suggested that the first three factors had good internal consistency, the fourth factor
had moderate internal consistency, and the fifth factor had poor internal consistency.
Factor 1 (General Acceptance of Beliefs; eigenvalue = 9.55, a = .86) included
10 items (1, 5, 11, 12, 14, 15, 18, 24,27, 35) relating to general acceptance of
religion-spirituality in therapy. For example, religious-spiritual beliefs provide a
sense of hope and prayer is helpful in coping with stress.
Factor 2 (Therapists Role; eigenvalue = 2.77, a = .85) included 10 items (5,
8, 22, 26, 30, 31, 32, 33, 36, 37) relating to therapists role regarding religion-
spirituality in therapy. For instance, therapists should address religious-spiritual
42


Table 2.5
Percentages of Responses to Items on RITQ
Items Overall p* c* Ch*
1. Meditation is an appropriate way to 1 3.0 3.3 3.8 1.9
incorporate religion-spirituality into therapy. 2 7.2 11.4 7.7 1.9
3 18.3 14.6 22.1 18.7
4 47.6 54.5 41.3 45.8
5 24.0 16.3 25.0 31.8
Mean 3.8 3.7 3.7 4.0
SD .98 .98 1.04 .87
N 334 123 104 107
2. Clients feel comfortable discussing 1 9.6 13.7 9.5 4.7
religious-spiritual issues only with therapists 2 39.7 55.6 30.5 30.2
of the same religious-spiritual background. 3 19.4 12.1 21.9 25.5
4 25.7 17.7 31.4 29.2
5 5.7 .8 6.7 10.4
Mean 2.8 2.4 2.9 3.1
SD 1.10 .96 1.13 1.09
N 335 124 105 106
3. Therapists should consult with clergy only 1 19.2 20.3 16.7 20.4
when other interventions have failed. 2 42.6 52.8 31.4 41.7
3 22.8 22.8 25.5 20.4
4 10.5 2.4 19.6 11.1
5 4.8 1.6 6.9 6.5
Mean 2.4 2.1 2.7 2.4
SD 1.06 .82 1.17 1.13
N 333 123 102 108
4. Therapists whose religious-spiritual beliefs 1 6.9 7.3 5.7 7.5
are too strong may not be as effective with 2 16.2 17.1 12.4 18.9
their clients. 3 15.6 13.8 21.9 11.3
4 46.7 44.7 45.7 50.0
5 14.7 17.1 14.3 12.3
Mean 3.5 3.5 3.5 3.4
SD 1.13 1.18 1.07 1.15
N 334 123 105 106
43


Table 2.5 (Cont.)
Items Overall P C Ch
5. Therapists should offer to pray with clients 1 7.8 17.5 4.7 -
who are dying. 2 13.0 25.8 6.6 4.7
3 22.3 33.3 20.8 11.3
4 39.2 20.0 43.4 56.6
5 17.8 3.3 24.5 27.4
Mean 3.5 2.7 3.8 4.1
SD 1.16 1.09 1.05 .76
N 332 120 106 106
6. Religious-spiritual beliefs should be given 1 1.8 - 4.8 1.0
the same importance as age, race, or gender in 2 4.9 5.9 4.8 3.8
therapy. 3 10.4 11.0 10.5 9.5
4 52.4 55.1 55.2 46.7
5 30.5 28.0 24.8 39.0
Mean 4.1 4.1 3.9 4.2
SD .88 .79 .99 .83
N 328 118 105 105
7. Therapists religious-spiritual beliefs 1 3.0 1.7 6.7 1.0
influence the type of treatment they give to 2 11.8 14.2 12.4 8.6
clients. 3 17.9 14.2 25.7 14.3
4 55.2 63.3 41.9 59
5 12.1 6.7 13.3 17.1
Mean 3.6 3.6 3.4 3.8
SD .95 .87 1.08 .85
N 330 120 105 105
8. Therapists religious-spiritual beliefs 1 3.0 1.7 5.7 1.9
influence the type of treatment they give to 2 17.1 19.7 19.0 12.3
clients. 3 22.6 22.2 27.6 17.9
4 45.7 47.0 35.2 54.7
5 11.6 9.4 12.4 13.2
Mean 3.5 3.4 3.3 3.7
SD 1.00 .97 1.09 .93
N 328 117 105 106
44


Table 2.5 (Cont.)
Items Overall P C Ch
9. Religious-spiritual beliefs are harmful to 1 48.0 50.8 35.6 57.0
psychological well-being. 2 35.0 37.5 34.6 32.7
3 9.7 8.3 16.3 4.7
4 4.5 0.8 11.5 1.9
5 2.7 2.5 1.9 3.7
Mean 1.8 1.7 2.1 1.6
SD .98 .86 1.08 .95
N 331 120 104 107
10. Usually, therapists consider religious- 1 4.0 2.5 3.9 6.1
spiritual issues or problems in therapy. 2 31.5 47.5 16.5 27.6
3 31.2 27.5 35.9 30.6
4 29.6 21.7 37.9 30.6
5 3.7 0.8 5.8 5.1
Mean 3.0 2.7 3.3 3.0
SD .96 .86 .94 1.02
N 321 120 103 98
11. Religious-spiritual faith is important 1 1.2 0.8 2.9 -
when coping with death. 2 3.9 5.0 4.8 1.9
3 5.1 10.1 2.9 1.9
4 40.4 49.6 39.0 31.5
5 49.4 34.5 50.5 64.8
Mean 4.3 4.1 4.3 4.6
SD .84 .85 .95 .63
N 332 119 105 108
12. It is appropriate for therapists to pray 1 3.0 5.8 2.9 -
privately for clients. 2 6.9 11.7 6.7 1.9
3 19.3 30.8 16.3 9.3
4 42.0 37.5 42.3 46.7
5 28.7 14.2 31.7 42.1
Mean 3.9 3.4 3.9 4.3
SD 1.01 1.06 1.01 .71
N 331 120 104 107
45


Table 2.5 (Cont.)
Items Overall P C Ch
13. Religious-spiritual activity (e.g., church 1 2.4 3.3 2.9 1.0
attendance) can be an appropriate treatment 2 5.2 5.8 5.8 3.8
goal. 3 16.7 17.5 18.3 14.3
4 54.7 61.7 44.2 57.1
5 21.0 11.7 28.8 23.8
Mean 3.9 3.7 3.9 4.0
SD .89 .87 .98 .79
N 329 120 104 105
14. Therapists should pray with clients when 1 4.8 9.2 2.8 1.9
clients request it. 2 11.1 28.3 1.9 0.9
3 20.1 39.2 13.2 5.6
4 38.7 20.0 49.1 49.5
5 25.2 3.3 33.0 42.1
Mean 3.7 2.8 4.1 4.3
SD 1.11 .98 .89 .78
N 333 120 106 107
15. Religious-spiritual beliefs are important 1 1.5 2.5 1.0 0.9
in therapists lives. 2 6.1 7.5 6.7 3.8
3 28.8 35 27.9 22.6
4 38.8 38.3 36.5 41.5
5 24.8 16.7 27.9 31.1
Mean 3.8 3.6 3.8 4.0
SD .94 .94 .95 .88
N 330 120 104 106
16. Therapists should be aware of clients 1 0.3 - 1.0 -
religious-spiritual beliefs. 2 4.5 1.6 7.7 4.7
3 9.0 8.9 13.5 4.7
4 51.2 50.4 48.1 55.1
5 35.0 39.0 29.8 35.5
Mean 4.2 4.3 4.0 4.2
SD .79 .69 .91 .74
N 334 123 104 107
46


Table 2.5 (Cont.)
Items Overall P C Ch
17. Therapists feel comfortable discussing 1 12.4 19.5 9.7 6.7
religious-spiritual issues only with clients of 2 49.4 69.9 35.0 39.4
the same religious-spiritual background. 3 25.8 8.1 34.0 38.5
4 11.2 2.4 20.4 12.5
5 1.2 - 1.0 2.9
Mean 2.4 1.9 2.7 2.7
SD .89 .61 .94 .89
N 330 123 103 104
18. Religious-spiritual journal writing is an 1 1.5 1.6 2.9 -
appropriate way to incorporate religion- 2 4.2 4.9 4.8 2.8
spirituality into therapy. 3 31.5 38.2 33.7 21.7
4 49.5 48.0 48.1 52.8
5 13.2 7.3 10.6 22.6
Mean 3.7 3.5 3.6 4.0
SD .81 .77 .85 .75
N 333 123 104 106
19. Therapists are generally willing to refer 1 1.9 3.3 2.0 -
clients to clergy. 2 25.1 41.0 11.0 19.8
3 31.6 23.0 38.0 35.6
4 37.2 30.3 45.0 37.6
5 4.3 2.5 4.0 6.9
Mean 3.2 2.9 3.4 3.3
SD .92 .97 .81 .87
N 323 122 100 101
20. Therapists should incorporate clients 1 1.2 1.6 2.0 -
religious-spiritual beliefs when providing 2 6.6 5.7 7.8 6.5
treatment. 3 19.9 29.3 17.6 11.2
4 56.9 52.0 57.8 61.7
5 15.4 11.4 14.7 20.6
Mean 3.8 3.7 3.8 4.0
SD .83 .82 .87 .76
N 332 123 102 107
47


Table 2.5 (Cont.)
Items Overall P C Ch
21. In general, clients think religion- 1 1.8 0.8 2.9 1.9
spirituality is relevant to psychotherapy. 2 19.8 27.6 15.7 14.4
3 33.4 36.6 30.4 32.7
4 38.9 30.9 41.2 46.2
5 6.1 4.1 9.8 4.8
Mean 3.3 3.1 3.4 3.4
SD .91 .88 .97 .86
N 329 123 102 104
22. Therapists should share their religious- 1 13.9 30.9 5.8 1.9
spiritual background when a client is in crisis. 2 31.3 42.3 22.3 27.4
3 26.5 24.4 24.3 31.1
4 22.9 2.4 38.8 31.1
5 5.4 - 8.7 8.5
Mean 2.8 2.0 3.2 3.2
SD 1.12 .81 1.07 .99
N 332 123 103 106
23. It is appropriate for therapists to consult 1 1.5 1.6 2.0 0.9
with clergy. 2 9.1 7.3 12.9 7.5
3 19 23.6 22.8 10.3
4 55 57.7 48.5 57.9
5 15.4 9.8 13.9 23.4
Mean 3.7 3.7 3.6 4.0
SD .88 .82 .95 .85
N 331 123 101 107
24. Religious-spiritual beliefs are important 1 0.6 0.8 1.0 -
in clients lives. 2 1.5 1.6 - 2.8
3 13.8 15.4 15.4 10.3
4 48.2 55.3 42.3 45.8
5 35.9 26.8 41.3 41.1
Mean 4.2 4.1 4.2 4.3
SD .76 .75 .78 .75
N 334 123 104 107
48


Table 2.5 (Cont.)
Items Overall P C Ch
25. Clients are generally willing to be 1 0.9 0.8 2.0 -
referred to clergy. 2 15.9 19.7 13.9 13.5
3 48.9 58.2 46.5 40.4
4 30.3 19.7 29.7 43.3
5 4.0 1.6 7.9 2.9
Mean 3.2 3.0 3.3 3.4
SD .79 .70 .87 .75
N 327 122 101 104
26. It is appropriate for therapists to 1 6.0 6.5 10.6 0.9
recommend religious-spiritual books to 2 12.5 18.5 12.5 5.6
clients. 3 25.4 35.5 26.9 12.1
4 48.4 33.1 45.2 69.2
5 7.8 6.5 4.8 12.1
Mean 3.4 3.2 3.2 3.9
SD 1.00 1.01 1.08 .73
N 335 124 104 107
27. Religious-spiritual beliefs provide a sense 1 1.5 0.8 1.9 1.9
of hope. 2 1.8 1.6 2.9 0.9
3 8.1 15.3 5.8 1.9
4 51.5 59.7 43.7 49.5
5 37.1 22.6 45.6 45.8
Mean 4.2 4.0 4.3 4.4
SD .79 .72 .86 .74
N 334 124 103 107
28. In general, therapists think religion- 1 2.1 3.2 1.0 2.0
spirituality is relevant to psychotherapy. 2 20.8 31.5 11.8 16.8
3 40.1 41.1 42.2 36.6
4 32.1 23.4 37.3 37.6
5 4.9 0.8 7.8 6.9
Mean 3.2 2.9 3.4 3.3
SD .89 .84 .83 .90
N 327 124 102 101
49


Table 2.5 (Cont.)
Items Overall P C Ch
29. If clients ask, therapists should tell clients 1 3.0 4.0 3.8 1.0
their religious-spiritual background. 2 10.8 17.7 10.6 2.9
3 21.1 24.2 16.3 22.1
4 55.7 49.2 58.7 60.6
5 9.3 4.8 10.6 13.5
Mean 3.6 3.3 3.6 3.8
SD .91 .96 .95 .73
N 332 124 104 104
30. Religious-spiritual beliefs influence 1 1.5 - 2.9 1.9
whether or not older adults seek counseling. 2 12.8 17.9 9.8 9.6
3 33.4 43.1 24.5 30.8
4 43.8 33.3 50.0 50.0
5 8.5 5.7 12.7 7.7
Mean 3.5 3.3 3.6 3.5
SD .88 .82 .94 .85
N 329 123 102 104
31. It is appropriate for therapists to 1 3.0 5.6 2.0 0.9
recommend that clients participate in 2 11.8 14.5 13.9 6.6
religious-spiritual activity to cope with stress. 3 24.8 29.0 26.7 17.9
4 47.1 46.0 43.6 51.9
5 13.3 4.8 13.9 22.6
Mean 3.6 3.3 3.5 3.9
SD .97 .97 .97 .87
N 331 124 101 106
32. Therapists bringing up scripture is an 1 14.5 30.6 5.9 3.8
appropriate way to incorporate religion- 2 24.5 34.7 17.6 19
spirituality into therapy. 3 26.3 27.4 26.5 24.8
4 26 5.6 39.2 37.1
5 8.8 1.6 10.8 15.2
Mean 2.9 2.1 3.3 3.4
SD 1.20 .97 1.07 1.08
N 331 124 102 105
50


Table 2.5 (Cont.)
Items Overall P C Ch
33. Usually, religious-spiritual beliefs 1 6.4 12.1 5.0 1.0
influence whether or not clients follow their 2 28.2 41.1 22.8 17.8
treatment. 3 37.7 41.9 28.7 41.6
4 22.7 4.0 33.7 34.7
5 4.9 0.8 9.9 5.0
Mean 2.9 2.4 3.2 3.3
SD .98 .79 1.06 .84
N 326 124 101 101
34. In general, clients are more open to 1 1.8 1.6 2.9 1.0
discussing religious-spiritual beliefs than are 2 8.2 9.7 5.9 8.7
therapists. 3 30.9 32.3 29.4 30.8
4 51.5 50.8 49.0 54.8
5 7.6 5.6 12.7 4.8
Mean 3.6 3.5 3.6 3.5
SD .82 .81 .89 .76
N 330 124 102 104
35. Prayer is helpful in coping with stress. 1 0.6 1.7 - -
2 2.7 4.1 2.9 0.9
3 8.7 14.9 7.6 2.8
4 43.3 58.7 35.2 33.9
5 44.8 20.7 54.3 62.4
Mean 4.3 3.9 4.4 4.6
SD .78 .82 .76 .60
N 335 121 105 109
36. Therapists should address religious- 1 2.4 4.1 2.9 -
spiritual faith in therapy. 2 12.7 19.0 11.7 6.5
3 29.5 37.2 27.2 23.1
4 40.4 31.4 41.7 49.1
5 15.1 8.3 16.5 21.3
Mean 3.5 3.2 3.6 3.9
SD .98 .98 1.00 .83
N 332 121 103 108
51


Table 2.5 (Cont.)
Items Overall P C Ch
37. Poor mental health is punishment from 1 86.0 96.7 74.3 85.3
God or a higher being. 2 9.0 3.3 15.2 9.2
3 4.2 - 7.6 5.5
4 0.9 - 2.9 -
5 - - - -
Mean 1.2 1.0 1.4 1.2
SD .55 .18 .75 .52
N 335 121 105 109
Note. Scale is as follows: 1 {strongly disagree), 2 {disagree), 2 {neutral),
4 {agree), 5 {strongly agree).
* P is Professional, C is Community, and Ch is Church,
faith in therapy and therapists should offer to pray with clients who are dying.
Factor 3 (Clients Perspective; eigenvalue = 1.92, a = .74) included seven
items (6, 7, 16,20, 21, 23, 34) relating to clients perspective regarding religion-
spirituality in therapy. Items included, in general, clients are more open to
discussing religious-spiritual beliefs than are therapists and therapists should
incorporate clients religious-spiritual beliefs when providing treatment.
Factor 4 (General Judgments; eigenvalue = 1.61, a = .68) included four items
(10,19, 25, 28) relating to general judgments about, or estimates of, religion-
spirituality in therapy. Items included, therapists are generally willing to refer
clients to clergy and usually, therapists consider religious-spiritual issues or
problems in therapy.
Factor 5 (Negativity/Skepticism; eigenvalue = 1.32, a = .53) included five
items (2, 3,4, 9, 17) relating in some way to negativity of beliefs. For example,
therapists whose religious-spiritual beliefs are too strong may not be as effective
52


with their clients and religious-spiritual beliefs are harmful to psychological well-
being.
Items 13 and 29 did not load onto any of the five factors.
Analyses of RITO
In the analyses that follow, I used the five factor scores generated by the
factor analysis to compare means.
Educational Type. Professionals were divided into two groups: those who
had a Ph.D (N= 81) and those who did not (N= 41). A one-way ANOVA was
conducted to determine differences in attitudes on the five factors between the two
groups. None of the factors significantly related to educational type.
Population and Gender. A 3 x 2 ANOVA conducted on each of the five
factors of the RITQ with the between-subjects factors of population (professionals,
community older adults, church older adults) and gender (male, female) revealed
significant main effects relating to population on Factors 1, 2, 4, and 5, and gender on
Factor 1.
The analysis of Factor 1 (General Acceptance of Beliefs) showed a main
effect for population, F(2, 271) = 22.5, p < .001. Subsequent Bonferroni tests showed
that each of the three groups differed significantly from the other two, with the older
adult church group (M= .486, SD .795, N= 86) having the highest score, then the
older adult community group (M = .089, SD = .956, N = 85), followed by the
53


professionals {M = -.500, SD = .928, N = 106).
The ANOVA also yielded a main effect for population on Factor 2
(Therapists Role), F(2, 271) = 28.3,p < .001. Bonferroni tests showed that
professionals (M= -.573, SD = .821) had a lower score on Factor 2 than either the
church group (M = .415, SD = .798) or the community group (M= .184, SD = 1.03).
A main effect was also found for Factor 4 (General Judgments), F(2, 271) =
9.9, p < .001. The professionals rated Factor A\M= -.362, SD .922) lower than
both the community group (M= .353, SD = .878) and church group (M= .054, SD =
1.01),
Factor 5 (Negativity/Skepticism) also showed a main effect for population,
F(2,271) = 51.1, p < .001. Each of the three groups differed significantly from the
other two, with the professionals (M= -.671, SD = .748) having a lower score than
both the community (M= .624, SD = .906) and church (M = .218, SD = .861) groups.
The community group rated Factor 5 significantly higher than the church group.
Women rated Factor 1 (General Acceptance of Beliefs; M- .079, SD = .916)
higher than did men (M= -.218, SD = 1.10), F(l, 271) = 4.09,/? = .044.
Practice Type and Gender. A 2 x 2 ANOVA showed significant main effects
for practice type on Factors 1, 2, and 3. The spiritual practice group rated Factor 1
(General Acceptance of Beliefs; M= .077, SD = .669, N= 29) higher than the non-
spiritual group (M= -.732, SD = .936, N= 74), F(l, 99) = 17.9,/? < .001. The
spiritual group also rated Factor 2 (Therapists Role; M- .073, SD = .622) higher
54


than did the non-spiritual group (M= -.827, SD = .766), F(1,99) = 28.7,/) < .001. In
addition, the spiritual group rated Factor 3 (Clients Perspective; M= .427, SD =
.821) higher than the non-spiritual group (M= -.132,5D = .878), F(1,99) = 7.90,/) =
.006.
Marital Status and Gender. A 2 x 2 ANOVA revealed significant main effects
for marital status on Factors 1,2, and 4. The analysis also uncovered a significant
interaction between marital status (married vs. unmarried) and gender on Factor 5.
The married group rated Factor 1 (General Acceptance of Beliefs; M= -.221,
SD = 1.02, N= 147) lower than the unmarried group (M = .222, SD = .898, N= 130),
F(l,273) = 7.51,/) = .007. The married group rated Factor 2 (Therapists Role; M=
-.282, SD = .964) lower than the unmarried group (M= .246, SD = .934), F(l, 273) =
16.8,/) < .001. The married group rated Factor 4 (General Judgments; M- -.236, SD
= .895) lower than the unmarried group (M= .238, SD 1.02), F(l, 273) = 10.2,/) =
.002.
There was a significant marital status and gender interaction on Factor 5
(Negativity/Skepticism), F(l, 273) = 4.27,/) = .04.. Unmarried women were more
likely to rate Factor 5 (M = .276, SD = .962, N= 107) higher than married women (M
= -.217, SD = .892, AT = 84).
Religious Affiliation and Gender. A 2 x 2 ANOVA revealed significant main
effects for religious affiliation on Factors 2 and 3. The analysis also showed a
significant interaction between religious affiliation (Christian vs. non-Christian) and
55


gender on Factor 1.
Christians rated Factor 2 (Therapists Role; M= .259, SD = .874) higher than
non-Christians (M- -.356, SD = 1.01), F(l, 270) = 30.8,/? < .001. Christians also
rated Factor 3 (Clients Perspective; M= .072, SD = 1.02) higher than non-Christians
(M= -.114, SD = .943), F(l, 270) = 4.5,p = .035.
There was a significant religious affiliation and gender interaction on Factor 1,
F(l, 270) = 5.12,p = .024. Among Christians, no difference between men and
women occurred on Factor 1 (General Acceptance of Beliefs). However, among non-
Christians, women rated Factor 1 (M= -.140, SD = .962, N = 90) significantly higher
than men (M= -.741, SD = 1.14, N= 39).
Religious Affiliation and Population. A 2 x 3 ANOVA revealed significant
main effects for religious affiliation on Factors 2 and 3, as well as population main
effects on Factors 2, 4, and 5. The religious affiliation and population main effects
mirrored the results above. There was also a significant interaction between religious
affiliation and population type on Factor 1, F(2,269) = 3.25,p = .04. Among the
non-Christians, the church group rated Factor 1 (General Acceptance of Beliefs; M-
.439, SD = .859, N= 33) higher than both the community {M--.459, SD 1.13, N=
30) and professionals (M = -.673, SD = .948, N- 67). In addition, the Christian
community group rated Factor 1 (M= .330, SD = .808, N = 56) significantly higher
than the non-Christian community group. The Christian church group did not
significantly differ from the non-Christian church group, nor did the Christian
56


professionals differ from the non-Christian professionals.
Religious Affiliation and Marital Status. A 2 x 2 ANOVA uncovered no
significant interaction between religious affiliation and marital status. Significant
main effects mirrored results presented above.
Population and Marital Status. A 3 x 2 ANOVA found no significant
interaction between population and marital status. Significant main effects mirrored
results presented above.
Population and Spiritual Status. A 3 x 3 ANOVA did not uncover a
significant interaction between population and spiritual status (high, medium, low).
There were significant main effects for population as discussed above, as well as
main effects for spiritual status on Factor 1, F(2, 272) = 84.5,/? < .001, Factor 2, F{2,
272) = 36.6,P < -001, and Factor 3, F(2, 272) = 33.4,/? < .001.
Bonferroni tests on Factor 1 (General Acceptance of Beliefs) showed that
each of the three groups differed significantly from the other two, with the high
spiritual status group having the highest score (M= .809, SD = .664, N= 90), then the
medium spiritual status group (M = .072, SD = .609, N = 96), followed by the low
spiritual status group (M = -.885, SD = .863, N = 95).
Bonferroni tests on Factor 2 (Therapists Role) revealed that each of the three
groups differed significantly from the other two, with high group having the highest
score (M= .670, SD = .779). then the medium group (M= -.038, SD = .840), followed
by the low group (M = -.665, SD = .857).
57


Bonferroni tests on Factor 3 (Clients Perspective) uncovered that each of the
three groups differed significantly from the other two, with the high group having the
highest score (M= .505, SD = .909), then the medium group (M= -.0076, SD .801),
followed by the low group (M = -.517, SD = 1.01).
Older Adult Experience. A one-way ANOVA did not reveal any significant
effects of professionals job experience in working with older adults on any of the
five factors or spiritual status.
Years of License. Pearson product-moment correlations were run to evaluate
the relationship between the number of years professionals had been licensed and
their attitudes on each of the five factors. The longer a professional had been
licensed, the more likely he/she rated Factor 5 (Negativity/Skepticism) higher, r(106)
= .24,/? = .014. Also, the longer a professional had been licensed, the lower he/she
rated Factor 2 (Therapists Role), r(106) = -.24, p = .014 and Factor 3 (Clients
Perspective), r(106) = -.24,/? = .012. In addition, a Pearson product-moment
correlation found a correlation between the number of years professionals had been
licensed and spiritual status. The longer a professional was licensed, the lower
his/her spiritual status, r( 121) = -.23, p = .011.
Discussion
These data illuminate the perspectives of mental health professionals, older
adults from the general community, and older adults with connections to churches on
58


the role of religious-spiritual behaviors and issues in therapy. Interestingly, the
majority in all three groups thought religious-spiritual beliefs should be given the
same importance as age, race, or gender in therapy (see Table 5, Item 6). However,
a discrepancy seems to exist between professionals and older adults attitudes toward
integrating religion-spirituality into therapy. In general, therapists are more hesitant
to initiate certain spiritual interventions. In addition, more experienced professionals
are less willing to discuss religion-spirituality in therapy. Also, older adults tend to
expect religion-spirituality to be addressed in therapy, relatively more so if they are
affiliated with a church, are female, unmarried, or Christian. Hence, even though all
three populations may agree that religion-spirituality is a variable to consider in
therapy, the groups hold different perspectives on this issue.
In this discussion, I will first focus on differences among professionals and
older adults. Then I will examine specific discrepancies between the groups. Next, I
will discuss the implications of the data for professionals and older adults and end
with limitations of the study and directions for future research.
Professionals reported a lower spiritual status than did older adults.
Congruently, professionals appear to be less inclined to accept religious-spiritual
beliefs (Factor 1) in therapy than older adults. For example, professionals endorsed
the item prayer is helpful in coping with stress, less than the two older adult groups
(see Table 5, Item 35). Moreover, professionals (regardless of educational
background) who were licensed longer rated negativity/skepticism (Factor 5) toward
59


religion-spirituality in therapy higher and therapists role (Factor 2) and clients
perspective (Factor 3) lower than those who were licensed for a shorter period of
time. This difference is most likely due to older professionals having been trained in
a time when religion-spirituality in therapy was considered inappropriate. As
evidenced by the fact that all psychiatry residency programs must now address
religious factors in order for psychiatrists to better understand clients (Pulchalski,
Larson, & Lu, 2000), it seems that younger professionals are trained in a time when
religion-spirituality is considered more relevant to treating clients.
Furthermore, among professionals, differences existed between those who had
a spiritual practice and those who had a non-spiritual practice. The spiritual practice
group rated general acceptance of beliefs (Factor 1), therapists role (Factor 2), and
clients perspective (Factor 3) toward religion-spirituality in therapy higher than the
non-spiritual practice group. This may be expected, as the spiritual practice group
had a higher spiritual status than the non-spiritual practice group, leading the spiritual
practice group to be more open to religion-spirituality in therapy. This finding is
congruent with Bilgrave and Deluty (1998), who found that 72% of psychologists
claimed their religious beliefs influenced their practice of psychotherapy. Another
reason for this finding may be that the spiritual practice group is more likely to see
spiritual-oriented clients. Hence, in order to best treat their clients, therapists with a
spiritual practice are more willing to address religion-spirituality in therapy.
In addition, professionals rated general judgments (Factor 4) about religious-
60


spiritual related practices occurring in therapy lower than both the community and
church groups. For example, professionals endorsed the item usually therapists
consider religious-spiritual issues or problems in therapy slightly less than the older
adult groups. However, professionals also rated negativity toward religious-spiritual
beliefs lower than the other two groups. What might account for this seemingly
contradictory result? Therapists could be separating their observations about what is
actually occurring in therapy and their values about religion-spirituality in therapy.
As we have seen, professionals have a lower spiritual status than older adults. Hence,
religion-spirituality may not be as important to therapists lives, and they may think it
even less important in therapy, so they do not address it. Moreover, therapists may
know of other therapists who hold the same beliefs. Subsequently, in therapists
experience religious-spiritual issues occur rarely in therapy, so their judgments are
lower. At the same time, therapists may not view religion-spirituality in a negative
light, which is why their rating of negativity toward religion-spirituality is lower than
the other groups. Therapists may simply believe that religion-spirituality in therapy is
fine, but with a religious-spiritual oriented therapist.
Overall, professionals seemed to think religion-spirituality is less compatible
with therapy. For instance, professionals rated item 28, in general, therapists think
religion-spirituality is relevant to psychotherapy, lower than the older adult groups.
Older adults, on the other hand, appeared to feel that religion-spirituality is relevant to
therapy and therapists should actively address religious-spiritual beliefs. However,
61


even among older adults, attitudes differed between the community and church
groups. In particular, the church group had a higher spiritual status than both the
professionals and community group. This higher spiritual status may be why the
church group rated general acceptance of beliefs in therapy higher than the
community group and professionals. The church group apparently thinks acceptance
of religious-spiritual beliefs (Factor 1) in therapy is a good idea as spirituality may
play a more central role in their lives and is relevant to providing good treatment.
The church group also rated therapists role (Factor 2) in integrating religious-
spiritual beliefs into therapy higher than did the community group. The church group
may believe that therapists should be aware of their beliefs and they may expect
therapists to address their religious-spiritual background without having to mention it
first. On the other hand, the community group may think it is appropriate for
therapists to discuss religious-spiritual issues, but it is not as important a topic for
them in therapy (which is congruent with their lower spiritual status compared to the
church group), so it is not necessary for therapists actively to raise questions about
clients religion-spirituality.
Although the church group had higher ratings on Factor 1 and 2, the
community group had higher ratings than the church group in judgments (Factor 4)
about religious-spiritual issues or behaviors in therapy. It seems as though the
community group thinks these behaviors are more likely to occur in therapy than the
church group, even though the community group rated general acceptance of beliefs
62


lower than the church group. The reason for this difference could be that the church
group may hold an anti-psychology bias. They may believe that therapists are
unwilling to consider religion-spirituality in therapy. In addition, the church group
could believe that therapists harbor negative attitudes toward religion-spirituality.
After all, there was a time when therapists ignored or pathologized religious/spiritual
issues in treatment (Turner, Lukoff, Bamhouse, & Lu, 1995). This, in turn,
perpetuates the church groups negative stereotype against therapists. As spirituality
is not as high for the community group, they may be less sensitive in their perceptions
of therapists consideration of religious-spiritual issues in therapy. The community
group may think that therapists do so, if and when necessary.
However, the community group rated negativity toward religion-spirituality
higher than the church group. Why might this be? The community group, having a
lower spiritual status, may be more likely to think religion-spirituality can be a
negative force, such as blinding one from being rational or logical. In addition, the
community group could think that religion-spirituality is a topic that is not relevant to
the therapeutic setting. That is, the community group may be more likely to separate
their religious-spiritual life from the other aspects of their lives, whereas the church
group does not.
The data analysis also discovered various effects of demographic variables on
peoples attitude toward religion-spirituality in therapy. Married women were less
skeptical or negative (Factor 5) toward religion-spirituality in therapy than were
63


unmarried women. This may be because unmarried women rely on religion-
spirituality more as a form of support, leading them to be more sensitive about how
religion-spirituality is handled in therapy, whereas married women may rely more on
their husbands for support rather than religion-spirituality, so this is not as important
an issue for them in therapy. Along this line, the majority of unmarried people in this
study were widowed or divorced. The difficulty of adjusting to their loss may lead
unmarried people turn to religion-spirituality, which is a stable support mechanism.
But the use of religion-spirituality may be more of a negative coping mechanism, e.g.,
a negative event is punishment from God (Koenig, 1998), therefore leading
unmarried women to look at religion-spirituality in therapy in a negative/skeptical
light.
In general, Christians rated therapists role (Factor 2) in integrating religious-
spiritual beliefs and clients perspective (Factor 3) higher than did non-Christians.
Perhaps this is because Christians find therapy (cognitive-behavioral) to be flexible
with their values (Propst, as cited in Koenig, 1998), leading them to believe it is
appropriate for clients to expect religion-spirituality to be addressed in therapy and
for therapists to actively engage this issue. Non-Christians, however, may believe
that therapists promoting religious-spiritual techniques could lead to an undermining
of their own beliefs. In addition, as non-Christians have a lower spiritual status than
Christians, they probably believe clients do not think it is important to involve
religion-spirituality into therapy.
64


In addition, among Christians, men and women rated general acceptance of
beliefs (Factor 1) in therapy equally. However, among non-Christians, women rated
general acceptance of beliefs in therapy higher than did men. This may be due to
Christianity being the prevalent religion in this country. Consequently, Christians,
regardless of gender, are able more easily to find therapists who are familiar with and
accepting of their religious-spiritual views (even if therapists are not as spiritual
compared to the general population). Hence, Christians may find the items on Factor
1 (e.g., therapists should offer to pray with clients who are dying) appropriate and
sensible in therapy. In contrast, non-Christians will have a more difficult time finding
therapists of the same religious-spiritual background. Thus, they rate general
acceptance of beliefs lower because they may think such practices in therapy will not
be congruent with their own beliefs. However, as women are more spiritual than
men, non-Christian women are likely to rate general acceptance of beliefs higher than
non-Christian men.
Thus far, I have looked primarily at differences among each group. Now I
will examine differences between groups. The data show that both professionals and
older adults agree that religious-spiritual beliefs are important in clients lives (see
Table 5, Item 24). In addition, there is agreement that therapists should be aware of
clients religious-spiritual beliefs (see Table 5, Item 16). The question then arises,
where lie the discrepancies between older adults and professionals attitudes toward
religion-spirituality in therapy? Various items on the RITQ looked at whether or not _
65


respondents agreed with different spiritual interventions. There are discrepancies on
four items (5,14,22, 32) that highlight the differences in attitudes between mental
health professionals and older adults. The common theme among these four items is
that therapists should actively engage in or initiate spiritual interventions. Therapists
tended to disagree with these items, while older adults tended to agree with them. It
seems therapists do not think such interventions are appropriate. Perhaps therapists
think it is not their place to do so. They may feel that such interventions are an
imposition of religious-spiritual behaviors not held by older adult clients. Also, as
mentioned previously, religious-spiritual behaviors in therapy is an area which
therapists may not find important. Therefore, they might think older adults are not
interested either or that older adults would feel offended by such interventions. Older
adults, on the other hand, seem to believe these spiritual interventions are appropriate.
In particular, the church group may think therapists should use these interventions
without the client having to ask.
What do these data mean for professionals and older adults in the therapeutic
setting? Older adults seeking therapy most likely expect therapists to address
religious-spiritual faith in therapy (see Table 5, Item 36). Fifty-eight percent of
community older adults and 70.4% of church older adults agreed or strongly agreed
with this statement. The likelihood that older adult clients expect therapists to
involve religion-spirituality in therapy increases if the older adult has a high spiritual
status, is unmarried, female, affiliated with a church, or is Christian. In contrast, the
66


likelihood that a therapist will not include religion-spirituality in therapy increases if
the therapist has been licensed for a longer period of time, has a non-spiritual
practice, has a lower spiritual status, is non-Christian, and male. Both professionals
and older adults need to be aware of how these variables affect attitudes toward
integrating religion-spirituality into therapy. The results of this study could help
begin a dialogue among these groups. Older adults might realize that professionals
may not address religious issues based out of fear of being unknowledgeable, rather
than religious aversion. Professionals may realize that it is appropriate and respectful
to be aware of their clients faith system. Professionals have a responsibility to treat
their clients with the utmost respect and dignity, which includes all aspects of their
beliefs.
Although this study produced some interesting results, there are limitations.
The factor analysis results should be treated with caution, as not enough subjects
completed the questionnaire fully. The factor analysis was based only on 285 people
who answered all 37 items.
Another limitation is religious affiliation. Most of the respondents were
Christian. The attitudes held by Christians may be different from those of other
religions. It would be valuable to gather data from people with other spiritual
backgrounds like Islam, as well as non-monotheistic religions such as Hinduism.
Also, in this study, Atheists and Agnostics were grouped with Spiritualists, Catholics,
67


and other religious affiliations. This could have affected the results, as atheists and
agnostics attitudes probably differ from those who hold religious beliefs.
Ethnic background was also a limitation in this study. The vast majority of
respondents were white. It would be interesting to know if people of other ethnicities
viewed religion-spirituality in therapy as crucial, helpful, or unnecessary.
Also, most professionals who responded to the survey did not have a
religious-spiritual based practice. A future study can focus on professionals with a
religious based practice to discover if these two groups vary greatly in agreement or
disagreement of religion-spirituality in therapy. Also, it would be helpful to know on
what basis the professionals choose or do not choose a religious-based practice. Do
therapists shy away from a religious-based practice because they feel they are not
adequately trained? Or, is it because they think the number of clients they see will be
reduced due to preconceived notions of how effective they might be?
Another limitation to this study is that not enough therapists who work
exclusively or mainly with older adults responded. A future study could focus on
such therapists to see if incorporating or addressing religion-spirituality in therapy is
an important issue for older adults in treatment.
In regard to the factor analysis, Factor 5 apparently has items that did not
measure the same underlying construct. These items should be dropped from the
scale for future use, or the items need to be re-written. All the other factors had high
internal consistency indicating the items were consistent. Although these factors are
68


related, there are some slight nuances that distinguish them. Apparently, some items
measure behaviors more oriented toward therapists actions, and others concerned
more with older adult clients viewpoints.
Finally, this study is limited in generalization as the professional participants
were limited to the state of Colorado and the older adult participants were from the
Denver Metro Area. Future studies need to look at professionals and older adults in
other states around the nation to see if they hold similar attitudes. Perhaps, attitudes
will differ from region to region. Those in this study might be more religious-
spiritual in nature than those living on either coast of the country or less religious-
spiritual than those living in the South.
69


APPENDIX A
Role of Religious-Spiritual Issues in Therapy Questionnaire
Directions: This questionnaire is about how religious-spiritual issues may play a role
in therapy with older adults. Using the following scale, circle the appropriate number
for each item. Please respond to each statement as honestly as you can. There are no
right or wrong answers. Do not spend time thinking too much about each statement.
Simply mark the response that reflects your first impression.
In the questionnaire you will see the term religious-spiritual. These two words are
used interchangeably. Both words refer to a higher being or power. Religious
usually refers to organized religion, with its rules and rituals. Spiritual usually
refers to more individual, personal, beliefs. When you answer the questions, think
about either term or both.
Scale:
1 = Strongly 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly
Disagree (D) (N) (A) Agree
(SD) (SA)
1. Meditation is an appropriate way to incorporate religion-
spirituality into therapy.
2. Clients feel comfortable discussing religious-spiritual
issues only with therapists of the same religious-spiritual
background.
3. Therapists should consult with clergy only when other
interventions have failed.
4. Therapists whose religious-spiritual beliefs are too strong
may not be as effective with their clients.
5. Therapists should offer to pray with clients who are dying.
6. Religious-spiritual beliefs should be given the same
importance as age, race, or gender in therapy.
SD D N A SA
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
70


SD D N A SA
7. Therapists religious-spiritual beliefs influence the type of
treatment they give to clients. 8. Therapists religious-spiritual beliefs influence the type of 1 2 3 4 5
treatment they give to clients. 9. Religious-spiritual beliefs are harmful to psychological 1 2 3 4 5
well-being. 10. Usually, therapists consider religious-spiritual issues or 1 2 3 4 5
problems in therapy. 11. Religious-spiritual faith is important when coping with 1 2 3 4 5
death. 1 2 3 4 5
12. It is appropriate for therapists to pray privately for clients. 13. Religious-spiritual activity (e.g., church attendance) can 1 2 3 4 5
be an appropriate treatment goal. 1 2 3 4 5
14. Therapists should pray with clients when clients request it. 15. Religious-spiritual beliefs are important in therapists 1 2 3 4 5
lives. 16. Therapists should be aware of clients religious-spiritual 1 2 3 4 5
beliefs. 17. Therapists feel comfortable discussing religious-spiritual issues only with clients of the same religious-spiritual 1 2 3 4 5
background. 18. Religious-spiritual journal writing is an appropriate way 1 2 3 4 5
to incorporate religion-spirituality into therapy. 1 2 3 4 5
19. Therapists are generally willing to refer clients to clergy. 20. Therapists should incorporate clients religious-spiritual 1 2 3 4 5
beliefs when providing treatment. 21. In general, clients think religion-spirituality is relevant to 1 2 3 4 5
psychotherapy. 22. Therapists should share their religious-spiritual 1 2 3 4 5
background when a client is in crisis. 1 2 3 4 5
23. It is appropriate for therapists to consult with clergy. 1 2 3 4 5
24. Religious-spiritual beliefs are important in clients lives. 1 2 3 4 5
25. Clients are generally willing to be referred to clergy. 26. It is appropriate for therapists to recommend religious- 1 2 3 4 5
spiritual books to clients. 1 2 3 4 5
27. Religious-spiritual beliefs provide a sense of hope. 28. In general, therapists think religion-spirituality is relevant 1 2 3 4 5
to psychotherapy. 29. If clients ask, therapists should tell clients their religious- 1 2 3 4 5
spiritual background. 1 2 3 4 5
71


30. Religious-spiritual beliefs influence whether or not older SD D N A SA
adults seek counseling. 31. It is appropriate for therapists to recommend that clients 1 2 3 4 5
participate in religious-spiritual activity to cope with stress. 32. Therapists bringing up scripture is an appropriate way to 1 2 3 4 5
incorporate religion-spirituality into therapy. 33. Usually, religious-spiritual beliefs influence whether or 1 2 3 4 5
not clients follow their treatment. 34. In general, clients are more open to discussing religious- 1 2 3 4 5
spiritual beliefs than are therapists. 1 2 3 4 5
35. Prayer is helpful in coping with stress. 36. Therapists should address religious-spiritual faith in 1 2 3 4 5
therapy. 37. Poor mental health is punishment from God or a higher 1 2 3 4 5
being. 1 2 3 4 5
72


APPENDIX B
The Spiritual Involvement and Beliefs Scale
Directions: This questionnaire is about spiritual beliefs and actions. Please respond
to each statement as honestly as you can. There are no right or wrong answers. Do
not spend time thinking too much about each statement. Simply mark the response
which reflects your first impression.
Please answer the questions by using the following scale and circling the appropriate
number.
Scale:
1 = Strongly 2 = Disagree 3 Neutral 4 Agree 5 = Strongly
Disagree (D) (N) (A) Agree
(SD) (SA)
1. In the future, science will be able to explain everything.
2. I can find meaning in times of hardship.
3. A person can be fulfilled without pursuing an active
spiritual life.
4. I am thankful for all that has happened to me.
5. Spiritual activities have not helped me become closer to
other people.
6. Some experiences can be understood only through ones
spiritual beliefs.
7. A spiritual force influences the events in my life.
8. My life has a purpose.
9. Prayers do not really change what happens.
10. Participating in spiritual activities helps me forgive other
people.
11. My spiritual beliefs continue to evolve.
12. I believe there is a power greater than myself.
13. I probably will not reexamine my spiritual beliefs.
SD D N A SA
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
73


SD D N A SA
14. My spiritual life fulfills me in ways that material
possessions do not. 1 2 3 4 5
15. Spiritual activities have not helped me develop my identity. 1 2 3 4 5
16. Meditations does not help me feel more in touch with my inner spirit. 1 2 3 4 5
17. I have a personal relationship with a power greater than myself. 1 2 3 4 5
18. I have felt pressure to accept spiritual beliefs that I do not agree with. 1 2 3 4 5
19. Spiritual activities help me draw closer to a power greater than myself. 1 2 3 4 5
Please indicate how often you do the following:
Always Usually Sometimes Rarely Never
20. When I wrong someone, I
make an effort to apologize. ____________ ________ ___________ __________ _______
21. When I am ashamed of
something I have done, I tell
someone about it. _______ ________ ___________ __________ _______
22. I solve my problems without
using spiritual resources. _______ ________ ___________ __________ _______
23. I examine my actions to see
if they reflect my values. _______ ________ ___________ __________ _______
24. During the last WEEK, I prayed.. .(check one)
______10 or more times.
______7-9 times.
______4-6 times.
______1-3 times.
______0 times.
25. During the last WEEK, I meditated.. .(check one)
______10 or more times.
______7-9 times.
______4-6 times.
______1-3 times.
0 times.
74


26. Last MONTH, I participated in spiritual activities with at least one other
person.. .(check one)
______more than 15 times.
______11-15 times.
______6-10 times.
______1-5 times.
0 times.
75


APPENDIX C
Form C
Demographic Information
Gender: ______Male ________Female
Age in years: ______
Marital Status: ____Married _____________Widowed ___________Divorced
_____Separated ___________Single
Ethnic Background: White ______African American
______Hispanic ___________Asian/Pacific Islander
______Native American
______Other (please specify): _______________
Religious Affiliation:_____Christian (Orthodox & Protestant denominations)
______Catholic ___________Jewish Muslim
______Hindu ______Buddhist
______Native American Religions
______Spiritualist _______Atheist
______Agnostic
______Other (please specify): _________
(Continued on next page)
76


Location:
City or metropolitan area
Medium-sized town
Rural or small town
Living Situation: _______Independent-living
______Assisted-living
______Nursing home
77


APPENDIX D
Demographic Information
Form P
Gender: ______Male ________Female
Age in years: ______
Marital Status: ____Married _____________Widowed ____________Divorced
_____Separated ___________Single
Ethnic Background: ________White ________African American __________Hispanic
Asian/Pacific Islander Native American
Other (please specify):
Religious Affiliation:______Christian (Orthodox & Protestant denominations)
______Catholic _____________Jewish ____________Muslim
______Hindu _______Buddhist
______Native American Religions
______Spiritualist _________Atheist
______Agnostic
______Other (please specify): ____________
(Continued on next page)
78


Practice Location:
City or metropolitan area
Medium-sized town
Rural or small town
How many years have you been licensed? _________
Which of the following most accurately represents the percentage of your total
clinical experience working with elderly clients:
______0% (no experience working with older adults)
______25%
______50%
______75%
______100% (I have worked exclusively with older adults)
Highest educational degree earned:
______Masters Degree
*
______Ph.D.
______Psy.D.
______Other (please specify): _______
Is your practice religious-spiritual based? ____Yes ___________Partly _______No
79


APPENDIX E
Research Information
We would like you to complete a short survey as part of a masters thesis project at
the University of Colorado at Denver. It should take about 20 minutes of your time.
The following information is provided so that you can decide whether you wish to
participate in the present study.
The purpose of this study is to measure peoples attitudes toward various
religious/spiritual issues and behaviors in counseling or psychotherapeutic settings
with older adults. We are also interested in gathering information about the nature of
religious/spiritual beliefs in peoples personal lives.
Attached is a three-part survey, most of which is composed of opinion questions. If
you do not want to answer specific questions, simply leave them blank.
Your participation is requested, but strictly voluntary; you may withdraw at any time.
Please do not write your name anywhere on this questionnaire. Given that you are
assured of complete confidentiality, please respond to the statements as honestly and
as accurately as possible. We will not share your individual responses with anyone.
If you have any questions about the study, feel free to contact Dr. Mitch Handelsman
at 303-556-2672, or the CU-Denver Office of Academic Affairs, CU-Denver
Building Suite 700, 303-556-2550.
Thank you for participating in our study!
Sincerely,
Shaalon Joules
Clinical Psychology Masters Student
Mitchell M. Handelsman, Ph.D
Professor of Psychology
CU Presidents Teaching Scholar
80


APPENDIX F
Cover Letter
Dear Participant,
We would like you to complete a short survey as part of a masters thesis project at
the University of Colorado at Denver. It should take about 20 minutes of your time.
The following information is provided so that you can decide whether you wish to
participate in the present study.
The purpose of this study is to measure peoples attitudes toward various
religious/spiritual issues and behaviors in counseling or psychotherapeutic settings
with older adults. We are also interested in gathering information about the nature of
religious/spiritual beliefs in peoples personal lives.
Enclosed is a three-part survey, most of which is composed of opinion questions. If
you do not want to answer specific questions, simply leave them blank.
Your participation is requested, but strictly voluntary; you may withdraw at any time.
Please do not write your name anywhere on this questionnaire. Given that you are
assured of complete confidentiality, please respond to the statements as honestly and
as accurately as possible. We will not share your individual responses with anyone.
If you have any questions about the study, feel free to contact Dr. Mitch Handelsman
at 303-556-2672, or the CU-Denver Office of Academic Affairs, CU-Denver
Building Suite 700, 303-556-2550.
Thank you for participating in our study!
Sincerely,
Shaalon Joules
Clinical Psychology Masters Student
Mitchell M. Handelsman, Ph.D
Professor of Psychology
CU Presidents Teaching Scholar
81


APPENDIX G
Cover Letter
Dear Dr.:
We would like you to complete a short survey as part of a masters thesis project at
the University of Colorado at Denver. It should take about 20 minutes of your time.
We have a small, randomly selected sample of psychologists and would very much
value your participation.
The purpose of this study is to measure peoples attitudes toward various
religious/spiritual issues and behaviors in the therapeutic setting with older adults. .
We are also interested in gathering information about the nature of religious/spiritual
beliefs in peoples personal lives.
Enclosed is a three-part survey, most of which is composed of opinion questions.
Even if you do not work with older adult clients, please select answers that most
accurately reflect your views. We have provided you with a return, postage-paid
envelope for your convenience. Returning the survey constitutes consent to
participate. Please do not write your name anywhere on the survey to ensure
anonymity.
We appreciate your participation in our study. Should you have questions, please
contact Shaalon Joules at sjoules@ouray.cudenver.edu or Dr. Mitch Handelsman at
303-556-2672 or mitchell.handelsman@cudenver.edu. You may also contact the
research office at the CU-Denver Office of Academic Affairs at 303-556-2550.
Thank you very much for your time and help.
Sincerely,
Shaalon Joules
Clinical Psychology Masters Student
Mitchell M. Handelsman, Ph.D.
Professor of Psychology
CU Presidents Teaching Scholar
82


REFERENCES
Allman, L. S., De la Rocha, O., Elkins, D. N., & Weathers, R. S. (1992).
Psychotherapists attitudes toward clients reporting mystical experiences.
Psychotherapy. 29 (4), 564-569.
American Psychiatric Association. (1994). Diagnostic and statistical manual
of mental disorders (4th ed.). Washington, DC: Author.
Argyle, M. (2000). Psychology and religion. London: Routledge.
Bamhouse, R. T. (1986). How to evaluate patientsreligious ideation. InL.
H. Robinson (Ed.), Psychiatry and religion: Overlapping concerns (pp. 89-106).
Washington, DC: American Psychiatric Press.
Bilgrave, D. P., & Deluty, R. H. (1998). Religious beliefs and therapeutic
orientations of clinical and counseling psychologists. Journal for the Scientific Study
of Religion. 37 (2), 329-349.
Boehnlein, J. K. (2000). Psychiatry and religion: The convergence of mind
and spirit. Washington, DC: American Psychiatric Press.
Bower, G. (1996). Relational Resilience: A new perspective for
understanding the elderly persons relationship to the notion of God. Journal of
Geriatric Psychiatry. 29 (1), 83-104.
Brody, C. M., & Semel, V. G. (1993). Strategies for therapy with the
elderly: Living with hope and meaning. New York: Springer Publishing Company.
83


Burgess, E. O., Schmeeckle, M., & Bengtson, V. L. (1998). Aging individuals and
societal contexts. In I. H. Nordhus, G. R., VandenBos, S. Berg, & P. Fromholt
(Eds.). Clinical Geropsychology (pp. 15-31). Washington, DC: American
Psychological Association.
Cloud, H. & Townsend, J. (1992). Boundaries. Grand Rapids, MI:
Zondervan Publishing House.
Conn, D. K. & Kaye, A. (1992). Depression and other mood disorders. In
D. K. Conn, N. Herrmann, A. Kaye, D. Rewilak, A. Robinson, & B. Schogt
(Eds.). Practical psychiatry in the nursing home: A handbook for staff (pp. 87-108).
Seattle, WA: Hogrefe & Huber Publishers.
Cooley, S., Deitch, I. M., Harper, M. S., Hinrichsen, G., Lopez, M. A., &
Molinari, V. A. (1998). What practitioners should know about working with older
Adults. Washington, DC: American Psychological Association. Retrieved October
5,2000, from the World Wide Web:
http://www.apa.org/pi/aging/practitioners/homepage.html
Department of Health and Human Services. (1999). Mental health: A report
of the surgeon general. Washington, DC: U.S. Government Printing Office.
Retrieved October 5, 2000, from the World Wide Web:
http://www.surgeongeneral.gOv/library/mentalhealth/chapter2/sec2_l.html#table2_6
Department of Health and Human Services. (1999). Mental health: A report
of the surgeon general. Washington, DC: U.S. Government Printing Office.
84


Retrieved October 5,2000, from the World Wide Web:
http://www.surgeongeneral.gov/library/mentalhealth/chapter5/secl.html
Ehmann, C. (1999). The age factor in religious attitudes and behavior.
Princeton, NJ: The Gallup Organization. Retrieved October 5, 2000, from the World
Wide Web: http://www.gallup.com/polls/releases/pr990714b.asp
Faith and health: Divine intervention or good behavior? (1998, October 27).
Washington, DC: Center for the Advancement of Health. Retrieved October 5, 2000,
from the World Wide Web: http://www.cfah.org/website2/newsrelease/981027e.htm
Hatch, R. L., Burg, M., Naberhaus, D. S., & Hellmich, L. K. (1998). The
spiritual involvement and beliefs scale: Development and testing of a new
instrument. The Journal of Family Practice, 46 (6), 476-486.
Heilman, G. L. (1999, August/September). Psychotherapy and spirituality:
Birds of a feather. The Episcopal New Yorker, 164 (4). Retrieved September 3,
2000, from the World Wide Web:
http ://www.dioceseny. org/ eny/augsept99/psycho .html
Jeste, D. V., Alexopoulos, G. S., Bartels, S. J., Cummings, J. L., Gallo, J.
J., Gottlieb, G. L., Halpain, M. C., Palmer, B. W., Patterson, T. L., Reynolds, C.
F., Ill, Lebowitz, B. D. (1999). Consensus statement on the upcoming crisis in
geriatric mental health: Research agenda for the next 2 decades. Archives of General
Psychiatry. 56. 848-853.
Jones, S. L. (1994). A constructive relationship for religion with the science _
85


and profession of psychology: Perhaps the boldest model yet. American
Psychologist. 49 (31.184-199.
Josephson, A. M., Larson, D. B., & Juthani, N. (2000). Whats happening
in psychiatry regarding spirituality? Psychiatric Annals. 30 (8), 533-541.
Kaas, M. J., & Lewis, M. L. (1999). Cognitive behavioral group therapy for
residents in assisted-living facilities. Journal of Psychosocial Nursing & Mental
Health Services, 37 (10). Retrieved November 7, 2000, from NORTHERNLIGHT
database on the World Wide Web:
http://www.Northemlight.com/PN19991025050005107.html?cb=0&sc=0#doc
Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K.
E., Pbert, L., Lenderking, W. R., & Santorelli, S. F. (1992). Effectiveness of a
meditation-based stress reduction program in the treatment of anxiety disorders.
American Journal of Psychiatry, 149 (7), 936-943.
Kelly, E. W., Jr. (1998). Spirituality and religion in counseling and
psychotherapy-Part 1. ACAeNews, 1 (14). Retrieved October 5, 2000, from the
Worldwide Web: http://www.counseling.org/enews/volmne_l/0113a.htm
Koenig, H. G. (1994). Aging and God: Spiritual pathways to mental health
in midlife and later years. New York: The Haworth Press.
Koenig, H. G. (Ed.). (1998). Handbook of religion and mental health. San
Diego, CA: Academic Press.
Koenig, H. G., Bearon, L. B., & Dayringer, R. (1989). Physician
86


perspectives on the role of religion in the physician-older patient relationship. The
Journal of Family Practice. 28 (4), 441-448.
Koenig, H. G., & Larson, D. B. (1998). Religion and mental health. In
Encyclopedia of mental health (Vol. 3, pp. 381-392). San Diego, CA: Academic
Press.
Koenig, H. G., Larson, D. B., & Matthews, D. A. (1996). Religion and
psychotherapy with older adults. Journal of Geriatric Psychiatry. 29 (2), 155-184.
Lukoff, D., & Lu, F. G. (1999). Cultural competence includes religious and
spiritual issues in clinical practice. Psychiatric Annals. 29 (8), 469-472.
Markides, K. S. (1983). Aging, religiosity, and adjustment: A longitudinal
analysis. Journal of Gerontology. 38 (51. 621-625.
Markides, K. S., Levin, J. S., &Ray, L. A. (1987). Religion, aging, and life
satisfaction: An eight-year, three-wave longitudinal study. The Gerontologist. 27
(5), 660-665.
Meador, K. G., & Koenig, H. G. (2000). Spirituality and religion in
psychiatric practice: Parameters and implications. Psychiatric Annals. 30 (8), 549-
555.
McMinn, M. R., Chaddock, T. P., Edwards, L. C., Lim B., & Campbell, C.
D. (1998). Psychologists collaborating with clergy. Professional Psychology,
Research and Practice. 29 (6), 564-570.
Miller, W. R. (Ed.). (1999). Integrating spirituality into treatment:
87


Resources for practitioners. Washington, DC: American Psychological Association.
Nordhus, I. H., Nielsen, G. H., &Kvale, G. (1998). Psychotherapy with
older adults. Ini. H. Nordhus, G. R. VandenBos, S. Berg, &P. Fromholt (Eds.),
Clinical geropsvchology (pp. 289-311). Washington, DC: American Psychological
Association.
Northcut, T. B. (2000). Constructing a place for religion and spirituality in
psychodynamic practice. Clinical Social Work Journal, 29 (2). Retrieved September
3.2000, from NORTHERNLIGHT database on the World Wide Web:
http://www.Northemlight.com/AA20000817010000420.html?cb=&sc=:0#doc
Oyama, O., & Koenig, H. G. (1998). Religious beliefs and practices in
family medicine. Archives of Family Medicine. 7.431 -435.
Pachana, N. A. (1999). Developments in clinical interventions for older
adults: A review. New Zealand Journal of Psychology, 28 (2). Retrieved November
7.2000, from NORTHERNLIGHT database on the World Wide Web:
http ://www.Northemlight. com/AA20000417030003842.html?cb=&sc=0#doc
Pincharoen, S. (1997). Spirituality and health in elderly Thai persons: A
qualitative descriptive study. Masters thesis, University of Colorado, Denver.
Prayer aids in mental health. (1999, November 12). BBC News. Retrieved
October 5,2000, from the World Wide Web:
http://www.news.bbc.co.uk/hi/english/health/newsid_516000/516350.stm
Puchalski, C. M. (2000). F.I.C.A.: A spiritual assessment. Rockville, MD:
88


National Institute for Healthcare Research. Retrieved October 5, 2000, from the
World Wide Web: http://www.nihr.org/education/fica.html
Puchalski, C. M., Larson, D. B., & Lu, F. G. (2000). Spirituality courses in
psychiatry residency programs. Psychiatric Annals. 30 (81. 543-548.
Ramsey, J. L., & Blieszner, R. (1999). Spiritual resiliency in older women:
Models of strength for challenges through the lifespan. Thousand Oaks, CA: Sage
Publications.
Richards, P. S., & Bergin, A. E. (Eds.). (2000). Handbook of
psychotherapy and religious diversity. Washington, DC: American Psychological
Association.
Roof, W. C. (1999). Spiritual marketplace. Princeton, NJ: Princeton
University Press.
Ruiz, P. (1998). The role of culture in psychiatric care. American Journal of
Psychiatry. 155. 1763-1765.
Sadavoy, J. (1992). Psychotherapy for the institutionalized elderly. InD. K.
Conn, N. Herrmann, A. Kaye, D. Rewilak, A. Robinson, & B. Schogt (Eds.),
Practical psychiatry in the nursing home: A handbook for staff (pp. 217-236).
Seattle, WA: Hogrefe & Huber Publishers.
Schultz-Ross, R. A., & Gutheil, T. G. (1997). Difficulties in integrating
spirituality into psychotherapy. Journal of Psychotherapy Practice and Research. 6
(2), 130-138.
89


Shafranske, E. P. (Ed.). (1996). Religion and the clinical practice of
psychology. Washington, DC: American Psychological Association.
Shafranske, E. P. (2000). Religious involvement and professional practices
of psychiatrists and other mental health professionals. Psychiatric Annals, 30 (8),
525-532.
Shafranske, E. P., & Malony, H. P. (1990). Clinical psychologistsreligious
and spiritual orientations and their practice of psychotherapy. Psychotherapy, 27 (1),
72-78.
Sollod, R. N. (1993). Integrating spiritual healing approaches and techniques
into psychotherapy. In G. S. Strieker and J. R. Gold (Eds.), Comprehensive
handbook of psychotherapy. Retrieved September 17, 2000, from the World Wide
Web: http://www.psywww.com/psyrelig/sollod2.html
Sperry, L. (2000). Spirituality and psychiatry: Incorporating the spiritual
dimension into clinical practice. Psychiatric Annals. 30 (8), 518-523.
Standard, R. P., Sandhu, D. S., & Painter, L. C. (2000). Assessment of
spirituality in counseling. Journal of Counseling & Development, 78 (2). Retrieved
November 7, 2000, from NORTHERNLIGHT database on the World Wide Web:
http://www.Northemlight.coxn/AA20000508030001341 .html?cb=0&sc=0#doc
Taggart, S. R. (1994). Living as if: Belief systems in mental health practice.
San Francisco: Jossey-Bass Publishers.
Thomas, L. E., & Eisenhandler, S. A. (Eds.). (1999). Religion, belief, and
90


spirituality in late life. New York: Springer Publishing Company.
Turner, R. P., Lukoff, D., Bamhouse, R. T., & Lu, F. G. (1995). Religious
or spiritual problem: A culturally sensitive diagnostic category in the DSM-IV. The
Journal of Nervous and Mental Disease. 183 (7), 435-444.
U.S. Census Bureau. (1995). Sixty-five plus in the United States.
Washington, DC: Author. Retrieved September 3,2000, from the World Wide Web:
http://www.census.gov/socdemo/www/agebrief.html
Worthington, E. L., Kurusu, T. A., Sandage, S. J., & McCullough, M. E.
(1996). Empirical research on religion and psychotherapeutic processes and
outcomes: A 10-year review and research prospectus. Psychological Bulletin. 119
(3), 448-487.
91