Rational-Emotive Assessment with Religious Clients | SpringerLink

Journal of Rational-Emotive & Cognitive-Behavior Therapy Volume 16, Number 2, Summer 1998

RATIONAL-EMOTIVE ASSESSMENT WITH RELIGIOUS CLIENTS W. Brad Johnson George Fox University

Stevan Lars Nielsen Brigham Young University

ABSTRACT: Rational Emotive Behavior Therapy (REBT), when practiced effectively and flexibly, can be an excellent treatment modality for religious clients. Most of the American population acknowledges some religious belief and/or practice and religious clients sometimes present with unique disturbances and concerns about psychotherapy. In this article we discuss the rapidly changing literature relative to religiousness and mental health and highlight the ethical-professional risks of failing to carefully assess and responsibly manage client religiousness when it is personally and clinically salient. We conclude by outlining a model for focused assessment of religiousness early in REBT and recommend that REBT practitioners consider different components of religiousness and the manner in which they may impact response to treatment. Careful assessment along cognitive, emotional and behavioral dimensions is a hallmark of Rational-Emotive Behavior Therapy (REBT). Although REBT practitioners are encouraged to consider the client's unique contextual and cultural variables in conducting assessments (Ellis and Dryden, 1997; DiGiuseppe, 1991; Walen, DiGiuseppe, & Dryden, 1992), religiousness is seldom considered a salient client variable in the REBT assessment process. Lack of attention to the religious dimension may be attributable to many factors, not the least of which is the rejection of the possibility of healthy religiousness by Albert Ellis Address correspondence to W. Brad Johnson, Ph.D., Graduate School of Clinical Psychology, George Fox University, 414 N. Meridian St., Newberg, Oregon 97132-2697; e-mail: bjohnson @georgefox.edu. 101

© 1998 Human Sciences Press, Inc.

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early in the development of rational-emotive theory (Ellis, 1960; 1971; 1973). In these early writings, Ellis frequently noted that religion was an insidious propaganda which nearly always compromised the mental health of those who believed in a supernatural or spiritual reality. In those years Ellis noted "It [RET] is one of the few systems of psychotherapy that will truly have no truck whatever with any kind of miraculous cause or cure, any kind of God or Devil, or any kind of sacredness . . ." (Ellis, 1973, p. 16). Nonetheless, Albert Ellis has substantially altered his perspective on religion and its relationship to mental health and psychotherapy (Johnson, 1992; 1994; 1996). To a large extent, these changes have been facilitated by research on mental health and religious commitment. Currently, Ellis and other leaders in REBT are active in promoting the importance of religious variables in assessment and practice. In this article, we will describe recent literature on the relationship of religiousness to mental health with emphasis on Ellis' current perspective on the subject. We will then briefly consider the REBT approach to assessment and emphasize the unique concerns and professional issues involved when assessing religious clients. In light of the dearth of literature on REBT assessment with this population, we will present a model for careful REBT assessment with religious clients with an emphasis on ethical and pragmatic approaches to evaluating religious beliefs. REBT AND RELIGION In spite of the profound impact of Albert Ellis on the field of psychotherapy, it is unlikely that any other theorist in the field has garnered such intense criticism and rejection from religious authors and practitioners. Religious authors have often objected to rational-emotive philosophy, Ellis's equation of religiousness with psychopathology and his personal "probabilistic atheism" (Johnson, 1994). Although Ellis originally rejected all religious belief as nearly synonymous with disturbance and pathology (Ellis, 1960; 1971; 1973), he later modified this view and began to distinguish between "devout" and "mild" religiousness (Ellis, 1980; 1983; 1986). Ellis contended that those who strongly or devoutly adhere to religious beliefs are likely to be quite disturbed and distressed while those who were mild, moderate, liberal and "nonorthodox" in their religious adherence could be both religious and relatively free of pathology.

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More recently however, Albert Ellis has more clearly and helpfully distinguished between dogmatism/rigidity and religious beliefs themselves (Ellis, 1992; 1994; 1996). He has written "More than particular religious beliefs, it is absolute, dogmatic devotion to beliefs which helps to create emotional disturbance. This is true of dogmatic adherence to atheism or to political ideas as much as it is true of religion" (Ellis, 1994, p. 328), and "My view now is that religious and nonreligious beliefs in themselves do not help people to be emotionally 'healthy' or 'unhealthy'. Instead, their emotional health is significantly affected by the kind of religious and nonreligious beliefs that they hold" (Ellis, 1996, p. 4). Ellis has noted that many religious clients and psychotherapists are rather open-minded and non-absolutist. He has further emphasized the substantial compatibility between the essential principles of REBT and many tenants of Judeo-Christian religions (Ellis, 1996) and has worked to "translate" REBT to religious language of clients. At least part of the reason for Ellis' changing perspective on religion has been his openness and responsiveness to research on the interface of religiousness and health. Large scale reviews of the relationship between religious belief and commitment and subsequent physical and psychological health offer no consistent evidence for a positive correlation between religiousness and disturbance (Bergin, 1983; Donahue, 1985; Ferraro & Albrecht-Jensen, 1991; Gartner, Larson, & Allen, 1991; Johnson, 1992; Masters, Bergin, Reynolds, & Sullivan, 1991). For example, Ferraro and Albrecht-Jensen (1991) found that higher levels of religious practice were positively associated with better physical health regardless of age. Gartner et al. (1991) found that when "hard" variables such as delinquency, marital satisfaction and clear mental health outcomes are utilized, religious belief and practice is nearly always positively correlated with better health. In a now classic study by Sharkey and Malony (1986), clients at the Albert Ellis Institute in New York who described themselves as very religious were found to report fewer presenting problems than clients who self-described as "atheist." Similarly, Demaria and Kassinove (1988) found that although religiousness was a significant predictor of guilt in religious adults, careful analysis revealed that endorsement of irrational beliefs (versus religious affiliation or degree of religiousness) was the best predictor of guilt. In spite of these findings, however, there is evidence that certain forms of religiousness are more likely to correlate with negative mental health outcomes (Donahue, 1985; Lovinger, 1994; Richards & Bergin, 1997). In this paper, we will focus on those quali-

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ties of religious belief and behavior which should be assessed early in REBT. TRADITIONAL REBT ASSESSMENT REBT posits that at the heart of psychological disturbance is the tendency to make devout, absolutistic evaluations of the perceived events in one's life (Ellis & Dryden, 1997). Such demands are typically phrased as dogmatic musts, shoulds, have to's and oughts. These beliefs nearly always impede and obstruct people in pursuit of their basic goals and purposes. Assessment is an intentionally dynamic (versus static), integrated feature of the REBT treatment process (DiGiuseppe, 1991). REBT sessions include an ongoing flow of generating and testing hypotheses about the client's beliefs, coupled with interventions designed to help the client change those beliefs most intimately linked with their distress. As the effects of interventions provide ongoing information regarding the accuracy of hypotheses about the role of the client's beliefs in their upset, the assessment-intervention cycle in REBT is continuous. Assessment and intervention are inextricably linked. Starting with the presenting problem (typically an emotional C), the REBT therapist attempts to expeditiously move to an understanding of the primary activating event (A) and the core irrational beliefs) (IBs). Typically, the REBT therapist employs assessment strategies such as inference chaining and conjunctive phrasing ("yes, and that would mean?") repeatedly until the client's core irrational belief and its derivatives are identified. DiGiuseppe (1991) and others have emphasized that REBT assessment should focus only on issues relevant to treatment and that assessment should demonstrate clear treatment utility. Although the goal of REBT is to detect and help clients to alter irrational beliefs, this is seldom best accomplished via a "slash and burn" campaign against all irrationality. In the context of an REBT session, evaluation of the irrationality of a given belief, including a religious belief, is best guided by at least four essential criteria: (a) is the irrational belief linked at a core level to the presenting upset? (b) is the core irrational belief self-defeating as defined by the client's own goals? (c) is the core irrational belief absolutistic? (d) is the core belief an evaluative belief? Assessment of religious clients in REBT has been minimally addressed in the literature and there appears to be a wide range of


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approaches to religious session content by trained REBT psychotherapists. Traditionally, Ellis recommended that religious beliefs be treated like any other irrational and therefore disturbance-inducing belief on the basis that they are unverifiable and therefore anti-scientific (Ellis, 1980; 1983). Thus if a religious belief is not testable scientifically and/ or a violation of logic as defined by the therapist, the belief would be a target for disputation and eventual modification. Although few would argue that certain religious beliefs appear distorted, incongruent with the client's religious culture and perhaps rigidly adhered to, there are obvious concerns inherent with attempts to alter religious faith and commitment. Further, certain of the philosophies of rational-emotive psychology may be incongruent with the theistic perspective of a number of religious clients. For example, the Christian client may adhere to biblical calls to self-sacrifice and community service and yet be evaluated by the REBT therapist as excessively dependent and inadequately self-interested. Rather than assess the extent to which such religious beliefs may actually facilitate some degree of favorable adjustment and certain positive emotional outcomes, the misguided REBT practitioner may move quickly to dispute the client's religious beliefs on the basis of some negative consequence perceived to be related to the client's religious beliefs. Such rapid (and potentially misguided) assessment poses numerous pragmatic and ethical problems. Support for this concern comes from a program of research by Paul Watson and his colleagues at the University of Tennessee (Watson, Folbrecht, Morris, & Hood, 1990; Watson, Morris, & Hood, 1988; Watson, Morris, Hood, & Folbrecht, 1991). These authors offer considerable evidence that traditional measures of irrational beliefs are questionably valid with religious clients. For example, intrinsically religious clients tend to obtain less elevated scores on measures of psychopathology, yet higher scores on irrational belief subscales such as "dependency." When considered from within the context of the client's religious faith, however, dependency may be equivalent to social responsibility and emotional empathy. Watson et al. (1991) are concerned about attempts to define any universal set of criteria for rationality which would be used to assess a client's beliefs as inherently pathologic "modern psychotherapies promote individualism without understanding how an excessive emphasis on the self can work against humane social life and how a healthy interdependency can work toward it" (p. 344). When an REBT assessment tool (Jones, 1968) identifies the statement "people need a source of strength outside of themselves" as irrational and dependent, there are obvious concerns about

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the extent to which a client's religious beliefs can be accurately and sensitively evaluated. Whenever the process of therapy and the client's presentation permit, we strongly recommend adherence to the steps—or at least adoption of the attitudes implicit in the steps—suggested by Dryden and DiGiuseppe (1992) for conducting REBT assessment and psychotherapy. Though apparently obvious and straightforward, the first two of these 13 steps to treatment are foundational for collaborative assessment of religious clients. First, ask for and second, come to agreement with the client regarding goals for the session. Though these steps may naturally need to be revisited throughout therapy, careful adherence to such a strategy assists the REBT therapist in focusing assessment on those irrational beliefs most relevant to the client's primary goals. This helps to ensure that when religious beliefs are not related to essential client goals, they will not become an inappropriate focus of assessment and treatment. Wadsworth and Checketts (1980) found that religious psychologists were not significantly influenced by client religiousness in their case conceptualization and diagnosis of clients, However, some literature suggests that psychotherapists are generally less religious than the population at large and that they may be inclined to implicitly pathologize religious belief and behavior in clients (Richards & Bergin, 1997). REBT therapists may frequently lack formal training in service provision to religious clients. Very few graduate training programs provide course work and supervision on religious and spiritual issues in mental health and psychotherapy, though they provide training in other areas of diversity (Kelley, 1993; Richards & Bergin, 1997; Shafranske & Malony, 1990; Tan, 1993). Therapists may additionally be inexperienced with the specific religious beliefs and practices presented by individual clients. Although professional guidelines require training and "expertise" when providing services to diverse client groups, there is comparatively little literature regarding the unique clinical issues commonly presented by specific religious groups. In this vacuum of training and experience, the REBT practitioner is vulnerable to decision-making errors at the assessment stage of treatment. They may rely on their own preconceptions (perhaps informed by rational-emotive philosophy) about the connection between religiousness and mental health and may make false attributions regarding the etiology of client disturbance (Rowan, 1996). Specifically, the therapist may ignore religious beliefs altogether, or may search only for deleterious effects of religious factors.


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ETHICAL/PROFESSIONAL CONCERNS Several Ethical Code (APA, 1992) and Specialty Guideline (APA, 1993) requirements appear to speak directly to assessment and therapy with religious clients. The ethics code requires psychologists to provide services only within the boundaries of their competence, based on education, training and supervised experience. Psychologists also respect human differences, including religion, which might affect their work with particular clients and make appropriate referrals when unprepared to address such differences. Most important for the current discussion, section 2.04 (Use of Assessment in General and with Specific Populations) of the code requires psychologists to identify situations in which specific assessment techniques or norms may not be applicable or require adjustment because of client factors, including religiousness. Similarly, the Specialty Guidelines for providers to special populations (APA, 1993) specifically states that "Psychologists respect client's religious and/or spiritual beliefs and values, including attributions and taboos since they affect world view, psychosocial functioning, and expressions of distress" (p. 46). The REBT therapist is required by ethical and professional guidelines to respectfully acknowledge client religiousness as an important diversity variable and to understand the potential value of religious faith in the individual client. Yet psychotherapy is a clearly valueladen process and most all psychotherapists, to some extent, communicate values to their clients (Bergin, 1980; Tjeltveit, 1986). During the assessment process in psychotherapy, there appear to be at least four distinct but overlapping dangers when working with religious clients. These include: (a) ignoring important client data or salient consequences and activating events, merely because they are religious in nature, (b) intentionally pathologizing religious beliefs or practices such that faith-congruent beliefs or practices are linked to negative consequences and thereby assumed to be irrational and harmful, (c) explicit value imposition in which the therapist attempts to convince or persuade the client that his or her religious or spiritual ideology/world view is less correct, worthwhile or healthy than that of the therapist, (d) implicit value imposition (Richards & Bergin, 1997) in which the therapist subtly works to modify client moral, religious or spiritual goals without consent of the client. In our view each of these is a potential danger of an REBT approach to assessment which is not intentionally sensitive to client religious beliefs and practices.

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A MODEL FOR REBT ASSESSMENT WITH RELIGIOUS CLIENTS When confronted with an explicitly religious client and/or clear religious material in the context of an intake assessment, the REBT therapist is encouraged to conduct a more careful assessment of the client's unique religious beliefs, practices and problems. However, even when client's do not initially present with religious material, Richards and Bergin (1997) have argued that a broad Ecumenical Assessment is appropriate as part of a standard intake procedure for the purpose of gaining a global understanding of clients spiritual worldview, religious background, beliefs and lifestyle. Such a broad initial assessment is indicated by 1992 Gallop Pole data suggesting that 91% of the American population report an explicit religious preference and that 71% of Americans are members of a church or synagogue (Hoge, 1996). The same pole found that 66% have an active prayer life, 75% believe in an after life and 87% of Americans say that their religion is a "fairly" or "very" important part of their lives. Richards and Bergin (1997) suggested five essential reasons why clinicians should include a religious-spiritual component in the client assessment: (a) understanding a client's worldview may enhance the therapist's sensitivity and empathy, (b) understanding the nature and health of a client's religious-spiritual worldview may enhance understanding of its impact on the presenting problem, (c) the client's religious-spiritual beliefs and community may be utilized as resources for coping and changing, (d) such an assessment is the first step in determining whether spiritual interventions may be helpful for the client, and (e) such an assessment may help the therapist determine whether the client has unresolved spiritual doubts, concerns or needs. If the client presents with a clear religious worldview, perceives that their religious-spiritual beliefs are related to the presenting problem(s) and is willing to explore religious issues as part of treatment, the REBT therapist might then move to a more advanced or focused level of assessment which Richards and Bergin (1997) describe as a level two assessment. We recommend that REBT therapists consider a similar two stage process during standard REBT intakes. First, all religious REBT clients should be greeted with an attitude of collaboration and sincere interest, followed by an standard assessment of both personal and clinical religious salience. Second, for those clients who present with very


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devout religiousness or who offer presenting problems which are clearly linked to religious-spiritual beliefs and practices, a more detailed or advanced assessment process will be recommended. Collaboration Versus Arrogance Miller (1988) and others (DiGiuseppe, 1991; McMinn & Lebold, 1989) have warned cognitive-behavior therapists to avoid an approach to assessment which may be "arrogant" in the sense of being rooted in a narcissistic epistemology. Here the arrogant therapist assumes that what he or she believes to be true about a religious client's beliefs and behaviors must in fact be true. From such an arrogant perspective, certain religious beliefs may quickly be dismissed as "unhealthy," "stupid," "irrational," or otherwise pathological, while those beliefs and views endorsed by the therapist or rational-emotive philosophy, are defined as healthy, rational and desirable by contrast. When operating from such an epistemologic position, the therapist may be understandably swift in confronting and even disputing the client's religious beliefs and very likely, alienating a good number of devoutly religious clients. As an alternative, we highly recommend a collaborative approach to assessment with religious clients. Such an approach is intentionally collaborative and focused on developing an informed and individualized assessment of the client's unique experience and expression of religion and spirituality. Several practitioners have recommended such collaboration (DiGiuseppe, Robin, & Dryden, 1990; Lovinger, 1984; Miller, 1988; McMinn & Lebold, 1989; Richards & Potts, 1995) as a means of respecting the integrity of the client's belief system. It begins with an interest in exploration versus renovation and is interested in developing a picture of how the client has developed specific beliefs and how they function within a specific denomination or religious community. We concur with Richards and Potts (1995) that effective assessment and intervention from within the client's religious world view requires effective rapport building, explicit permission from the client to explore religious issues and a collaborative attempt to understand the client's unique religious beliefs and doctrinal commitments. After the REBT therapist has effectively communicated an attitude of collaboration to the religious client, it will typically be feasible to move forward with a preliminary assessment of the client's specific religiousness.

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Assessment of Religious Salience In addition to communication of a collaborative attitude toward the religious client, the REBT therapist is well served to engage in a preliminary or first level screening of the client's religiousness. Here, the therapist is interested in determining the extent to which the client's religiousness is salient in two distinct ways. Personal Salience. In the preliminary assessment, the most important question to address is the extent to which the client is engaged with his or her religion and the extent to which religious commitment and practice may be connected to the presenting problem(s). Worthington (1988) emphasized that clients high in religious salience may be either pro- or anti-religious. In contrast, a person low in religious salience is unlikely to even consider religion day to day. When the REBT therapist discerns that religion plays a significant role in the life of a client, it is reasonable to conclude that the client tends to evaluate their world on at least three important religious value dimensions including: (a) the role of authority of human leaders, (b) scripture or doctrine and (c) religious group norms (Worthington, 1988). At this stage, therapy may be facilitated by some understanding on the part of the therapist, of the client's beliefs about the universe and the nature of reality, religious affiliation and religious orthodoxy (Richards & Bergin, 1997). More orthodox clients accept the doctrinal beliefs of their religion and adhere to the moral teachings and practices of that group. In general, the more orthodox a client is, the more likely they will be to prefer a same faith therapist and view their religion and lifestyle as relevant to their problems and treatment. When evaluating the extent to which religion is salient or significant in the life of a client, it behooves the therapist to keep in mind that for high salience clients, there may be a great deal of affect (both positive and negative) associated with religious commitments. Religious subjects presented with statements which confirm or contradict their religious beliefs respond with considerable emotional arousal, as measured by Galvanic Skin Response (Stoudenmire, 1971). Contradictory statements appear to produce displeasure and significantly greater overall emotion than confirming statements. Related to this is the potential for religious salience to produce affective disturbance in clients for whom there exists a disparity between belief and behavior. Clients who articulate strong faith and doctrinal commitments are likely to be disturbed when their lifestyle (application of beliefs and values) is in-


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congruent with such beliefs (Shafranske & Malony, 1996). We refer to this as orthodoxy dissonance. A client will experience orthodoxy dissonance to a greater degree as beliefs and values become more disparate from actual behavior. During the assessment of personal salience of religion, this is an important dimension to consider. Clinically Salient Religion. To the extent that religion is personally salient to the client, the REBT therapist becomes increasingly vigilant to evidence that the client's faith or religious involvement is additionally connected to the current disturbance. In other words, the therapist assesses the extent to which religion is an "active issue" for the client clinically (Lovinger, 1984). Conceivably, religiousness could manifest itself in disturbed behavior and emotions (Cs), troubling activating events (As) and deeply held beliefs about self, others, the world and the supernatural (Bs). Religion would be clinically salient for the forty-year-old woman who presents with chronic depression related to her abusive marriage. She may have remained in the stifling and physically abusive marriage for 20 years secondary to firm belief that exiting a marriage is always a grievous and unforgivable sin. This view, as well as others which place women in subservient roles to men may be strongly supported by her church. Religion would also be clinically salient for the 19-year-old college sophomore who comes to the REBT therapist seeking assistance for anxiety. Preliminary assessment reveals a recent conversion to an evangelical Christian denomination though the client comes from an anti-religious atheistic family. He fears the consequences of informing his family of conversion, and believes their response will overwhelm him. In both cases, religious events and beliefs are clearly connected to the presenting problem and the REBT therapist will recognize that some handling of religious material is indicated for treatment to be maximally successful. However, client religious concerns are not always so immediately apparent and therapists must consider whether standard REBT protocols can be employed without incorporation of explicitly religious material and interventions. The therapist asks "does maximal therapeutic gain hinge on a focal assessment of the nature of religious belief and expression?" When the answer to this question is affirmative, the therapist is encouraged to consider moving to a more detailed assessment of the client's unique religiousness. We recommend assessment of some of the following dimensions of religiousness.

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Focused Assessment of Religiousness Having determined that religion is personally and clinically salient, the REBT therapist now asks more specific assessment question about "how" the client is religious. Rather than ask whether a client's religiousness is pathologic or irrational, the effective therapist recognizes that religion is complex, multidimensional and nearly infinite in the range of ways it may be expressed (Hood, Spilka, Hunsberger, & Gorsuch, 1996). In asking how a client is religious, the therapist is interested in the extent to which the client expresses idiosyncratic versus group attitudes, ideas and practices (Lovinger, 1984) and the nature of the individual's religious orientation, beliefs, practices and affiliations (Shafranske & Malony, 1996). What role does religion play in their evaluation people and events? Does the client's unique religious involvement serve as a treatment resource or treatment obstacle? Before using spiritual interventions in psychotherapy, religious clinicians recommend several preliminary criteria (Richards & Potts, 1995). We believe these are relevant to more detailed assessment of religiousness as well: (a) establish a relationship of trust, (b) obtain client consent before detailed scrutiny of religious belief and practice, (c) assess specific beliefs and doctrinal understanding, (d) keep the assessment geared to the clients level of functioning and spirituality, (e) if religion is part of the presenting problem, be particularly cautious about how the client might perceive inquiry about religious issues. Having considered these issues, the following areas may be helpful to assess with religion-salient clients. Religious Orientation. Allport and Ross (1967) were the first to distinguish between intrinsic and extrinsic religiousness. Extrinsic values are always instrumental and utilitarian. Persons with this orientation may find religion useful in a variety of ways— to provide security and solace, sociability and distraction, status and self-justification . . . Persons with this (intrinsic) orientation find their master motive in religion . . . having embraced a creed the individual endeavors to internalize it and follow it fully. (p. 434)

According to Allport and Ross, among extrinsics, "the embraced creed is lightly held or else selectively shaped to fit more primary needs" (1967, p. 434), This of course is similar to Ellis' view that religious beliefs are most healthy when "lightly held" (Ellis, 1983; 1992). How-


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ever, a considerable body of research using the Religious Orientation Scale (ROS) (Allport & Ross, 1967) suggests that extrinsic religiousness is associated with prejudice, dogmatism, trait anxiety, fear of death and a range of pathology (Donahue, 1985). Thus extrinsic or superficial (self-serving) religiousness would typically be a poor prognostic indicator and raise concerns about rigidity, immaturity and greater pathology. Intrinsic religiousness on the other hand correlates positively with internal locus of control, purpose in life and negatively with dogmatism, prejudice, anxiety and other forms of disturbance. To assess intrinsic and extrinsic religiousness, the clinician may consider use of the ROS, a 20-item measure with nine intrinsic and eleven extrinsic items. The ROS is the most psychometrically sound and well researched instrument in the field of psychology and religion. It is possible to score the ROS to obtain a four-fold typology including extrinsic, intrinsic, nonreligious and indiscriminately proreligious (endorses both intrinsic and extrinsic items) categories. Spiritual Weil-Being. Traditional measures of well-being or satisfaction with life have tended to focus exclusively on material and psychological well-being. For this reason the Spiritual Well-Being (SWB) scale was developed (Bufford, Paloutzian, & Ellison, 1991). The SWB incorporates a spiritual satisfaction or well-being focus. It includes 20 items on two subscales. The first assesses Religious Well-Being (the vertical dimension of spirituality or the relationship between person and God). The second is titled Existential Well-Being and evaluates the horizontal dimension of well being including a sense of life purpose and life satisfaction. The SWB scale has strong psychometric properties and may be particularly useful in evaluating the extent to which a client considers him or herself satisfied and adjusted in relation to God and the human religious community. Religious Coping and Problem-Solving. Pargament et al. (1988) have described three major styles of religious coping which may have value for the clinician. These include: (a) the Self-directing style in which the person assumes change is their responsibility, (b) the Deferring style is characterized by waiting on God for change or problem resolution, (c) finally, the Collaborative style is characterized by the belief that God and the individual are both responsible for change. Obviously, these divergent styles may lead naturally to different dispuational strategies in REBT. Specifically, effective treatment will more likely require intentionally religious content and interventions when working with

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deferring or collaborative clients. Also, deferring and collaborative clients may be better suited to the more directive/confrontive interventions in the REBT arsenal. Pargament et al. (1993) have also noted that when religious clients appear to surrender personal agency and efficacy, the clinician must be careful to understand the personal significance of this for the client. For example "denial" as a coping style may not mean denial of losses or difficult events, but denial of negative emotional impact or any sort of ultimately significant consequence. Degree of Conflict. At times, a client's unique religious orientation, belief and behavior may place him or her in conflict with the system and others in the social or religious surround. Grau (1977) has suggested that the religious person's religiousness should be cause for concern if, in any area of human experiencing (thinking-feeling-behaving), they are in conflict with: (a) data supported empirical reality, (b) his or her short and long term goals, (c) inner peace or a sense of well-being, (d) the environment including family, friends and the religious community, (e) a healthful process of self-integration. When the REBT therapist discerns conflict in any of these dimensions secondary to focal religious beliefs or behaviors, a more careful collaborative assessment is indicated. Incongruence within the client's beliefs should be highlighted as well as incongruence between his or her commitments and those of the broader faith community. Pragmatic disputations are often most helpful when it comes to treatment for such clients. In essence, the therapist will be asking the client how his or her demands, evaluations or rigid behaviors are helping him or her achieve personal and community goals or attain a reasonable degree of satisfaction and harmony with others. Related to this is the previously mentioned problem with orthodoxy dissonance. When clients present with conflict between their articulated values and actual lifestyle, the therapist remains alert to musturbatory demands for greater adherence to values, catastrophizing evaluations of their lack of adherence and self-downing beliefs regarding the incongruence. Research suggests that religious persons are considerably vulnerable to guilt related to perceived incongruence in "real" and "ideal" performance (Eastburg, Johnson, Woo, & Lucy, 1988). Guilt is a special concern during assessment with religious clients. Religious clients may be more likely to experience guilt (Richards, 1991). Many emotional experiences are a complex mix of ideas and emotions; jealousy is such a complex emotional experience (Ellis,


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Sichel, Yeager, DiMattia, & DiGiuseppe, 1989). We have found that guilt is often such a complex emotional experience incorporating a number of beliefs and associated affective states. Although some beliefs associated with guilt may be rational, others are irrationally demanding. This suggests that the resulting emotional consequences may be both self-defeating and potentially helpful. Because some religious clients may endorse guilt, even though uncomfortable, a simplistic approach to assessing guilt as dysfunctional, and subsequent attempts to dispute guilt-inducing beliefs may yield resistance. REBT is particularly well suited to assessment of the components which contribute to complex emotional experiences such as guilt. Rational beliefs such as "this is a bad situation," yield sadness, which may be quite helpful. However, such rational beliefs may be accompanied by irrational beliefs such as "I SHOULD be able to change or stop this bad situation," which will yield anxiety or depression. If a religious client believes "I have acted badly, I have sinned," they may experience regret. However, if the religious client also believes "and because I have sinned I am BAD," the experience of guilt will include shame. The regret may be helpful, while the shame will almost certainly be self-defeating. The religious client's experience of guilt is frequently a mixture of regret and sadness, which may be quite healthy and helpful, and anxiety and shame, which are quite self-defeating. Inflexibility (Closed-Mindedness). During a more focused assessment of client religiousness, it may be helpful to consider the extent to which the client presents as particularly dichotomous or black and white in thinking style. Is the client's religiousness tied to a very rigid and narrow interpretation of doctrine or tradition? To the extent that a client appears cognitively rigid and dogmatic with respect to "acceptable" beliefs, thoughts and behaviors, the clinician may expect to find higher levels of disturbance (depending of course on how congruent such cognitive styles happen to be within the client's faith community) (Lovinger, 1984). Meissner (1996) has suggested that when clients are cognitively rigid and closed to alternative perspectives and beliefs, they are also likely to present with characteristics such as: (a) high distinction between beliefs and disbeliefs, (b) stark rejection of all disbeliefs, (c) a threatening view of the world, (d) an absolute and authoritarian view of authority, (e) a role within the religious community defined in terms of submission to obedience, and (f) a set of criteria for acceptance or rejection of others defined in terms of extent of agreement versus dis-

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agreement with sectarian authorities. Although certain religious communities may by nature be more "closed" or rigid in belief and lifestyle demands, we believe the nature of the community is often distinct from the client's own cognitive style. The therapist may facilitate assessment and therapy by formulating hypotheses about a client's beliefs based on the client's religious community. However, the client's actual belief system—how they interpret and evaluate their world, including how they interpret the belief traditions of their religious community—is the assessment issue at hand. So, it is possible to maintain great flexibility and openness to alternatives even within very conservative and rigid denominations. Although the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and other instruments may offer some indication of rigidity versus flexibility, we have not found a good clinical measure of cognitive rigidity. Rokeach (1960) offered a good description of the fixed and inflexible belief style, or what he referred to as "closed-mindedness," however a valid clinical device for assessing this dimension is lacking. Potentially Pathologic Religious Behaviors. Although the range of ways to "be" religious may be nearly infinite (Hood et al., 1996), certain expressions of religiousness may at times suggest psychopathology and/ or disturbing beliefs. Several "markers" of pathology or problem religiousness have been discussed in the literature (Hood et al., 1996; Lovinger, 1984; 1996; Pruyser, 1971; 1977) and we will briefly describe them here. In offering this list, we recognize that attempts to link specific religious behaviors with disturbance is a potentially dangerous exercise for clinicians and clients alike. None of these potential markers of disturbance is always indicative of such, although they nonetheless serve to alert therapists to possible clinical concerns: (a) Does the client go out of his or her way to create a self-oriented (narcissistic) display of religious fidelity? (b) Does the client view religion as a constant aid and reward in navigating the most ordinary of life events? If so, does this appear adaptive and healthy for the client or indicative of substantial alienation/loneliness? (c) Is the client intensely scrupulous and compulsive secondary to fear of committing sins or other religion-related errors? (d) Does the client appear to relinquish responsibility in an antisocial manner for his or her behavior on religious grounds? (e) Are there episodes of unregulated or unmodulated intense affect associated with religious experience? Are such episodes of "ecstatic frenzy" common of the client's religious community? (f) Does the client have difficulty maintaining stable affiliation with a church or community mani-


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fested by frequent shopping for new churches? (g) Has the client been the recipient or perpetrator of religious behavior which is clearly harmful yet cloaked in religious language and context such that disputing or rejecting it would be difficult? (h) Does the client view the Bible or other scripture as a moment-to-moment guide to truth such that ordinary self-direction and responsibility is relinquished? (i) Does the client inordinately fear or report actual experience with demon possession? If so, is this a common experience within the client's religious community? (j) Does the client report a sudden religious conversion versus a more gradual decision to commit to a religious faith? (k) Does the client report frequent speaking in tongues? Although common of certain charismatic Christian groups, glossolalia would not be considered normal and would not be rewarded within most religious communities. (1) Finally, is there a report on the part of the client of mystical experiences (spiritual encounters, visions, etc.) and are these prevalent and rewarded within their religious community? Again, it is important to emphasize that none of these religious behaviors or experiences would be adequate in an of themselves to suggest disturbance or irrational thinking. However, each would suggest the possibility of such and lead to some additional assessment. For example, a client who reports a recent sudden religious conversion is likely to score higher on indices of manifest anxiety (Spellman, Baskett, & Byrne, 1971) prior to the conversion, raising the concern that conversion may be a pseudosolution for the convert's problems. Additionally, those who report sudden conversion experiences are less likely to maintain their religious beliefs and lifestyle and may quickly return to previous ways of believing or find another cause or religious group with which to affiliate (Lovinger, 1996; Pruyser, 1971; Salzman, 1953). The REBT therapist would be careful to explore the client's response to conversion as an activating event, be alert to beliefs about the conversion and the consequences of those specific beliefs. Assessment of Religious Beliefs Though Ellis (1960; 1971) once encouraged disputation of client religious beliefs on the basis that they were irrational and unverifiable, he has changed his view: Normally, I don't dispute people's religious beliefs unless they are self-defeating and include some absolutistic musts which they devoutly hold. If they want to believe in their own kind of religion, that's fine ... In psychotherapy I would be unethical if I didn't

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pretty much try to limit my focus to the clients problems, their goals, and their self-fulfillment. Now every once in awhile we may get into some philosophical discussion, and we may be having a good time doing so. But then I remind them, 'you know, the time is passing. We'd better get back to your specific problems.' I enjoy this kind of discussion, but that's not what therapy is for. (Nielsen & Ellis, 1994, p. 330).

Most would now agree with Ellis that attacking the client's religious beliefs, per se, would be potentially dangerous for the client and ethically dubious. Meissner (1996) noted "the problem in evaluating religious belief systems is that not only is there no convincing evidence for them, but there is also no convincing evidence contradictory to them" (p. 249). Even when the REBT therapist has substantial experience with religion or religious clients, evaluating specific client beliefs as pathologic or nonpathologic will inevitably rely on subjective criteria. If the REBT therapist is lured into attempting to determine the truth value of a religious belief or belief system, we suspect he or she is not only doing less elegant REBT, but also creating circumstances for significant ethical risk (APA, 1992; 1993). An alternative question is "does the religious belief system as held by this individual client and expressed via his or her unique cognitive and personality structure, result in significant disturbance?" For example, a client may present with a primary emotional consequence of depression secondary to and emotional activating event, anger, at his spouse for critiquing his lack of career success. To get himself depressed about his anger, the REBT therapist quickly discerns that his core beliefs include some strong religious content ("The Bible tells me not to let the sun set on my anger and because I can't stop being angry with my wife by the end of each day, I'm committing a sin before God"). Here the REBT therapist would wisely elect not to dispute the truth or falseness of the Biblical scripture enjoining Christians not to let the sun set on their anger. Instead, he or she may pursue a focus on how the client is disturbing himself about his anger. Although religious beliefs ("I am committing a sin before God") may provide content for a religious client's upset, these beliefs are still, themselves, primarily activating events for deeper, core evaluative beliefs. For example, the inference, "I am committing a sin before God," may well be linked with the absolutistic demand "as I must NEVER do" or, the irrational evaluation "and therefore I am utterly WORTHLESS!" These evaluative irrational beliefs, while associated with religious beliefs, are not inextricably linked with religious content. They


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are disputable without reference to the client's religiousness. Furthermore, it is also possible to use the client's own religious belief system to dispute such evaluative beliefs. For example, the client can be asked "how is it God's will that you be depressed?" "How will being depressed help you become less angry?" "Why are you choosing to be depressed about that sin and not all the others you undoubtedly commit on a daily basis?" "Why can't you choose to tolerate your own sinfulness?" "How will downing yourself for your humanness help you become more holy and less angry?" The point here is that, for the most part, religious beliefs in and of themselves do not make people "healthy" or "unhealthy." Certainly, there are millions of devoutly religious men and women who never come to the attention of a psychotherapist and lead relatively well adjusted lives. Instead, as Ellis has recently pointed out (1996), it is largely the style of belief (i.e. dogmatism) which is equivalent to irrational thinking and emotional disturbance. In conducting an REBT assessment with a religious client, the therapist is advised to consider two steps in the assessment of religious beliefs. First, attempt to evaluate the client's unique style (rigid versus flexible) of belief. Is the client cognitively closed and rigid? Does the client present with a philosophy of demanding with respect to their faith or a philosophy of humble desiring and preferring? Ideally, the client will be open to exploring the pragmatics of his or her specific beliefs and the manner in which they are repeatedly disturbing themselves about those beliefs. At this stage, the therapist is interested in the sequlai of beliefs, not their accuracy or congruence from within the client's overall faith surround. The REBT therapist wishes to help the client see how his or her demandingness and rigidity in general is creating a good deal of disturbance. This is as true of demandingness and evaluation along religious lines as it is of believing about other content areas. Second, when the client appears to present with highly idiosyncratic religious beliefs, some careful evaluation of belief content may be attempted. However, it is imperative to keep in mind that this sort of REBT intervention is considerably more risky from an ethical perspective. Here, the primary task is assessment of the extent to which religious beliefs (and only those which appear directly related to presenting symptoms and disturbance) are congruent with other aspects of the client's identified religion. The therapist continues to avoid evaluation of the truthfulness or validity of the beliefs). The essential clinical question here is "to what extent is the disturbing quality of the client's religious belief related to an incomplete or clearly idiosyncratic

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interpretation of scripture or doctrine?" This is related to DiGiuseppe, Robin and Dryden's (1990) discussion of selective abstraction. They noted "people do not become disturbed because of their belief in religion: rather, their disturbance is related to their tendency to selectively abstract certain elements of their religion to the exclusion of attending to others" (p. 358). The skilled REBT therapist will be alert to the possibility that the primary disturbing belief, though clearly religious in content, appears quite incongruent with other components of the person's larger religious affiliation. REFERENCES Allport, G. W., & Ross, J. M. (1967). Personal religious orientation and prejudice. Journal of Personality and Social Psychology, 5, 432-443. American Psychological Association (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597-1611. American Psychological Association (1993). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. American Psychologist, 48, 45—48. Bergin, A. E. (1980). Psychotherapy and religious values. Journal of Consulting and Clinical Psychology, 48, 95-105. Bergin, A. E. (1983). Religiosity and mental health: A critical reevaluation and meta-analysis. Professional Psychology: Research and Practice, 14, 170-184. Bufford, R. K., Paloutzian, R. F., & Ellison, C. W. (1991). Norms for the spiritual well-being scale. Journal of Psychology and Theology, 19, 56-70. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Daemmer, B. (1989). Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manual for administration and scoring. Minneapolis: University of Minnesota Press. Demaria, T., & Kassinove, H. (1988). Predicting guilt from irrational beliefs, religious affiliation and religiosity. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 6, 259-272. DiGiuseppe, R. A. (1991). A rational-emotive model of assessment. In M. E. Bernard (Ed.), Using rational-emotive therapy effectively: A practitioner's guide (pp. 151-172). New York: Plenum. DiGiuseppe, R. A., Robin, M. W., & Dryden, W. (1990). On the compatibility of rational-emotive therapy and Judeo-Christian philosophy: A focus on clinical strategies. Journal of Cognitive Psychotherapy: An International Quarterly, 4, 355-368. Donahue, M. J. (1985). Intrinsic and extrinsic religiousness: Review and metaanalysis. Journal of Personality and Social Psychology, 48, 400-419.

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