merging horizons

Mental Health, Religion & CultureVolume 7, Number 1, March 2004, 59–77

Merging the horizons of psychotherapeuticand religious worldviews: New challengesfor psychotherapy in the global age

GARY E. MYERSSouthern Illinois University School of Medicine, Springfield, IL, USA

ABSTRACT By collapsing the space that had previously separated conflicting worldviews,

global trends force these worldviews into encounters that might not otherwise occur. This discussion

examines the impact on the practice of psychotherapy of one of these encounters, namely, the

encounter between the religious worldview of devout believers and the therapeutic worldview that

heavily influences the Western practice of psychotherapy. In the face of the combined effects of

immigration and the phenomenal worldwide growth of conservative religion, psychotherapy in the

USA and Europe will increasingly be offered to religiously committed people who distrust the

therapeutic viewpoint. Following an examination of the effects of global trends on the religiosity of

the populations from which many Western psychotherapists draw their patients, we present a

clinical vignette that demonstrates how these trends challenge therapists to become therapeutically

engaged with their patients’ religious beliefs and values. The vignette illustrates typical errors

made by therapists when treating devoutly religious patients and suggests guidelines for working

with patients’ religious beliefs.

Introduction

Historically the relationship between religion and psychotherapy has been a

tenuous one. From the beginning of the twentieth century, starting with Freud’s

comparison of religious belief to infantile thought and obsessional neurosis,

suspicion, bias, and competition have characterized their relationship (Zinnbauer

& Pargament, 2000). As a result, religion and psychotherapy have often competed

for the right to be the authoritative interpreter of the human condition (Sperry,

1988; Stokes, 1985). Nevertheless psychotherapy and some liberal expressions of

Protestantism, Catholicism, and Judaism, have, for the most part, set aside their

differences and have found enough common ground to develop productive

Correspondence to: Gary E.Myers, Ph.D.,M.Div., Southern Illinois University School ofMedicine,

913 North Rutledge Street, Springfield, Illinois 627914-9603, USA. E-mail: [email protected]

Mental Health, Religion & CultureISSN 1367-4676 print/ISSN 1469-9737 online � 2004 Taylor & Francis Ltd

http://www.tandf.co.uk/journalsDOI: 10.1080/13674670310001602427

working relationships (Richards & Bergin, 1997). As a result, psychotherapists

commonly recognize the importance of religion and spirituality in the lives of their

patients, and clergy frequently refer their congregants to psychotherapy. This

working relationship became possible primarily because the liberal mainline

religions in the USA and Europe adopted many of the core values of therapeutic

culture, which according to sociologist, Philip Rieff, relativizes all absolutes,

including religious faith, for the sake of maintaining a sense of personal well-being

(Bellah et al., 1985; Rieff, 1966; Vitz, 1994).

This accommodation between therapeutic culture and liberal religion,

however, will not, extend to the conservative and fundamentalist religions that

are rapidly growing in Western societies where psychotherapy is commonly

practiced. We argue that two global changes, namely, the worldwide growth of

conservative and fundamentalist religion and the immigration of religiously

conservative people into secular Western societies will challenge psychotherapists

to develop new therapeutic goals and strategies in order to meaningfully take

their patients’ religious beliefs and values into account (Gone, 2002). As patient

populations become increasingly religiously conservative it is less likely that we as

psychotherapists will continue to find a comfortable fit between the religious

beliefs of patients and the goals and strategies of psychotherapy. Consequently,

psychotherapists will discover that mediating between the discrepant worldviews

held by themselves and their patients will become a central focus of psychotherapy.

The growth of conservative religion and immigration driven by economic

and political factors are part of a complex global phenomenon dubbed by many as

globalization. Globalization is itself difficult to precisely define because its

compass seemingly includes everything. Politics, geography, religion, the world

economy, immigration, and culture all effect and are affected by it. However, it

may be possible to define it generally as a multifaceted process through which

people, money, information (facts, ideas and beliefs) move easily across national

and cultural boundaries to form what some would call a global society. Whether

globalization is good or bad is hotly debated, but it is certain that it increasingly

uproots people from their homelands and threatens to Westernize native cultures.

For the purposes of this discussion we will focus on how the movement of people

holding conservative or fundamentalist religious beliefs into Western secular

societies is likely to affect the practice of psychotherapy.

Worldwide growth of conservative and fundamentalist religion

Despite predictions that religion will decline as scientific thought and mental

health increase (Ellis, 1985; Freud, 1968) religion, especially religion in its more

conservative and fundamentalist forms, is experiencing unprecedented global

growth (Beyer, 1999; Wallis, 2002). For example, the world growth rate of

Christianity is 2.3% annually—about equal to the growth rate of the world’s

population—which is surpassed by the 2.9% annual growth rate of Islam

( Jay, 1997). The groups within Christianity showing the largest gains are the

60 Gary E. Myers

Pentecostal and Evangelical churches. Both are theologically conservative forms

of Christianity. Pentecostalism alone has a world growth rate of 19 million

adherents per year. There are currently over 450 million Pentecostals worldwide,

with the largest concentrations in Asia, Africa, and Latin America (Pentecostals,

1988). The increasing numbers of fundamentalist believers has also fueled the

rapid growth of Islam. In fact, fundamentalist movements are thriving all over the

world, including North and South America, South Korea, Japan, Taiwan, Africa,

and the Middle East.

Immigration and religion growth rate statistics show that the populations of

modern Western cultures, including the USA, are rapidly becoming more

culturally diverse and religiously conservative. Take, for example, the 25% growth

rate of Islam in the USA, making it this nation’s fastest growing religion. The

number of mosques in the USA increased 42% between 1990 and 2000 (Hartford

Institute of Religion Research, 2001). The growth rates in Europe are even more

striking; between 1989 and 1998, the Islamic population grew by more than

100% to 12.5 million ( Le Quesne, 2001).

Globalization and its effects on worldviews

It is clear that under the influence of globalization, nations and cultures are rapidly

changing. Global forces, such as immigration, the movement of workers across

national borders, and global communication through satellite and the Internet

bring together cultures andworldviews that normally do not inhabit the same space.

These changes can result in significant cognitive dissonance at both individual and

social levels and raise the question, ‘How will people who are transplanted into

new and unfamiliar cultural environments respond?’ Some experts claim that as

societies become more culturally and religiously diverse we will respond to this

diversity by forming blended or transcultural identities. They believe that we will

find a creative and progressive solution to this challenge (Robertson, 1992).

Others, however, see a more conflicted outcome as traditional identities resist the

threat of absorption into modern culture (Le Quesne, 2001). They anticipate a

conservative reaction against the blending of identity in the form of a strong

reassertion of cultural and religious consciousness. As evidence, they point to the

worldwide increase in conservative religion, especially fundamentalism.

We believe that those who claim that the blending forces of globalization will

become irresistible may be correct; nevertheless, there is bound to be a period

when people struggle to preserve their personal, cultural, and religious identities.

During times of instability and change, people, especially immigrants in a new

land, find stability through their religious faith (Le Quesne, 2001). We can expect,

for at least the next several generations, as a reaction against the homogenizing

trends of globalization, increases in both the number of believers and the intensity

with which they hold their beliefs. As people increasingly rely on their religious

beliefs to bring stability to their rapidly changing world, how will this impact the

practice of psychotherapy?

Merging the horizons 61

The effects of global trends on psychotherapeutic practice

One world-shrinking effect of globalization is the increasing levels of mistrust and

conflict between modern/secular and traditional/religious worldviews that have

been ‘compressed’ into the same global society. Recent research conducted in the

USA suggests that conflicting worldviews between patients and their therapists

cause the devout to avoid psychotherapy. Many religious and spiritual people

distrust mental health professionals and the therapies they provide because

psychotherapists, psychiatrists, and social workers are perceived by the devout as

promoting secular values and worldviews that are hostile to the beliefs of most

religious persons (King, 1978; Sell & Goldsmith, 1988; Worthington et al.,1996).

When we examine what has been published about the views of several

prominent figures in the field, it is not surprising to learn that religious patients

mistrust therapy. For example, Freud (1957–1966), in his 1907 works referred to

religion as the universal obsessional neurosis. Albert Ellis (1980), the founder of

rational emotive therapy, found religion to be even more pathological, referring to

it as a psychosis. Ellis writes that, ‘‘The elegant therapeutic solution to emotional

problems is quite unreligious. . . . The less religious [ patients] are, the more

emotionally healthy they will tend to be’’ ( p. 637). A more current example of

this kind of bias and dismissal of religion is reflected in a 1999 article published in

the European Journal of Psychotherapy in which the authors assert that ‘‘The role

and function of psychotherapy as a new paradigm for living is closely related,

we believe, to the replacement of old religious and spiritual values’’ ( Tantam &

vanDeurzen, 1999, p. 231). Statements like this support the religious community’s

suspicion that psychotherapists will not take their beliefs seriously and may

even try to replace their religious beliefs with a scientifically based therapy that

‘really works’ (Tantam & van Deurzen, 1999, p. 231).

Empirical data lend support to the hypothesis that the fear of psycho-

therapists attacking or at least failing to respect their faith may cause the devout to

either avoid therapy altogether or use therapy as a last resort. A survey of 1,000

likely voters in the USA found that the second most common reason for

respondents not seeking a mental health professional is that they ‘‘fear that their

religious beliefs and values may not be respected and taken seriously. Black

respondents were more likely than white respondents to fear that their values and

beliefs would not be respected when asked why they would not see a mental

health professional’’ (American Association of Pastoral Counselors Survey,

2000). An additional finding determined that devout Evangelicals are more likely

than their more liberal counterparts not to seek therapy because of their fear that

therapists would devalue their beliefs and values. These findings are relevant to

the current discussion because the African-American community, as a minority

community, and the religiously conservative communities in the USA, like those

in other societies, tend to rely more heavily on religion to support their cultural

and personal identities than do majorities and therefore demonstrate mistrust of

psychotherapy. Extrapolation of this finding to other such communities in the

62 Gary E. Myers

USA and Europe supports the claim that psychotherapists will need to more

effectively address the mistrust of a growing population of minorities and

religiously conservative people.

Mistrust challenges psychotherapists to develop new perspectives

and new skills

The trends toward globalization challenge psychotherapists to develop trusting

relationships both with religious communities and with individual religious

patients. Developing trust depends on therapists’ ability to take the religious

beliefs of their patients into account when formulating therapeutic goals and

strategies. As a supervisor and teacher of psychotherapy, I have observed two

commonly used approaches to dealing with the beliefs of patients that fail to build

trust in religious patients. The first approach ignores patients’ religious beliefs and

the second interprets beliefs as expressions of psychopathology or as psychological

defense (Lukoff & Lu, 1999; Lukoff et al., 1992). In the first approach, therapists

do not take the initiative to inquire about religious beliefs of patients. Should

patients introduce their religion into the therapeutic conversation, therapists

listen politely without response until patients get the message that there is no

place in therapy to consider religious beliefs. This approach may keep talk of

religion out of the session, but it also inhibits patients’ full self-disclosure by

signaling that there are some aspects of them that are unwelcome. Surely,

excluding what is sacred to patients does nothing to reassure them that they need

not abandon their beliefs in order to receive help from a therapist. In addition, by

using such an approach, therapists will fail both to discover how patients’ belief

systems might conflict with therapeutic goals and to understand how patients’

belief systems support their mental health (Koenig, 1997).

In the second approach, the therapist operates on the reductionist

assumption that religious beliefs, especially those that frustrate therapeutic

progress, are irrational derivatives of an unconscious conflict. Here, one respects

beliefs as one would respect any defense or illusion of the patient, but the goal is

always to interpret their meaning through a psychological perspective, which is

often considered by therapists to be more fundamental. Firmly held beliefs that

may seem to the therapist to be anti-therapeutic or pathological are interpreted

away in order to facilitate therapeutic progress. This is the approach that I myself

took with the patient in the following vignette.

Global realities enter the consultation room: Kei’s story

Here we examine a psychotherapy case that illustrates how two significant drivers

of globalization, namely religious belief and economic change, can bring together

therapists and patients who have differing worldviews. The patient—let’s call

her Kei—had been shaped by the intersection of two histories, one global and


one personal. Kei’s conservative Christian beliefs are not indigenous to her

Japanese culture. They came to her from ancestors who, during an earlier phase

of globalization occurring in the nineteenth century, were converted by

missionaries intent on spreading their religion across geographical, national and

cultural boundaries (Cary, 1909). This conservative and, at times severe,

expression of Christianity was adopted by Kei’s family and eventually contributed

to her need for psychotherapy.

The second effect of globalization occurs as the result of global economic

forces, which caused Kei and her husband to move from Japan to the USA.

Her husband worked for a large Japanese company that expanded its business

into several Western countries. He was assigned to a company office in a large city

in the southeastern USA. This reassignment uprooted Kei and her family from

many social and cultural supports, such as family, social networks, language,

traditions, and her religious community, that normally support personal and

cultural identity, mental health and a general sense of well-being,

As a result of the intersection of these two global forces with Kei’s personal

history, namely the death of her mother, she finds herself seeking help from a

psychotherapist with whom she shares little in common. A consequence of such

global forces is that both therapists and patients will increasingly face similar

situations in which they must address differences in culture, religion, and

language in order for therapy to precede.

Kei was in many ways a traditional Japanese woman, referred to me by her

primary care physician for help with a depression that did not respond to

antidepressant medication. We have many differences: when I extend my hand

for a handshake, she bows. While I relax in my comfortable therapist chair, she

sits on the very edge of her chair and keeps her back rigidly straight—and does so

for 18 months. I am accustomed to being called Dr. Myers; she calls me teacher.

I depended on nonverbal communication through facial expressions, but when

our eyes met, she looks to the ground. The differences did not end there: she is a

fundamentalist Christian and I, a liberal theologian, trained in psychoanalytic

therapy, owing many intellectual debts to the work of Sigmund Freud. Our

many fundamental differences—of worldview, culture, language (at times), and

religion—were constantly at play in our therapeutic work.

Despite the clear differences between us, Kei had a personal history that

established familiar points of contact between patient and therapist. Everyone is

part of a family and will one day have to cope with the loss of loved ones. This part

of her history was universal and connects all of human kind. The challenge for me

as her therapist was to understand her personal history in the light its global

context. She and her husband had been in the USA for about four years. Their

daughter and only child was born in the USA during the second year of their stay.

They visited their families in Japan about twice a year. Her father was a nationally

prominent minister of a conservative Christian congregation. She admired her

father from a distance and respected him highly. She had one brother who was

five years younger. She had had a close relationship with her mother, whom she

described as very loving and self-sacrificing, always putting the family’s welfare

64 Gary E. Myers

ahead of her own. Kei reported that her mother died of ovarian cancer when she

was 17 years old.

Following the death of her mother, Kei became the mother surrogate of the

family. She took responsibility for cooking meals, housecleaning, raising her

younger brother, and providing emotional support for her father, who had

become depressed after the death of his wife. She continued to do well in school,

but had little time for herself. At the age of 22, about the time that her younger

brother entered college, she married. Over the course of therapy, I learned that

Kei’s religious faith was extremely important to her. She read the Bible daily,

prayed often, attended church every Sunday, and volunteered for church

programs. She had internalized her belief system and her religious community,

both of which seemed to function as mirroring maternal objects. During times of

crises and great stress, these internal structures would sooth and comfort her, as

well as help her to maintain her identity. But they also contributed to her

depression. Kei had become identified with a community that interpreted

expressions of grief as a sign of one’s lack of faith that God would adequately

provide for those who ‘passed on.’ Therefore they celebrated rather than grieved

the death of loved ones because in death they had reached their goal—to be in the

presence of God. While participation in this community’s worldview provided a

context of meaning for coming to terms with her mother’s death, ‘she has gone to

be with God,’ these very beliefs obstructed and conflicted with her psychological

need to grieve the loss of her mother.

Mental health versus spiritual integrity: Kei’s dilemma

A conflict emerged as it became clear that Kei’s therapy must include reclaiming

and working through her grief. This path to mental health conflicted with her

devoutly held belief that grieving, in this instance, shows a lack of faith. The

conflict precipitated a therapeutic stalemate that presented us with an occasion

to learn several important lessons about treating religiously committed patients.

The analysis of this stalemate will help us in three ways: to identify common errors

that therapists make when treating religiously committed patients, to examine the

distress experienced by religious patients when their beliefs are not taken into

account in therapy, and to identify an alternative approach that can help patients

to integrate their beliefs with therapeutic goals.

In the first session, Kei said that she was afraid to see me, but felt that she had

no choice because she had been getting worse. She could not tell her minister that

she was seeing a therapist, because he had told the congregation that psychology

was the enemy of faith. In addition, she had asked her husband not to speak of it

to anyone in the congregation. She told me that she felt guilt and shame about her

decision to see me, because it meant that she was a bad Christian and did not

trust God. Up to this point, Kei had been able to overcome significant obstacles

to arriving in psychotherapy consultation room, but the literature suggests that

many religious patients do not.


Resistances related to conflicts between and within worldviews challenge

psychotherapists in ways that are qualitatively and quantitatively different from

expressions of resistance that occur when therapists challenge patients’ defenses,

maladaptive behaviors, and other distortions of reality that contribute to patients’

problems. Conflicts in therapy related to religious beliefs involve patients’ a priori

assumptions about their internal and external reality. Worldviews are internalized

as basic psychic structures that provide the foundation from which identity, value,

and purpose in life are constructed—much in the same way as the internalized

mothering object provides the mirroring that confirms a sense of self and value to

the child. ( Josselson, 1992). Whether one’s worldview is religious or secular, it is

within this view that one must see and be seen and find meaning adequate to

support one’s life. Changes in worldview do not come easily and are not without

consequences.

Without an appreciation for the crucial role that deeply held religious beliefs

perform for patients, psychotherapists can easily minimize their assessment of the

stress that patients feel when receiving an interpretation of their problems that

challenges their belief systems. Even patients’ acknowledgement that they have

problems that they cannot resolve through their own spiritual resources can be

stressful and evoke resistance. For example, patients or patients’ religious com-

munities might attribute disturbances of affect, such as depression and anxiety, to

a lack of faith or a deficiency in one’s devotional life (Richards & Bergin, 2000).

Bipolar illness and psychosis might be attributed to demon possession, while

feelings of guilt and shame might be attributed to an unconfessed sin, and marital

conflict to the unwillingness of the wife to submit to her husband.

My approach was to treat Kei’s belief, that grieving for her mother was

inappropriate, as a defense against painful feelings associated with the loss of her

mother. What follows are the various interpretations of her defense that I offered

her over the course of the therapy. First, I suggested that she was trying to avoid

ambivalent feelings towards her mother that she felt were inappropriate. Could it

be that although she missed her mother very much, she was also angry with her

mother for abandoning her at the point in her life (age 17) when she needed to

rely on her parents to provide a stable environment that would make it safe for

her to become more invested in activities outside the family? It was time for an

adolescent’s expression of separation and individuation, but she found herself

being pulled back into the family unit. As a result, she had to put her develop-

mental needs on hold in order to replace her mother in the family. It was difficult

for Kei to accept this suggestion that she may be avoiding her grief in order to

avoid discovering that she felt abandoned and angry at the loss of her mother.

However, she seemed to think that this explanation was plausible and was willing

to consider it.

As the therapy continued, it seemed to me that Kei had received a good

deal of gratification from taking care of her father and becoming his confidante.

I suggested to her that she may have at times felt competitive with her mother for

her father’s attention and affection and now she may be feeling guilty that she has

survived her mother and won sole possession of her father. She acknowledged

66 Gary E. Myers

that she did feel guilty about taking her mother’s place and that she felt that she

could never be as good as her mother. She agreed that she enjoyed having her

father to herself, but also felt that this could be burdensome at times.

Kei described her father as being prone to depression and that the death of

her mother had affected him deeply. I asked her if her failure to grieve the loss of

her mother might also be related to her feeling that she needed to protect her

father from her sadness as well as from his own. If she perceived her father as

emotionally fragile, she may have felt that exposing him to her sadness might

overwhelm his defenses. The emotional loss of the father along with the physical

loss of the mother would be too much to bear. Perhaps she needed to protect her

father from her grief in order to protect him from his own. She seemed interested

in this interpretation and said that she did feel that her father was emotionally

vulnerable after the death of her mother and that had concerned her.

Kei listened attentively and respectfully to all that I had to say, and she even

expanded and deepened my interpretations with her own formulations. It seemed

to me that we had indeed formed a therapeutic alliance. I never directly addressed

her belief that grieving for her mother might be inappropriate because it would

express a lack of faith in God. It was my strategy to acknowledge it and to move

on, thinking that as her understanding of resistance to grieving increased, she

would become aware of her repressed conflicts and develop the capacity to

integrate them into her ego. In that case, so the theory goes, the need for the

religious support for her resistance would become unnecessary and would fade

away. I soon learned that I was mistaken.

After a while, I noticed that Kei seemed preoccupied in the sessions—not

fully present. I asked her about this, but she could not come up with an answer.

I asked her to tell me what she was thinking about. She reported that she was

blank. I asked her if she had any thoughts related to our discussion about why

she could not let herself grieve for her mother. She was evasive. This became a

pattern, which indicated to me that she had encountered new resistance to further

exploring her grief. During one session, I asked her if she had ever felt sad or

tearful about what we discussed in therapy. Then, with great difficulty, and with a

sense of shame, she told me that she could not feel sad or cry because this would

be against her faith and displeasing to God. At this point—after all of our good

interpretive work—I realized that I had missed something.

Intellectually, Kei had been following and accepting my interpretations

about her reactions to her mother’s death. They seemed to make sense to her; she

was even able to elaborate them with her own formulations, but she could only

accept them by keeping them separate from her other thoughts. I concluded that

she was only intellectually attracted to the explanatory power of my interpreta-

tions. In addition, I believed that her strong positive transference to me created

her receptivity for these insights that may have not otherwise have existed. She

had experienced me at times as an available and attentive father, a nurturing

mother, and an authoritative teacher whom she respected and wanted to please.

Her curious intellect along with her transference enabled her to identify with and

become invested in the insights that therapy had produced.


What I had not counted on was that Kei’s investment in the religious belief

that grieving was a sign of lack of faith would continue in spite of her new

psychological understanding of her feelings and behaviors. I had naively assumed

that, because we were no longer talking about her beliefs and the conflicts

that existed between these beliefs and the goals of therapy, the offending beliefs

had somehow dissolved. They had not. Now I had a conflicted patient and a

therapeutic stalemate. She could not integrate her beliefs with my interpretations;

they negated each other. If she grieves or cries or talks about her losses, thus

moving forward in life, making new libidinal investments, then she doubts God

and becomes estranged from her religious community. If she keeps the faith, she

represses vital feelings and suppresses newly acquired insights.

By providing Kei with a path to mental health that conflicts with her religious

beliefs, therapy presents Kei with a difficult choice, either she violates her belief

that she should not grieve her mother’s death, or she holds firm to her beliefs and

rejects the possibilities for healing that therapy offers. Feeling claimed by both her

religious faith and her wish to be free of her depression, she is paralyzed in the

face of an either or choice between them. Kei cannot decide which path; religious

faith or therapy is most worthy and true. Although, she could split her self into

two ambivalent and warring selves—one faithful, but depressed, the other

healthy, but sinful—she has a more hopeful alternative. If Kei can recruit her

therapist to help her to fashion an integrative solution, then the claims of faith and

the claims of her psychological needs can enter into a transforming dialogue that

integrates what had been previously experienced as competing claims.

Taking Kei’s beliefs into account

At some point during this stalemate, it became obvious that that we would need

to find a way to move forward that did not ignore or directly challenge Kei’s

religious beliefs. It occurred to me that religious traditions are rich and varied

accounts of the lives of individuals and communities as they attempt to

understand their life in terms of their relationship with God. Therefore, there

must be a full range of human emotions represented in religious texts. Could Kei

access one of the primary authorities of her faith, the Bible, and find a text that

depicts a scene in which people grieve the loss of friends or family? I asked her if

she could recall a biblical story in which someone grieved for the loss of a loved

one. She smiled slightly and said, ‘yes, the story of Lazarus and Jesus’. She is

referring to the story found the Gospel of John 11 : 35 (Revised English Bible:

with the Apocrypha) in which Jesus weeps with the family of his friend Lazarus as

they grieve his death. I asked her how this passage could illumine her life and our

work together in therapy.

This question shifted the therapeutic discourse towards a consideration of

her religious beliefs. We spoke about the nature of God, human nature, and the

kind of relationship that God wished to have with humans. In short, our

discussion noted that Jesus, according to Kei’s belief, was God incarnate and that

68 Gary E. Myers

Jesus cried at the loss of his friend. In this act, Jesus revealed that God not only

knows of human sadness, but affirms it by expressing it himself! This suggested

not only that grief was not offensive to God, but also that God stood in solidarity

with the human family in its sadness and grief. It also suggested that human

vulnerability could be an occasion for closeness to God. In fact, sharing all of

one’s reactions to life could be a demonstration of faith in God rather than of

doubt. These and other considerations framed our conversation over the next few

months.

As Kei integrated these thoughts into her belief system, her concept of God

changed in certain respects. She found that she was able to cry, and she cried for

many weeks. Her tears evoked an image from her that helped her to describe her

experience in therapy as an integrative experience through which separated

aspects of her self were reunited. When I had first asked Kei to tell me what

therapy had been like for her, she said that she could not find the right words.

Several sessions later, she said, ‘calling water— therapy is like calling water.

Do you know what calling water is?’ she said. ‘It is the water that you pour into

the top of a well pump ( priming the pump) to make it work. This water calls to

the water deep in the earth and the deep waters rise up to answer’, she said,

gesturing with a hand movement from her stomach up to her chest.

What had Kei meant by this allusion to water? My most immediate asso-

ciation was that the water of her tears, which had been dammed up through years

of repression, was now being called to the surface. In her religious tradition, water

could symbolize physical birth—the birth waters, spiritual birth—baptism, healing

and restoration—the healing pools, or rites of purification. Psychologically, water

could symbolize connecting repressed feelings with their ideas, or integrating

disavowed parts of her self into a fuller and more cohesive self-representation.

Therapy, to Kei, was like ‘calling water’. Later, we shall reflect more on the

meaning of this image, but for now, let us accept it as a representation of

restoration and wholeness.

The patient was neither defiant nor defensive about what my interpretations

revealed about her relationship with her parents, and it seemed that she wanted to

share with me what it had been like for her to lose her mother at such a young age.

However, to do so threatened something deeper than her desire for psychological

growth and healing. It threatened her identity—her way of being in the world.

Using my patient’s image of therapy as calling water, we can reflect on the nature

of the divide between her religious beliefs and the therapeutic process. Following

this image, we can say that a successful therapy, from a psychological point of

view, is able to unite the deeper, cut-off parts of the self with its consciously

experienced aspects. For example, if one must repress the nurturing and loving

parts of the self, it will be difficult to experience and express deep concern and

care for another person. Without a vital connection between the deep waters—or

to use a less imagistic reference, the unconscious drives—one’s experience, one’s

actions, one’s commitments would be emotionally flat, lacking passion, perhaps

determined only by instrumental reason.


To be fully human and engaged depends on the connection between depth

and surface. A psychological interpretation of the meaning of therapy described as

calling water might suggest that therapy, through its interpretations and expres-

sions of empathy, call to the long-forgotten and repressed depths of the self.

Therapy calls forth the forgotten desires, the forgotten wishes, and the forgotten

polarities of life, like hate and love, dependency and strength, and, yes, it also calls

to forgotten pain to enter and become a part of life.

From a spiritual or religious point of view, we might view this image

differently in certain respects. Here, the ‘deep waters’ could represent the soul.

The soul includes the human capacity to connect with that, which is larger

and more significant than the self. The soul connects us with the transcendent.

The transcendent could be nature, humanity, or the arts. For religious persons,

the soul connects the self with the Divine. The soul is healthy when it is fixed on

its proper object and becomes sick and distorted when its connection to its proper

object is interrupted.

Healing, in the religious sense, reconnects the soul with the transcendent.

In Kei’s case, we might say that her attachment to a rather limited conception

of God had made her soul sick. Given her particular situation as a 17-year-old

girl needing to grieve the death of her mother, her concept of God, as a strict

authority, who tolerated neither doubt nor sadness over the loss of a mother, cut

her off from her pain. Her concept of God seemed to deny her humanity, at least

in the sense that it is human to express pain and sadness at the loss of a mother.

Not only does it diminish humanity, it also seems to diminish the very notion of

God. God has somehow set God’s self against human nature—that is, against

God’s own creation. So, in this situation, we have a paradox of the patient’s

concept of God, to which she held so tenaciously, cutting her off from the fuller

reality of God. In other words, her soul had become sick because it had become

attached to a partial and inadequate representation of God that had cut her off

from fully entering and valuing human experience.

The ethics of judging beliefs: Universality versus relativity

The therapist’s determination that Kei’s ‘partial and inadequate representation of

God’ contributed to her illness is perhaps the most controversial aspect of this

case. Simply put, ‘what qualifies the therapist to make such a judgment about

a belief that originated in a religious community of which he is not a member?’

Is this not another example of cultural or spiritual hegemony in which a

modernist therapeutic perspective claims to know better than the ‘natives’? These

questions place us squarely in the ongoing debate of universality versus relativity.

Typically this debate focuses on the location of norms governing human rights,

but can be extended to include a host of other things, such as cultural/religious

belief, morality and standards for health and illness. Universalists believe

that norms are found in nature and are independent of cultural, religious, or

national contexts. Relativists argue that norms are socially constructed, context

70 Gary E. Myers

dependent, and can only be evaluated from within the cultural/religious context

in which they occur.

There are problems with both positions. On the one hand, universalists

typically make the error of assuming that their norms for determining what is

good and what is evil or what is health or unhealthy are valid for all. They fail

to recognize that their norms are products of their own limited cultural context

and therefore may not be valid in other contexts. For instance, universalism,

as it appears in the West, is heavily influenced by the modern emphasis on

individualism and the right of individuals to determine their own future, without

interference from traditional forms of domination such as religion, family,

patriarchy, caste, or class. But, we know that this emphasis on the emancipation

of the individual is itself a construction of a particular culture and has no objective

basis, thereby making it no more or less normative than the perspective of any

other culture. When this perspective is coercively applied to beliefs and policies of

nonwestern people it is nothing less than an example of cultural hegemony.

Cultural relativity, on the other hand, is no less flawed. Relativists assume

that each culture’s norms are uniquely their own and share no common ground

with other cultures. We know, however, that this view cannot account for the fact

that many cultures protest, for example, the needless loss of life and the suffering

of the innocent.

We also know that cultures and religions are not isolated totally self-

determined islands of uniqueness. They are by nature open and dynamic systems

that have historically adopted and adapted values and beliefs from outside their

own horizons.

Neither universalistic nor relativistic approaches are viable for therapists to

take when working with patients from cultures or religious communities that do

not share the perspectives of therapeutic culture. Universalistic therapists are

likely to assume that because their therapeutic assessments are grounded in the

norms of human nature they are, therefore, superior to the ‘unhealthy’ beliefs and

practices of their patients. This may result, as it initially did in my case, in the

therapist attempting to interpret away what he or she considers to be unhealthy

beliefs. On the other hand, relativistic therapists may be so concerned not to

violate the uniqueness of patients’ cultural/religious beliefs that they make no

assessments nor communicate therapeutic insights to patients for fear that they

would be imposing an alien perspective on them.

Is there an alternative way that incorporates aspects of both approaches?

Can the therapist’s universalistic concern for the emancipation of the individual

be balanced with respect for the unique beliefs of the patient? My work with

Kei suggests how a therapist might attempt such an integrated approach. Let us

consider the universalistic dimension of the approach. When Kei comes to my

office with a complaint of depression, she is essentially saying that she needs help

because all of her other resources, including her faith, have been unable improve

her condition. She turns to me reluctantly, but is nevertheless asking me for my

understanding of her condition which she could not obtain from within her

religious community. With this invitation I, as her therapist, may non-coercively


examine her life, including her religious beliefs, and offer my diagnostic opinion.

If in my judgment, which is of course shaped and limited by my own cultural

location and therefore subject to critique and revision, I find that her beliefs

contribute to her suffering, I am obligated to share this with her. Partial and

inaccurate as my hypothesis may be, it provides the patient with an alternative

view of her situation that can be the beginning of a process of change. This

alternative view, however, should be offered tentatively and with humility in the

full knowledge that one could be wrong and that the patient may find that it is not

a good fit for her given her cultural/religious context.

The relativistic dimension of this approach appears in the process through

which the therapist’s assessment becomes operative in the therapy. It should not

be imposed on the patient, as if the therapist is the final authority on the patient’s

spiritual beliefs, but should be used to open up a line of conversation that might

not otherwise occur. This conversation allows patients to both examine the

effects that their beliefs have on their lives and to reexamine and perhaps modify

their beliefs. Therapists provide hypotheses about patients’ conditions, which may

become a point of departure for an explorative conversation between therapists

and patients; patients themselves determine if the conversation produces insights

that are a good spiritual/cultural fit. I believe in Kei’s case that her use of the

calling water metaphor indicates therapy provided insight that was a good fit for

her. The relativist dimensions of this approach is that it is non-coercive and

respects the patient’s right of refusal.

How could therapy become calling water to the patient in the spiritual sense?

A devoutly religious patient’s experience in therapy is like taking a journey in a

strange land. No familiar landmarks, no familiar faces, full of strange sounds—

words and ideas that are both tempting and forbidding. It is an encounter with a

different worldview; it is an encounter with otherness. An encounter with what is

other could be so threatening that one immediately retreats. This could, of course,

result in premature termination. The encounter could also lead to an infatuation

with new ideas and a deconversion from belief. The religious patient might feel

liberated from restrictive beliefs and adopt the therapeutic worldview character-

ized by self-expression, individualism, autonomy, and enlightened self-interest.

Or, the patient could enter into dialogue with otherness and come away with a

different perspective that enables her to take a new look at beliefs that deepen

rather than weaken faith. This is what Kei did, but how did she do it?

In a sense, the deep waters of her faith were called to the surface. Therapy

had become an encounter with otherness that had enabled her to not only express

her deep feelings, but also to have a new encounter with God in the depths of

her being. We had found a way to move forward in the therapy within the

framework of her belief system. Her beliefs about God changed in a limited but

influential way, but these changes seemed compatible with that system. Many of

her beliefs did not change. Therapy was like calling water for Kei in a two-fold

way: it connected her feelings with life and connected her soul to a revised image

of God.

72 Gary E. Myers

New perspectives and skills needed by psychotherapists

Religion, technology, economics, and empire have been identified as the four

primary drivers of globalization (Mazrui, 1999). In Kei’s story, we have identified

two of these drivers that in this instance impacted psychotherapy, namely,

economics and religion. Economic pressures brought Kei and her family to a

foreign culture in which she sought help for her depression. Historical movements

bent on globalizing Christianity brought a foreign faith to Kei’s ancestors that

shaped her worldview into that of a fundamentalist Christian. Kei’s therapy

illustrates how the effects of globalization, namely increases in cultural diversity

and religious conservatism, are challenging therapists to develop and consider

new therapeutic approaches with patients which neither ignore nor interpret away

their religious beliefs.

Implications for psychotherapeutic practice

What concrete implications does all of this have to do with how we will practice

psychotherapy in a global society?

1. In order to: avoid overlooking the importance of patients’ religious values and

beliefs; to obtain clinically relevant information; and to signal one’s will-

ingness to take patients’ spirituality into account therapists should routinely

do a religious/spiritual assessment as a part of patients’ intake interviews.

Therapists should be aware of several helpful resources for doing religious/

spiritual assessments that have been written for clergy (Fitchett, 1993;

Pruyser, 1976) and mental health providers (Lovinger, 1984; Richards &

Bergin, 1997). Typically these assessments elicit the following information

from patients:

. Religious affiliation

. Particular beliefs that patients feel will be important to take into account

. Religious/spiritual issues patients feel are involved in their presenting

problems. Patients’ assessment of how their beliefs have been helpful or not helpful. Patients’ assessment of whether they consider themselves to be in good

standing with their respective religious communities. Therapists should explain to patients why the history is important and

proceed in a sensitive manner, eliciting information in a dialogical manner

rather than as responses to a series of interrogatives.

2. Therapists holding different worldviews from those of their patients run

the risk of devaluing the differences if they are not aware of their biases

(Sue, 1978). In the vignette, the therapist devalued the patient’s belief about

grieving by assuming that it was a nonessential accoutrement of her worldview


that could be relativized or replaced by a more rational and potentially more

healthy approach to grieving based on psychological insights. The bias that

‘rational’ and ‘healthy’ are universal values that should trump traditional

cultural and religious beliefs led to an imposition of these primarily Western

and secular values on to the patient and obscured the therapist’s awareness of

an impending stalemate. This illustrates the importance of therapists being

aware of their subtle and not-so-subtle biases that can result in a worldview

hegemony that subjugates the differing worldviews of patients.

3. Although therapists without theological training should avoid ‘playing priest’

by interjecting religious language or images into the therapy (Sims, 1988), it is

important to invite patients to access and explore their traditions in relation

to their experience. In this way therapists can better understand how their

patients’ call upon belief to interpret their life-experience both inside and

outside of therapy. In Kei’s case the therapist asked her if she could recall a

biblical story in which people grieved. She identified the Lazarus passage,

which opened up aspects of her tradition that she had not previously

considered and facilitated a discussion about God’s attitude towards grief

that seemed to be a novel and helpful discussion for her.

4. Unexamined countertransference related to spirituality can limit therapists’

openness to exploring the role that patients’ religious beliefs may play, both in

their presenting problems and in the therapeutic resolution of these problems.

Therefore it is important for therapists to examine their history and attitudes

with respect to their own spirituality, as well as spirituality in general.

5. We know from the literature and from the vignette that minority and

religiously conservative patients are apprehensive about seeking therapy.

They fear that their values and beliefs will not be respected; they feel guilty

about needing therapy, because they interpret their need for therapy as an

indication of their lack of character or lack of faith, and they feel that seeking

therapy might estrange them from their religious community. As a result,

these patients have high rates of premature termination. These trends suggest

that therapists should address any culturally and religiously based fears and

anxieties proactively and early in therapy in order to reduce resistance to

therapy and to facilitate trust building.

6. Given that some cultural and religious practices may be easily confused with

descriptions of pathology, it is important to assess these behaviors and

cognitions in their cultural and religious contexts in order to determine their

meaning (Lovinger, 1996). Therefore, it is necessary to assess whether the

patient’s cultural or religious community recognizes the patient’s behavior or

cognition as being within the community’s normal range of expectations.

This means that there will be occasions in therapy when it is important to

obtain the patient’s consent to consult with their cultural or religious

community in order to make an accurate assessment.

7. Flexibility is critical when treating culturally and religiously different patients.

It is important to remember that the values and assumptions of Western

worldviews from which the major systems of therapy, psychoanalysis,

74 Gary E. Myers

behaviorism, humanistic psychology, and family therapy, emerged are by no

means universal (Diaz-Guerrero, 1977). This means that at times the

framework of therapy with respect to time, location, self-disclosure, privacy,

methods, and even goals will need to be altered from time to time in order to

accommodate patients’ values and beliefs (Gone, 2003).

8. And finally, as in the case of Kei, there will be occasions in therapy when

therapists’ flexibility and sensitivity to patients’ beliefs will be helpful, but not

adequate in themselves to work through stalemates based on conflicts

between firmly held beliefs and the therapeutic process. On these occasions

therapists will need both to appreciate the fundamental importance of

beliefs to the core structures and functions of personality, such as mirroring,

idealization, sustaining personal and social identity, and regulating self-

esteem and to find ways to work within the belief systems of patients. In Kei’s

therapy the story of Jesus expressing grief over the death of his friend,

Lazarus, served as a bridging narrative between Kei’s beliefs and the goals of

therapy that enabled a modest, yet meaningful, integration of the respective

worldviews of belief and therapy. Integration will not be possible in every

such stalemate because integration between belief and conflicting treatment

goals depends on several factors, such as the nature of the conflict, the

capacity and the willingness of both patient and therapist to creatively search

for bridging concepts and narratives, and the nature and severity of the

patient’s psychopathology.

In closing, we acknowledge that these practical suggestions do not in themselves

provide all that is needed for therapists to competently address the impact that

globalization is having on the practice of psychotherapy. But we believe that they

can point the way to acquiring the knowledge, skills, and attitudes that will help us

to offer psychotherapy that can be both relevant and healing to the newcomers

who will be seeking our help.

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