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Conversations with Eeyore: Spirituality and the generation of hope among mental health providers Kenneth I. Pargament, PhD A growing body of research has highlighted the value of spiritual resources for patients and their families. However, spirituality has been largely overlooked as a source of hope and support for providers themselves. In this paper, the author draws on theory, research, and practical examples to suggest that spirituality could potentially assist providers struggling to generate and sustain their own hope in work with clients who are in the midst of despair. The paper focuses on three ways practitioners might access spiritual resources to facilitate hope in their work: (l) by illuminating the sacred character of mental health work; (2) by attending to the sacred dimension of clients’ lives; and (3) by attending to the experience of sacred moments in the healing relationship. These resources may be of value not only to theistically-oriented practitioners but to nontheists as well. (Bulletin of the Menninger Clinic, 77[4], 395-412)
“Good morning… If it is a good morning, which I rather doubt.”
—A. A. Milne, Winnie-the-Pooh This is the rather bleak way Eeyore greets Winnie the Pooh in A. A. Milne’s classic book. Eeyore is a sad ass. This is not a vulgarity. He is literally a sad ass, a forlorn donkey. Eeyore is the epitomy of gloominess, though he’s a sweet gloomy donkey. Those unfamiliar with Eeyore can find a modern day equivalent on YouTube in the Kenneth I. Pargament, PhD, is Professor of Psychology at Bowling Green State University, Bowling Green, Ohio, and Distinguished Scholar at the Institute for Spirituality and Health at the Texas Medical Center, Houston, Texas. Correspondence may be sent to Kenneth I. Pargament, PhD, Department of Psychology, Bowling Green State University, Bowling Green, Ohio 43403; E-mail: kpargam@ bgsu.edu (Copyright © 2103 The Menninger Foundation)
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form of Grumpy Cat. Grumpy Cat’s feline face is frozen into a mask of perpetual misery. One of the memes beneath Grumpy Cat’s picture reads: “Of all the nine lives I’ve lived, this is the worst.” I’ve mused about whether Eeyore and Grumpy Cat were, at some earlier point in their careers, mental health professionals. Ours is a wonderful field. We are tremendously fortunate to be able to touch the lives of patients who have the courage to come to us, revealing their deepest pain and their greatest dreams, in the hope that they can transform their lives. As Frank Reissman (Reissman, 1965) pointed out in 1965 and as others have elaborated since (Post, 2007; Roberts et al., 1999), in the process of helping others, we too are helped. We learn from our clients. We grow in our understanding of other people, ourselves, and the world. We develop our own sense of efficacy. And we can derive tremendous meaning and gratification from our work. But ours is also a difficult field. Health care providers face high rates of burnout, psychological problems, and even suicidality. For instance, in a recent study of over 27,000 physicians, 45.8% reported at least one symptom of burnout, with the highest rates among physicians who were engaged in more frontline care (Shanafelt et al., 2012). Even more alarming, studies show that physicians are more than twice as likely to kill themselves than the general population. According to Miller and McGowen (2000): “Each year, it would take the equivalent of 1 to 2 average-sized graduating classes of medical school to replace the number of physicians who kill themselves” (p. 967). Mental health work can be especially challenging, given the frequency with which providers are vicariously exposed to major life traumas and the peculiarly unreciprocal character of the relationship between client and therapist. I recall one clinical psychologist, a man of about 35, who had posted on his door a calendar with the number of years, months, and days listed in all their detail until the day of his planned retirement, thirty years in the future. This is an early sign of burnout, but only one among many signs that also include anger and irritability toward clients, feeling consistently overwhelmed, absenteeism, anxiety, depression, hopelessness, and the decision to leave the field entirely. In even more serious cases, mental health providers may engage in boundary
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violations in the misdirected effort to attain personal satisfaction at the expense of the well-being of clients (e.g., Gabbard, 1994). How do we sustain ourselves in the field? Researchers and practitioners have examined a number of potential resources that might protect mental health care providers from the stresses and strains of their role, such as social support, coping methods, exercise, travel, and so on (e.g., Kottler, 2012; Norcross, 2000). Another potentially important asset for practitioners is spirituality. A growing body of research has highlighted the value of spiritual resources for patients and their families (Koenig, King, & Carson, 2012; Pargament, Exline, Jones, Mahoney, & Shafranske, 2013). However, spirituality has been largely overlooked as a source of support for providers themselves. Why? Perhaps because mental health providers are, as a group, less religious and spiritual than the general population in the United States (Shafranske & Cummings, 2013). In this paper, I draw on theory, research, and practical examples to suggest that spirituality could potentially assist providers struggling to generate and sustain their own hope in work with clients who are in the midst of despair. From the outset, it is important to stress that I will be using spirituality in the broad sense of the term, one that embraces the diverse set of pathways, theistic and nontheistic, people take in search of whatever they may hold sacred in life. I will pay particular attention to three ways practitioners might access spiritual resources to facilitate hope in their work: (l) by illuminating the sacred character of mental health work; (2) by attending to the sacred dimension of clients’ lives; and (3) by attending to the experience of sacred moments in the healing relationship. As a prelude to this discussion, I begin by briefly describing my use of the terms religion and spirituality here. The meanings of religion and spirituality
Why are people religious? Traditionally, social scientists and mental health professionals have tended to treat religion as a way to serve presumably more basic psychological and social needs (see Pargament, 2013 for more extensive review). Freud spoke
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of religion as a source of impulse control and anxiety reduction. Durkheim viewed religion as a source of community and identity. Geertz emphasized the role that religion played in fostering meaning in life. More recently, Kirkpatrick has described religion as an evolutionary by-product. Despite their dissimilarities, these theorists share the view that religious life is rooted in something ultimately nonreligious in nature. A more parsimonious point of view is that religion is guided by a spiritual motivation; that is, the desire to seek out, form, and at times, transform a relationship with something perceived as sacred (Pargament, 2013). Theorists from diverse backgrounds have noted that human beings are seekers, motivated to pursue value and significance in their lives (e.g., Allport, 1937; Panksepp, 1998; White, 1963). Sacred goals represent one particularly important set of valued ends. People can perceive a wide range of objects as sacred; not only, gods and divine beings, but also other aspects of life that are imbued with divine-like qualities, such as transcendence, boundlessness, and ultimacy. Sacred objects include marriage, parenting, work, the environment, virtues, sports, and the soul. Thus, any seemingly secular aspect of life can be the container for a deeper dimension. Spirituality rests on this capacity to see more deeply. The yearning for the sacred (i.e., spirituality) may be at least partially irreducible. Psychologist of religion, Paul Johnson (1959) once wrote, “It is the ultimate thou the religious person seeks most of all” (p. 70). Other theorists have echoed this idea. For example, psychodynamic theorist, Hans Loewald (1978) maintained that spirituality is not simply a defense mechanism but rather a fundamental part of human character. He noted that within the primary process of even the youngest child, we find spiritual experiences that are marked by a sense of unity and timelessness. Similarly, cognitive psychologists such as Barrett and Zahl (2013) find that young children have a propensity to perceive powerful and caring figures in their lives, including gods. Neuroscientists have also suggested that people may be, in some respects, hardwired for spirituality. Newberg and Waldman (2006) maintain that “We are biologically inclined to ponder the deepest nature of our being and the deepest secrets of the universe. . . born to be-
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lieve” (p. xvii–xviii). Consistent with these assertions, empirical studies have generally not been able to fully explain the effects of religion and spirituality on health and well-being by psychological and social mediators, such as health practices, social support, and meaning in life (Pargament, 2013). Viewed in this manner, spirituality is the heart and soul of religious life. However, spirituality is not synonymous with religion. People can and do pursue sacred ends outside of as well as within religious institutional structures, and through a variety of traditional and nontraditional pathways. Moreover, what they hold sacred is not limited to theistic beings, but rather encompasses the full range of seemingly secular aspects of life. Even the most mundane parts of life may reveal themselves to be containers of a deeper dimension, if we are able to develop our capacity to see more deeply. Thus, spirituality is of relevance to both traditionally religious and nonreligious people and both traditionally religious and nonreligious concerns. The concept helps to move systematic psychological study of religion “from heaven to earth.” In fact, numerous studies have documented several significant implications of spirituality for human functioning: (1) people often draw on their spiritual resources in difficult times; (2) people invest themselves in whatever they hold sacred; (3) people derive strength and support from their spirituality; (4) spiritual experience is associated with powerful emotions, such as awe, uplift, gratitude, hope, and compassion; (5) spirituality offers people an organizing and guiding framework for life; and (6) people go to great lengths to preserve and protect what they hold sacred and react strongly when the sacred is lost, harmed, or violated (Pargament, 2013). We know less about the effects of spirituality on the health and well-being of mental health providers. However, clinical example and some limited research suggest several ways spirituality may be of value to providers. Illuminating the sacred character of mental health work
For most aspiring young people entering the field, mental health is more than a job; it is a vocation, a career that offers an opportunity to make a difference in the world by touching the lives of
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people who are suffering. Work is, in this sense, imbued with a deeper, sacred meaning (Carroll, 2013). People may sanctify their work theistically; that is, jobs may be understood as fulfilling a larger God-given purpose. People can also sanctify their work nontheistically by attributing to their jobs sacred or divine-like qualities; work can be perceived as a source of ultimate meaning, a way of expressing one’s own divine spark, a way to create a lasting legacy. In any case, when imbued with a deeper, sacred meaning, work becomes much more than a means of material gain; it becomes a source of self-identity and an expression of the passionate desire to help others. The process of sanctifying work in this fashion may also have a number of benefits for both mental health providers and those they serve. Several studies speak to this point. In a survey of employees of a university health service and small liberal arts college, Wrzesniewski, McCauley, Rozi, and Schwartz (1997) found that those who described their job as a calling reported higher levels of satisfaction with their job and with life in general than those who described their work as a job or career. Walker, Jones, Wuensch, Shahnaz, and Cope (2008) surveyed a range of employees and reported that those who viewed their work as sacred indicated greater job satisfaction, commitment to the job, and less intention to leave. Carroll (2008) reported similar results in a national study of employees at Roman Catholic secondary and middle schools; higher levels of sanctification of work were associated with greater job satisfaction, job commitment, and lower turnover intent, even after controlling for personality traits. In a more recent study of university employees, those who viewed their job as a calling indicated greater commitment to their jobs. The researchers concluded: experiencing a calling to a particular career is likely to lead one to become committed to a line of work, find a specific job that allows one to fulfill that commitment, and in turn be happier with, and committed, to a specific job. (Duffy, Dik, & Steger, 2011, p. 216)
In an investigation of mothers working in higher education, Oates (2008) found that individuals who saw their jobs as more of a calling experienced fewer conflicts in their roles as workers and
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mothers. Oates suggests that the stronger sense of purpose among those who see work as a calling helps them deal more effectively with interrole tensions and achieve greater wholeness and integration. These findings need to be extended to people who work in the mental health field. There is, however, a potential downside that accompanies the attachment of deeper, sacred meaning to work. When work is perceived as sacred, the everyday tensions and conflicts that are part and parcel of mental health practice can become especially painful, even intolerable; after all, these conflicts represent a threat to what is held precious. Without effective ways of dealing with these issues, perhaps most importantly without an on-going sense of hope, health care providers run the risk of losing touch with the sacred motivation that drew them to their careers, becoming disenchanted, cynical, and burnout as a result. In an effort to help health caregivers “reclaim their work as a sacred vocation,” Rabbi Samuel Karff, Dr. Benjamin Amick, and Dr. Thomas Cole from the McGovern Center for Humanities and Ethics at The University of Texas Medical School in Houston developed a Sacred Vocation Program (SVP) for medical residents (Karff, 2012, p. 20). The first phase of the program which I will focus on here involves five group sessions that address: (l) the notion of medicine as a vocation and a sharing of stories of what led the residents into medicine; (2) a discussion of what it means to be healer of body, mind, and spirit and a sharing of stories of the experience of being a healer; (3) frank dialogue about those times when residents may have done harm to others; (4) discussion about those barriers that interfere with being able to live out medicine as a sacred vocation, and ways to cope with these challenges; and (5) articulation of the principles of medicine as a sacred vocation and the chance to renew one’s commitment to healing in this fashion. Preliminary analyses of the effectiveness of this brief program have shown promising results; the residents report increases in their sense of empathy with patients, decreases in their levels of stress and frustration with others, and increases in their sense of the sacredness of their work. When I was applying to graduate schools in clinical psychology, I was warned not to come across as a do-gooder. Graduate programs, I was told, are looking for students who are committed Vol. 77, No. 4 (Fall 2013)
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to hard-core science and systematic approaches to change. The growing literature on the sanctification of work suggests that this was poor advice. People who are able to see a deeper meaning and purpose to their work may be better able to withstand the challenges of mental health work and sustain themselves over the course of their careers. We should do all we can to recruit to the field people who are passionately committed to the science and practice of mental health care, and we need to do all we can to foster this sacred vision in training and beyond. Attending to the sacred dimension of clients’ lives
Spirituality is many things, but it is never boring. As noted above, spiritual experience is tied to powerful energy and emotion. Spirituality then can serve as an important clinical resource, especially for people stuck in depression where de-activation, apathy, disconnection, and hopelessness are the norm. Attending to the sacred dimension in the lives of our clients may help activate them by mobilizing hope in themselves and their lives. But let me take it one step further and suggest here that by attending to a client’s spirituality, therapists may also find themselves more empowered in their work. Consider the story of Mary. Mary is a 55-year-old former physician who, perhaps not unintentionally, had specialized in pain management. She came to see me following a suicide attempt. As a child, Mary had experienced the extremes of both parental abuse and neglect. Bereft of the benefit of family support or guidance, she grew up without a clue of who she was or how she was supposed to live her life. Remarkably, Mary was able to make her way through medical school, though she often felt like an imposter who didn’t know what she was really doing. The stress and strain took their toll on Mary. She began to drink heavily at a young age and was unable to gain her license to practice medicine. All of this left Mary deeply depressed. Her suicide attempt was triggered by feelings of abandonment and ingratitude by her adult children who she loved deeply, but now had little to do with her. Work with Mary was challenging. On the positive side, she began to attend 12-step program meetings regularly and enjoyed
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connecting with other people. She was also invested in her psychotherapy. But in our first year of work together, Mary relapsed several times. On one occasion, she drove while drunk, had a car accident, yet somehow managed to avoid injuring herself, someone else, or police involvement. Mary spent much of her time in therapy talking about the pain and mistreatment she had suffered at the hands of her parents and children. Ill-equipped to deal with her wounds, alcohol seemed to be the only way she could find any relief. Mary voiced a great deal of despair. And I have to admit that, try as I might to keep my feet on secure ground for Mary, there were moments when I felt my own hopelessness for her. Given her deep history of trauma, her profound sense of worthlessness, her long-rooted addiction to alcohol, and her track record of failure what hope did this woman really have? One day, Mary came to a session and talked about the death of her good friend, an elderly woman who had been more of a mother to her than her own mother had been. Mary had stayed with her friend throughout the course of a long illness and was at her bedside when she died. In tears, Mary spoke about how she had witnessed her friend’s transition to the other side. When she died, Mary had felt her friend’s spirit, an aura of light and lightness in the room; it seemed that her friends’ spirit was passing through Mary’s own body. I asked Mary what meaning she took from this experience. She said that she came away from it with a sense of the preciousness and wonder of life. She paused and then said with unusual conviction: “And I realize I’m not ready to cross-over yet.” Why not, I asked? Mary said she felt like she had unfinished business. “There’s more for me do in this life,” she said. What might that be, I asked? Mary said, “My purpose is to care for people—my AA friends, people who don’t have a whole heckuva lot in the world, people who will let me care about them.” She went on, “I’m tired of focusing on all of the past hurt and injuries. I’m tired of trying to love people who won’t love me back. I’m moving on.” I noted that she was talking about a major transformation in her life. Mary simply nodded and said, “This is what I want to
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do.” And this is what Mary has done. She remains involved in AA and psychotherapy, has maintained her sobriety, and now serves as an informal medical advocate for older patients, many of them her friends—taking them to medical appointments, helping them with their questions about their conditions and treatment, and guiding them through the complexities of the medical system. Therapists may be reluctant to talk about spiritual matters with their clients. This is unfortunate for a spiritual conversation can help clients access deeply felt emotions and discover a new sense of meaning and hope that can have profound implications for health and well-being. How does this work? I don’t think we have a clear answer or a clear set of answers yet. Let me offer one simple thought here. Spirituality fosters the sense that things aren’t necessarily what they seem. There is a deeper stream that runs beneath our everyday experience. If we look beneath the surface then, we can find new and surprising possibilities. Problems that seem to be intractable are not necessarily so; as trapped as we may feel, there is a way out. Mary’s spiritual experience at the bedside of her dying friend triggered a life-transforming realization, a newfound belief that her life may in fact still have purpose and a hope that she might be able to realize this purpose. In my work with Mary, I was trying, in the cogent words of Jon Allen (2013a), to lend her some hope. But in my work with Mary, I received a repayment of the loan, and I might say with interest. Mary’s spiritual experience and transformation was inspirational and touched my own life, professionally and personally, with the reminder of the human capacity for change and growth in the midst of even the most seemingly hopeless situations. As our clients oscillate between despair and hope (cf., Allen, 2013b), our jobs are to keep our feet on the firm ground of hopeful realism. But we too are only human and, as caring providers, we would be less than empathic and perhaps less than helpful if we did not experience some of the client’s ups and downs ourselves, including periods of despair. However, attending to the spiritual dimension of our client’s lives can help us keep our feet on the firmer ground of hopeful realism. Just as providers can be vicariously traumatized by listening to client’s reports of horrific events, providers can be vicariously uplifted and re-energized by
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spiritual conversations with clients. We are lenders of hope, but in facilitating a spiritual conversation we are occasionally lifted up in turn by the hope experienced by our clients. An interesting hypothesis to test then would be whether spiritually integrated care yields value-added benefits, not only for clients, but providers as well. Attending to sacred moments in the healing relationship
Even though a great deal of time, effort, and financial resources have gone into studies which compare the effectiveness of different modes of psychotherapy, the findings have not been particularly revealing. In fact, with a few exceptions, differences between types of treatment account for only about 1% of the variance in treatment outcomes (Wampold, 2001). This leaves unanswered the critical question: What accounts for treatment effects? Empirical studies suggest that as much as 50% of the variance in treatment outcomes may be attributable to the therapist-patient alliance (Horvath, Del Re, Flückiger, & Symonds, 2001). A potentially key, but often overlooked element of an effective therapeutic alliance may have to do with the depth or spiritual character of the relationship between provider and patient. Several theorists and practitioners have articulated various elements that contribute to a spiritually profound helping relationship. These include: the therapist’s capacity to be relationally attuned to or mindful of the patient (Bruce, Manber, Shapiro, & Constantino, 2010), experiences of therapeutic inspiration in treatment (O’Grady & Richards, 2010), the therapist’s ability to relate to the patient as a full human being (i.e., I-Thou) rather than as an object (i.e., I-It; Buber, 1970; Scott, Scott, Miller, Stange, & Crabtree, 2009), and sensitivity to present moments in treatment that represent important opportunities for change (Stern, 2004). Sacred moments may be another potentially key marker of an effective therapeutic-patient alliance. What do I mean by sacred moments? Let me start my answer with an example. Several years ago, I worked with a woman, I’ll call her Angela, who had been infected with HIV/AIDS from her partner. Angela’s partner had abandoned her, and her friends had distanced
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themselves from her as well once they learned of her illness. One day, Angela came in distraught—her good friend and the mother of Angela’s much loved goddaughter had told Angela that she thought it best for her not to see her goddaughter anymore. She feared Angela would infect her daughter with AIDS. Angela sat in my office immobilized with pain. She spoke of how contaminated she felt, she spoke of how cut off she felt from other people, she talked about how no one had touched her even to give her a pat on the back for two years. She was, she felt, no longer a part of humanity. Now, I’m not a big fan of physical touch between clients and therapists—there is just too much room for misinterpretation. But in this case, I ignored the rule. “Angela,” I asked, “would you let me hold your hand.” She just nodded her head, so I reached out and held her hand as she cried. And that’s how we spent the rest of the session. She speaking of her profound isolation while I held her hand. I touched Angela and she touched me in a deeply spiritual way. This was a turning point in our relationship. It was a sacred moment. Sacred moments are extraordinary; they are set apart from our usual experience. These are the moments when we can see into who our clients are and they see into who we are. In sacred moments, we touch and are touched by each other. These are moments of profound interconnectedness. Sacred moments also reveal something that’s ultimately true; they go beneath the surface and beyond what’s artificial to what is really real. Sacred moments are timeless—they stay with us throughout our lives. Think of them as the Un-PTSD moments. These are the powerful, uplifting, inspiring, life changing experiences that make our work and our lives worthwhile. To put it more formally, sacred moments refer to brief periods of time in which people experience qualities of transcendence, ultimacy, boundlessness, interconnectedness, and spiritual emotions (Lomax, Kripal, & Pargament, 2011; Pargament & Mahoney, 2005). It is important to note that I am using the term “sacred” here in a psychological rather than theological sense. Sacred refers to human perceptions of qualities often associated with the divine or higher powers. These perceptions do not speak one way or the
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other to the ontological reality of the sacred, higher powers, or God. They do, however, reflect on human character and human relationships. Thus, nontheists as well as theists may experience sacred moments in their work. Sacred moments may not be altogether unusual. James Lomax has presented some remarkable examples of sacred moments drawn from his own psychiatric practice (Lomax & Pargament, 2011; Lomax et al., 2011). Sacred moments may be one of the critical ingredients of a healing relationship; they may a big part of what draws many mental health professionals to the field, what we remember about our work, what we take pride in, and what sustains us throughout our careers. We have done some research to test these notions. In one study, we examined 58 mental health providers, most of whom were psychiatrists. We asked the providers to describe an important moment they had experienced in treatment with a client in the past year. They then completed a number of questions about that important moment, and a series of other questions about the impact of this experience on their client, themselves, and the therapeutic alliance. Finally, the providers responded to a set of questions about their sense of meaning in work, their spiritual well-being, and burnout. We found that sacred moments were commonplace; 55.5% of the providers described their important moment as sacred. This was particularly striking since many of the providers were secular; this underscores the point that sacred moments are not limited to theists. We also found that providers who experienced a sacred moment (as opposed to an important but not sacred moment) reported that their clients gained more in treatment, that their therapeutic alliance was stronger, and that the moment was a source of motivation, satisfaction, and growth in their own lives. Moreover, providers who experienced a sacred moment reported greater meaning in their work and a greater sense of spiritual well-being. Interestingly, sacred moments were not tied to lower levels of burnout. We have recently replicated this study in a national sample of adults who have been in mental health treatment, and the findings have been quite similar.
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Conclusions
In this paper, I have offered the admittedly provocative thesis that spirituality may be a resource for hope and healing of not only clients but providers as well. In support of this point, I have suggested three ways practitioners might access spiritual resources to facilitate hope in their work: (l) by illuminating the sacred character of mental health work; (2) by attending to the sacred dimension of clients’ lives; and (3) by attending to the experience of sacred moments in the healing relationship. It is important to stress that none of these examples necessarily involves a fundamental shift in the practitioners’ own personal spiritual or religious orientation. Rather each involves a potential shift in the way mental health providers see clients, work, and healing relationships. And this shift toward a deeper way of seeing is open and available to nontheists and theists alike. Post (2013) illustrates this transformation of vision in the moving conclusion to his paper on caring for the deeply forgetful. He suggests, “Maybe that deeply forgetful person very near the end has already hopped on that last train for glory, but it just hasn’t quite left the station yet” (p. 24). This is a powerful form of spiritual visioning of the patient that may help sustain the patient, the family of the patient, and the provider. Of course, providers might also gain by accessing spiritual resources more fully in their own personal lives. A few studies have shown that providers benefit from spiritual practices. For example, Oman, Hedberg, and Thoresen (2006) conducted a randomized, clinical evaluation of an 8-week training program for health care providers who were taught to make use of nonsectarian, spiritual self-management tools, such as passage meditation, inspirational reading, and mantram meditation. The program produced significant reductions in levels of stress and improvements in levels of mental health, and these effects persisted 19 weeks after treatment. Similarly, Wasner, Longaker, Fegg, Johannes, and Gian (2005) offered a stress management class to palliative care nurses that included spiritual practices, such as controlled breathing, meditation, and journaling. The nurses reported significant
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increases in job satisfaction and reductions in work-related stress over the course of the program. As interesting as these findings are, questions remain whether they would apply to a wide range of providers, including those who may find personal spiritual practices objectionable. Spiritual beliefs and practices are more than tools that can be applied effectively in purely utilitarian fashion; they are sacred, tied to a deeper philosophy of life that must be ego-syntonic with the world view of providers. Thus, I am not recommending that we train all providers to become more personally religious or spiritual or that we use spirituality as a criterion for admissions to graduate school. I would suggest though that regardless of the providers’ own personal spiritual and religious orientation, greater sensitivity to the spiritual dimension of clients, therapists, and relationships may offer a critical source of hope and healing for both therapists and clients. Movement toward this kind of sensitivity may be challenging; we are after all a pretty secular bunch for the most part, and as Jon Allen (2013b) has noted, we may need crowbars to pry and keep our minds open enough to explore the spiritual domain. But if a crowbar is what we need, so be it, for the capacity to see and connect to people in this deep fashion may very well be a core competency for effective mental health care and a key to a satisfying long-term career in the field (Vieten et al., 2013). In our work, we can often detect the voice of Eeyore—the voice of gloom, defeatism, despair, and hopelessness. The voice of Eeyore can be heard not only from our clients but also from within ourselves, call it our inner Eeyore. We need to be attuned to that voice wherever it comes from. As we engage in our healing conversations with Eeyore, spirituality offers a potentially crucial resource to us, an anchor that can keep our own feet rooted on solid hopeful ground. Our conversations with Eeyore can be terribly trying and depleting, but we have to persist for there is one thing we can never allow. We can never let Eeyore have the last word.
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References Allen, J. G. (2013a). Hope in human attachment and spiritual connection. Bulletin of the Menninger Clinic, 77, 302–331. Allen, J. G. (2013b). Restoring mentalizing in attachment relationships: Treating trauma with plain old therapy. Arlington, VA: American Psychiatric Publishing. Allport, G. W. (1937). The functional autonomy of motives. American Journal of Psychology, 50, 141–156. Barrett, J., & Zahl, B. P. (2013). Cognition, evolution, and religion. In K. I. Pargament (Ed.-in-Chief), J. J. Exline & J. Jones (Assoc. Eds.), APA handbook of psychology, religion, and spirituality: Vol 1. Context, theory, and research (pp. 221–237). Washington, DC: American Psychological Association. Bruce, N. G., Manber, R., Shapiro, S. L., & Constantino, M. J. (2010). Psychotherapist mindfulness and the psychotherapy process. Psychotherapy Research: Theory, Research, Practice, Training, 47, 83–97. Buber, M. (1970). I and Thou. New York: Charles Scribner’s Sons. Carroll, S. T. (2008). The role of the sanctification of work, religion, and spirituality as predictors of work-related outcomes for individuals working at religiously affiliated institutions. Dissertation Abstract International: Section B. Sciences and Engineering, 69, 3887. Carroll, S. T. (2013). Addressing religion and spirituality in the workplace. In K. I. Pargament (Ed.-in-Chief), A. Mahoney, & E. Shafranske (Assoc. Eds.), APA handbook of psychology, religion, and spirituality: Vol. 2. An applied psychology of religion and spirituality (pp. 595–612). Washington, DC: American Psychological Association. Duffy, R. D., Dik, B. J., & Steger, M. F. (2011). Calling and work-related outcomes: Career commitment as a mediator. Journal of Vocational Behavior, 78, 210–218. Gabbard, G. O. (1994). Psychotherapists who transgress sexual boundaries with patients. Bulletin of the Menninger Clinic, 58, 124–135. Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16. Johnson, P. E. (1959). Psychology of religion. Nashville, TN: Abingdon Press. Karff, S. E. (2012). Spirituality and religion in health care: A rabbi’s personal journal. CCAR Journal: The Reform Jewish Quarterly, Summer, 8–24. Koenig, H. G., King, D., & Carson, V. B. (2012). Handbook of religion and health (2nd ed.). New York: Oxford Press. Kottler, J. A. (2012). The therapist’s workbook: Self-assessment, self-care, and self-improvement exercises for mental health professionals. Hoboken, NJ: John Wiley. Loewald, H. (1978). Psychoanalysis and the history of the individual. New Haven, CT: Yale University Press.
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Conversations with Eeyore Lomax, J. W., Kripal, J. J., & Pargament, K. I. (2011). Perspectives on “sacred moments” in psychotherapy. American Journal of Psychiatry, 168, 1–8. Lomax, J. W., & Pargament, K. I. (2011). Seeking ‘sacred moments’ in psychotherapy and in life. Psyche & Geloof, 11, 79–90. Miller, M. N., & McGowan, K. R. (2000). The painful truth: Physicians are not invincible. Southern Medical Journal, 93, 966–973. Newberg, A., & Waldman, M. R. (2006). Born to believe: God, science, and the origin of ordinary and extraordinary beliefs. New York: Free Press. Norcross, J. (2000). Psychotherapist self-care: Practitioner-tested, researchinformed strategies. Professional Psychology: Research and Practice, 31, 710–713. Oates, K. (2008). Calling and conflict: A quantitative study of interrole conflict and the sanctification of work and mothering. Dissertation Abstracts International: Section B. Sciences and Engineering, 68, 6326. O’Grady, K. A., & Richards, P. S. (2010). The role of inspiration in the helping professionals. Psychology of Religion and Spirituality, 2, 57–66. Oman, D., Hedberg, J., & Thoresen, C. E. (2006). Passage meditation reduces perceived stress in health professionals: A randomized, clinical trial. Journal of Consulting and Clinical Psychology, 74, 714–719. Panksepp, J. (1998). Affective science: The foundations of human and animal emotions. Oxford: Oxford University Press. Pargament, K. I. (2013). Searching for the sacred: Toward a non-reductionistic theory of spirituality. In K. I. Pargament (Ed.-in-Chief), J. J. Exline & J. Jones (Assoc. Eds.), APA handbook of psychology, religion, and spirituality: Vol 1. Context, theory, and research (pp. 257–274). Washington, DC: American Psychological Association. Pargament, K. I. (Editor-in-Chief), Exline, J. J., Jones, J., Mahoney, A., & Shafranske, E. (Assoc. Eds.). (2013). APA handbook of psychology, religion, and spirituality (Volumes 1 and 2). Washington DC: American Psychiatric Association Press. Pargament, K. I., & Mahoney, A. (2005). Sacred matters: Sanctification as a vital topic for the psychology of religion. International Journal for the Psychology of Religion, 15, 179–198. Post, S. G. (2007, Ed.). Altruism and health: Perspectives from empirical research. Oxford: Oxford University Press. Post, S. G. (2013). Hope in caring for the deeply forgetful: Enduring selfhood and being open to surprises. Bulletin of the Menninger Clinic, 77, 349–368. Reissman, F. (1965). The helper therapy principle. Social Work, 10, 27–32. Roberts, L., Salem, D., Rappaport, J., Toro, P. A., Luke, D. A., & Seidman, E. (1999). Giving and receiving help: Interpersonal transactions in mutual-help meetings and psychosocial adjustment of members. American Journal of Community Psychology, 27, 841–868. Scott, J. G., Scott, R. G., Miller, W. I., Stange, K. C., & Crabtree, B. F. (2009). Healing relationships and the existential philosophy of Martin Buber. Philosophy, Ethics, and Humanities in Medicine, 4, 1–9.
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Pargament Shafranske, E. S., & Cummings, J. P. (2013). Religious and spiritual beliefs, affiliations, and practices of psychologists. In K. I. Pargament (Ed.-inChief), A. Mahoney, & E. P. Shafranske (Assoc. Eds.), APA handbook of psychology, religion, and spirituality: Vol 2. An applied psychology of religion and spirituality (pp. 23–42). Washington, DC: American Psychological Association. Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., et al. (2012). Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population. Archives of Internal Medicine, 172, 1377–1385. Stern, D. N. (2004). The present moment in psychotherapy and everyday life. New York: W. W. Norton. Vieten, C., Scammell, S., Pilato, R., Ammondson, I., Pargament, K. I., & Lukoff, D. (2013). Spiritual and religious competencies for psychologists. Psychology of Religion and Spirituality, 5, 129–144. Walker, A., Jones, M., Wuensch, K., Shahnaz, A., & Cope, J. (2008). Sanctifying work: Effects on satisfaction, commitment, and intent to leave. International Journal for the Psychology of Religion, 18, 132–145. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahway, NJ: Erlbaum. Wasner, M., Longaker, C., Fegg, M., Johannes, B., & Gian, D. (2005). Effects of spiritual care training for palliative care professionals. Palliative Medicine, 19, 99–104. White, R. B. (1963). Ego and reality in psychoanalytic theory. Psychological Issues, 3, 1–120. Wrzesniewski, A., McCauley, C. R., Rozi, P., & Schwartz, B. (1997). Jobs, careers, and callings: People’s relations to their work. Journal of Research in Personality, 31, 21–33.
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Conversations with Eeyore: Spirituality and the generation of hope among mental health providers Kenneth I. Pargament, PhD A growing body of research has highlighted the value of spiritual resources for patients and their families. However, spirituality has been largely overlooked as a source of hope and support for providers themselves. In this paper, the author draws on theory, research, and practical examples to suggest that spirituality could potentially assist providers struggling to generate and sustain their own hope in work with clients who are in the midst of despair. The paper focuses on three ways practitioners might access spiritual resources to facilitate hope in their work: (l) by illuminating the sacred character of mental health work; (2) by attending to the sacred dimension of clients’ lives; and (3) by attending to the experience of sacred moments in the healing relationship. These resources may be of value not only to theistically-oriented practitioners but to nontheists as well. (Bulletin of the Menninger Clinic, 77[4], 395-412)
“Good morning… If it is a good morning, which I rather doubt.”
—A. A. Milne, Winnie-the-Pooh This is the rather bleak way Eeyore greets Winnie the Pooh in A. A. Milne’s classic book. Eeyore is a sad ass. This is not a vulgarity. He is literally a sad ass, a forlorn donkey. Eeyore is the epitomy of gloominess, though he’s a sweet gloomy donkey. Those unfamiliar with Eeyore can find a modern day equivalent on YouTube in the Kenneth I. Pargament, PhD, is Professor of Psychology at Bowling Green State University, Bowling Green, Ohio, and Distinguished Scholar at the Institute for Spirituality and Health at the Texas Medical Center, Houston, Texas. Correspondence may be sent to Kenneth I. Pargament, PhD, Department of Psychology, Bowling Green State University, Bowling Green, Ohio 43403; E-mail: kpargam@ bgsu.edu (Copyright © 2103 The Menninger Foundation)
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form of Grumpy Cat. Grumpy Cat’s feline face is frozen into a mask of perpetual misery. One of the memes beneath Grumpy Cat’s picture reads: “Of all the nine lives I’ve lived, this is the worst.” I’ve mused about whether Eeyore and Grumpy Cat were, at some earlier point in their careers, mental health professionals. Ours is a wonderful field. We are tremendously fortunate to be able to touch the lives of patients who have the courage to come to us, revealing their deepest pain and their greatest dreams, in the hope that they can transform their lives. As Frank Reissman (Reissman, 1965) pointed out in 1965 and as others have elaborated since (Post, 2007; Roberts et al., 1999), in the process of helping others, we too are helped. We learn from our clients. We grow in our understanding of other people, ourselves, and the world. We develop our own sense of efficacy. And we can derive tremendous meaning and gratification from our work. But ours is also a difficult field. Health care providers face high rates of burnout, psychological problems, and even suicidality. For instance, in a recent study of over 27,000 physicians, 45.8% reported at least one symptom of burnout, with the highest rates among physicians who were engaged in more frontline care (Shanafelt et al., 2012). Even more alarming, studies show that physicians are more than twice as likely to kill themselves than the general population. According to Miller and McGowen (2000): “Each year, it would take the equivalent of 1 to 2 average-sized graduating classes of medical school to replace the number of physicians who kill themselves” (p. 967). Mental health work can be especially challenging, given the frequency with which providers are vicariously exposed to major life traumas and the peculiarly unreciprocal character of the relationship between client and therapist. I recall one clinical psychologist, a man of about 35, who had posted on his door a calendar with the number of years, months, and days listed in all their detail until the day of his planned retirement, thirty years in the future. This is an early sign of burnout, but only one among many signs that also include anger and irritability toward clients, feeling consistently overwhelmed, absenteeism, anxiety, depression, hopelessness, and the decision to leave the field entirely. In even more serious cases, mental health providers may engage in boundary
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violations in the misdirected effort to attain personal satisfaction at the expense of the well-being of clients (e.g., Gabbard, 1994). How do we sustain ourselves in the field? Researchers and practitioners have examined a number of potential resources that might protect mental health care providers from the stresses and strains of their role, such as social support, coping methods, exercise, travel, and so on (e.g., Kottler, 2012; Norcross, 2000). Another potentially important asset for practitioners is spirituality. A growing body of research has highlighted the value of spiritual resources for patients and their families (Koenig, King, & Carson, 2012; Pargament, Exline, Jones, Mahoney, & Shafranske, 2013). However, spirituality has been largely overlooked as a source of support for providers themselves. Why? Perhaps because mental health providers are, as a group, less religious and spiritual than the general population in the United States (Shafranske & Cummings, 2013). In this paper, I draw on theory, research, and practical examples to suggest that spirituality could potentially assist providers struggling to generate and sustain their own hope in work with clients who are in the midst of despair. From the outset, it is important to stress that I will be using spirituality in the broad sense of the term, one that embraces the diverse set of pathways, theistic and nontheistic, people take in search of whatever they may hold sacred in life. I will pay particular attention to three ways practitioners might access spiritual resources to facilitate hope in their work: (l) by illuminating the sacred character of mental health work; (2) by attending to the sacred dimension of clients’ lives; and (3) by attending to the experience of sacred moments in the healing relationship. As a prelude to this discussion, I begin by briefly describing my use of the terms religion and spirituality here. The meanings of religion and spirituality
Why are people religious? Traditionally, social scientists and mental health professionals have tended to treat religion as a way to serve presumably more basic psychological and social needs (see Pargament, 2013 for more extensive review). Freud spoke
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of religion as a source of impulse control and anxiety reduction. Durkheim viewed religion as a source of community and identity. Geertz emphasized the role that religion played in fostering meaning in life. More recently, Kirkpatrick has described religion as an evolutionary by-product. Despite their dissimilarities, these theorists share the view that religious life is rooted in something ultimately nonreligious in nature. A more parsimonious point of view is that religion is guided by a spiritual motivation; that is, the desire to seek out, form, and at times, transform a relationship with something perceived as sacred (Pargament, 2013). Theorists from diverse backgrounds have noted that human beings are seekers, motivated to pursue value and significance in their lives (e.g., Allport, 1937; Panksepp, 1998; White, 1963). Sacred goals represent one particularly important set of valued ends. People can perceive a wide range of objects as sacred; not only, gods and divine beings, but also other aspects of life that are imbued with divine-like qualities, such as transcendence, boundlessness, and ultimacy. Sacred objects include marriage, parenting, work, the environment, virtues, sports, and the soul. Thus, any seemingly secular aspect of life can be the container for a deeper dimension. Spirituality rests on this capacity to see more deeply. The yearning for the sacred (i.e., spirituality) may be at least partially irreducible. Psychologist of religion, Paul Johnson (1959) once wrote, “It is the ultimate thou the religious person seeks most of all” (p. 70). Other theorists have echoed this idea. For example, psychodynamic theorist, Hans Loewald (1978) maintained that spirituality is not simply a defense mechanism but rather a fundamental part of human character. He noted that within the primary process of even the youngest child, we find spiritual experiences that are marked by a sense of unity and timelessness. Similarly, cognitive psychologists such as Barrett and Zahl (2013) find that young children have a propensity to perceive powerful and caring figures in their lives, including gods. Neuroscientists have also suggested that people may be, in some respects, hardwired for spirituality. Newberg and Waldman (2006) maintain that “We are biologically inclined to ponder the deepest nature of our being and the deepest secrets of the universe. . . born to be-
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lieve” (p. xvii–xviii). Consistent with these assertions, empirical studies have generally not been able to fully explain the effects of religion and spirituality on health and well-being by psychological and social mediators, such as health practices, social support, and meaning in life (Pargament, 2013). Viewed in this manner, spirituality is the heart and soul of religious life. However, spirituality is not synonymous with religion. People can and do pursue sacred ends outside of as well as within religious institutional structures, and through a variety of traditional and nontraditional pathways. Moreover, what they hold sacred is not limited to theistic beings, but rather encompasses the full range of seemingly secular aspects of life. Even the most mundane parts of life may reveal themselves to be containers of a deeper dimension, if we are able to develop our capacity to see more deeply. Thus, spirituality is of relevance to both traditionally religious and nonreligious people and both traditionally religious and nonreligious concerns. The concept helps to move systematic psychological study of religion “from heaven to earth.” In fact, numerous studies have documented several significant implications of spirituality for human functioning: (1) people often draw on their spiritual resources in difficult times; (2) people invest themselves in whatever they hold sacred; (3) people derive strength and support from their spirituality; (4) spiritual experience is associated with powerful emotions, such as awe, uplift, gratitude, hope, and compassion; (5) spirituality offers people an organizing and guiding framework for life; and (6) people go to great lengths to preserve and protect what they hold sacred and react strongly when the sacred is lost, harmed, or violated (Pargament, 2013). We know less about the effects of spirituality on the health and well-being of mental health providers. However, clinical example and some limited research suggest several ways spirituality may be of value to providers. Illuminating the sacred character of mental health work
For most aspiring young people entering the field, mental health is more than a job; it is a vocation, a career that offers an opportunity to make a difference in the world by touching the lives of
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people who are suffering. Work is, in this sense, imbued with a deeper, sacred meaning (Carroll, 2013). People may sanctify their work theistically; that is, jobs may be understood as fulfilling a larger God-given purpose. People can also sanctify their work nontheistically by attributing to their jobs sacred or divine-like qualities; work can be perceived as a source of ultimate meaning, a way of expressing one’s own divine spark, a way to create a lasting legacy. In any case, when imbued with a deeper, sacred meaning, work becomes much more than a means of material gain; it becomes a source of self-identity and an expression of the passionate desire to help others. The process of sanctifying work in this fashion may also have a number of benefits for both mental health providers and those they serve. Several studies speak to this point. In a survey of employees of a university health service and small liberal arts college, Wrzesniewski, McCauley, Rozi, and Schwartz (1997) found that those who described their job as a calling reported higher levels of satisfaction with their job and with life in general than those who described their work as a job or career. Walker, Jones, Wuensch, Shahnaz, and Cope (2008) surveyed a range of employees and reported that those who viewed their work as sacred indicated greater job satisfaction, commitment to the job, and less intention to leave. Carroll (2008) reported similar results in a national study of employees at Roman Catholic secondary and middle schools; higher levels of sanctification of work were associated with greater job satisfaction, job commitment, and lower turnover intent, even after controlling for personality traits. In a more recent study of university employees, those who viewed their job as a calling indicated greater commitment to their jobs. The researchers concluded: experiencing a calling to a particular career is likely to lead one to become committed to a line of work, find a specific job that allows one to fulfill that commitment, and in turn be happier with, and committed, to a specific job. (Duffy, Dik, & Steger, 2011, p. 216)
In an investigation of mothers working in higher education, Oates (2008) found that individuals who saw their jobs as more of a calling experienced fewer conflicts in their roles as workers and
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mothers. Oates suggests that the stronger sense of purpose among those who see work as a calling helps them deal more effectively with interrole tensions and achieve greater wholeness and integration. These findings need to be extended to people who work in the mental health field. There is, however, a potential downside that accompanies the attachment of deeper, sacred meaning to work. When work is perceived as sacred, the everyday tensions and conflicts that are part and parcel of mental health practice can become especially painful, even intolerable; after all, these conflicts represent a threat to what is held precious. Without effective ways of dealing with these issues, perhaps most importantly without an on-going sense of hope, health care providers run the risk of losing touch with the sacred motivation that drew them to their careers, becoming disenchanted, cynical, and burnout as a result. In an effort to help health caregivers “reclaim their work as a sacred vocation,” Rabbi Samuel Karff, Dr. Benjamin Amick, and Dr. Thomas Cole from the McGovern Center for Humanities and Ethics at The University of Texas Medical School in Houston developed a Sacred Vocation Program (SVP) for medical residents (Karff, 2012, p. 20). The first phase of the program which I will focus on here involves five group sessions that address: (l) the notion of medicine as a vocation and a sharing of stories of what led the residents into medicine; (2) a discussion of what it means to be healer of body, mind, and spirit and a sharing of stories of the experience of being a healer; (3) frank dialogue about those times when residents may have done harm to others; (4) discussion about those barriers that interfere with being able to live out medicine as a sacred vocation, and ways to cope with these challenges; and (5) articulation of the principles of medicine as a sacred vocation and the chance to renew one’s commitment to healing in this fashion. Preliminary analyses of the effectiveness of this brief program have shown promising results; the residents report increases in their sense of empathy with patients, decreases in their levels of stress and frustration with others, and increases in their sense of the sacredness of their work. When I was applying to graduate schools in clinical psychology, I was warned not to come across as a do-gooder. Graduate programs, I was told, are looking for students who are committed Vol. 77, No. 4 (Fall 2013)
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to hard-core science and systematic approaches to change. The growing literature on the sanctification of work suggests that this was poor advice. People who are able to see a deeper meaning and purpose to their work may be better able to withstand the challenges of mental health work and sustain themselves over the course of their careers. We should do all we can to recruit to the field people who are passionately committed to the science and practice of mental health care, and we need to do all we can to foster this sacred vision in training and beyond. Attending to the sacred dimension of clients’ lives
Spirituality is many things, but it is never boring. As noted above, spiritual experience is tied to powerful energy and emotion. Spirituality then can serve as an important clinical resource, especially for people stuck in depression where de-activation, apathy, disconnection, and hopelessness are the norm. Attending to the sacred dimension in the lives of our clients may help activate them by mobilizing hope in themselves and their lives. But let me take it one step further and suggest here that by attending to a client’s spirituality, therapists may also find themselves more empowered in their work. Consider the story of Mary. Mary is a 55-year-old former physician who, perhaps not unintentionally, had specialized in pain management. She came to see me following a suicide attempt. As a child, Mary had experienced the extremes of both parental abuse and neglect. Bereft of the benefit of family support or guidance, she grew up without a clue of who she was or how she was supposed to live her life. Remarkably, Mary was able to make her way through medical school, though she often felt like an imposter who didn’t know what she was really doing. The stress and strain took their toll on Mary. She began to drink heavily at a young age and was unable to gain her license to practice medicine. All of this left Mary deeply depressed. Her suicide attempt was triggered by feelings of abandonment and ingratitude by her adult children who she loved deeply, but now had little to do with her. Work with Mary was challenging. On the positive side, she began to attend 12-step program meetings regularly and enjoyed
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connecting with other people. She was also invested in her psychotherapy. But in our first year of work together, Mary relapsed several times. On one occasion, she drove while drunk, had a car accident, yet somehow managed to avoid injuring herself, someone else, or police involvement. Mary spent much of her time in therapy talking about the pain and mistreatment she had suffered at the hands of her parents and children. Ill-equipped to deal with her wounds, alcohol seemed to be the only way she could find any relief. Mary voiced a great deal of despair. And I have to admit that, try as I might to keep my feet on secure ground for Mary, there were moments when I felt my own hopelessness for her. Given her deep history of trauma, her profound sense of worthlessness, her long-rooted addiction to alcohol, and her track record of failure what hope did this woman really have? One day, Mary came to a session and talked about the death of her good friend, an elderly woman who had been more of a mother to her than her own mother had been. Mary had stayed with her friend throughout the course of a long illness and was at her bedside when she died. In tears, Mary spoke about how she had witnessed her friend’s transition to the other side. When she died, Mary had felt her friend’s spirit, an aura of light and lightness in the room; it seemed that her friends’ spirit was passing through Mary’s own body. I asked Mary what meaning she took from this experience. She said that she came away from it with a sense of the preciousness and wonder of life. She paused and then said with unusual conviction: “And I realize I’m not ready to cross-over yet.” Why not, I asked? Mary said she felt like she had unfinished business. “There’s more for me do in this life,” she said. What might that be, I asked? Mary said, “My purpose is to care for people—my AA friends, people who don’t have a whole heckuva lot in the world, people who will let me care about them.” She went on, “I’m tired of focusing on all of the past hurt and injuries. I’m tired of trying to love people who won’t love me back. I’m moving on.” I noted that she was talking about a major transformation in her life. Mary simply nodded and said, “This is what I want to
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do.” And this is what Mary has done. She remains involved in AA and psychotherapy, has maintained her sobriety, and now serves as an informal medical advocate for older patients, many of them her friends—taking them to medical appointments, helping them with their questions about their conditions and treatment, and guiding them through the complexities of the medical system. Therapists may be reluctant to talk about spiritual matters with their clients. This is unfortunate for a spiritual conversation can help clients access deeply felt emotions and discover a new sense of meaning and hope that can have profound implications for health and well-being. How does this work? I don’t think we have a clear answer or a clear set of answers yet. Let me offer one simple thought here. Spirituality fosters the sense that things aren’t necessarily what they seem. There is a deeper stream that runs beneath our everyday experience. If we look beneath the surface then, we can find new and surprising possibilities. Problems that seem to be intractable are not necessarily so; as trapped as we may feel, there is a way out. Mary’s spiritual experience at the bedside of her dying friend triggered a life-transforming realization, a newfound belief that her life may in fact still have purpose and a hope that she might be able to realize this purpose. In my work with Mary, I was trying, in the cogent words of Jon Allen (2013a), to lend her some hope. But in my work with Mary, I received a repayment of the loan, and I might say with interest. Mary’s spiritual experience and transformation was inspirational and touched my own life, professionally and personally, with the reminder of the human capacity for change and growth in the midst of even the most seemingly hopeless situations. As our clients oscillate between despair and hope (cf., Allen, 2013b), our jobs are to keep our feet on the firm ground of hopeful realism. But we too are only human and, as caring providers, we would be less than empathic and perhaps less than helpful if we did not experience some of the client’s ups and downs ourselves, including periods of despair. However, attending to the spiritual dimension of our client’s lives can help us keep our feet on the firmer ground of hopeful realism. Just as providers can be vicariously traumatized by listening to client’s reports of horrific events, providers can be vicariously uplifted and re-energized by
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spiritual conversations with clients. We are lenders of hope, but in facilitating a spiritual conversation we are occasionally lifted up in turn by the hope experienced by our clients. An interesting hypothesis to test then would be whether spiritually integrated care yields value-added benefits, not only for clients, but providers as well. Attending to sacred moments in the healing relationship
Even though a great deal of time, effort, and financial resources have gone into studies which compare the effectiveness of different modes of psychotherapy, the findings have not been particularly revealing. In fact, with a few exceptions, differences between types of treatment account for only about 1% of the variance in treatment outcomes (Wampold, 2001). This leaves unanswered the critical question: What accounts for treatment effects? Empirical studies suggest that as much as 50% of the variance in treatment outcomes may be attributable to the therapist-patient alliance (Horvath, Del Re, Flückiger, & Symonds, 2001). A potentially key, but often overlooked element of an effective therapeutic alliance may have to do with the depth or spiritual character of the relationship between provider and patient. Several theorists and practitioners have articulated various elements that contribute to a spiritually profound helping relationship. These include: the therapist’s capacity to be relationally attuned to or mindful of the patient (Bruce, Manber, Shapiro, & Constantino, 2010), experiences of therapeutic inspiration in treatment (O’Grady & Richards, 2010), the therapist’s ability to relate to the patient as a full human being (i.e., I-Thou) rather than as an object (i.e., I-It; Buber, 1970; Scott, Scott, Miller, Stange, & Crabtree, 2009), and sensitivity to present moments in treatment that represent important opportunities for change (Stern, 2004). Sacred moments may be another potentially key marker of an effective therapeutic-patient alliance. What do I mean by sacred moments? Let me start my answer with an example. Several years ago, I worked with a woman, I’ll call her Angela, who had been infected with HIV/AIDS from her partner. Angela’s partner had abandoned her, and her friends had distanced
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themselves from her as well once they learned of her illness. One day, Angela came in distraught—her good friend and the mother of Angela’s much loved goddaughter had told Angela that she thought it best for her not to see her goddaughter anymore. She feared Angela would infect her daughter with AIDS. Angela sat in my office immobilized with pain. She spoke of how contaminated she felt, she spoke of how cut off she felt from other people, she talked about how no one had touched her even to give her a pat on the back for two years. She was, she felt, no longer a part of humanity. Now, I’m not a big fan of physical touch between clients and therapists—there is just too much room for misinterpretation. But in this case, I ignored the rule. “Angela,” I asked, “would you let me hold your hand.” She just nodded her head, so I reached out and held her hand as she cried. And that’s how we spent the rest of the session. She speaking of her profound isolation while I held her hand. I touched Angela and she touched me in a deeply spiritual way. This was a turning point in our relationship. It was a sacred moment. Sacred moments are extraordinary; they are set apart from our usual experience. These are the moments when we can see into who our clients are and they see into who we are. In sacred moments, we touch and are touched by each other. These are moments of profound interconnectedness. Sacred moments also reveal something that’s ultimately true; they go beneath the surface and beyond what’s artificial to what is really real. Sacred moments are timeless—they stay with us throughout our lives. Think of them as the Un-PTSD moments. These are the powerful, uplifting, inspiring, life changing experiences that make our work and our lives worthwhile. To put it more formally, sacred moments refer to brief periods of time in which people experience qualities of transcendence, ultimacy, boundlessness, interconnectedness, and spiritual emotions (Lomax, Kripal, & Pargament, 2011; Pargament & Mahoney, 2005). It is important to note that I am using the term “sacred” here in a psychological rather than theological sense. Sacred refers to human perceptions of qualities often associated with the divine or higher powers. These perceptions do not speak one way or the
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other to the ontological reality of the sacred, higher powers, or God. They do, however, reflect on human character and human relationships. Thus, nontheists as well as theists may experience sacred moments in their work. Sacred moments may not be altogether unusual. James Lomax has presented some remarkable examples of sacred moments drawn from his own psychiatric practice (Lomax & Pargament, 2011; Lomax et al., 2011). Sacred moments may be one of the critical ingredients of a healing relationship; they may a big part of what draws many mental health professionals to the field, what we remember about our work, what we take pride in, and what sustains us throughout our careers. We have done some research to test these notions. In one study, we examined 58 mental health providers, most of whom were psychiatrists. We asked the providers to describe an important moment they had experienced in treatment with a client in the past year. They then completed a number of questions about that important moment, and a series of other questions about the impact of this experience on their client, themselves, and the therapeutic alliance. Finally, the providers responded to a set of questions about their sense of meaning in work, their spiritual well-being, and burnout. We found that sacred moments were commonplace; 55.5% of the providers described their important moment as sacred. This was particularly striking since many of the providers were secular; this underscores the point that sacred moments are not limited to theists. We also found that providers who experienced a sacred moment (as opposed to an important but not sacred moment) reported that their clients gained more in treatment, that their therapeutic alliance was stronger, and that the moment was a source of motivation, satisfaction, and growth in their own lives. Moreover, providers who experienced a sacred moment reported greater meaning in their work and a greater sense of spiritual well-being. Interestingly, sacred moments were not tied to lower levels of burnout. We have recently replicated this study in a national sample of adults who have been in mental health treatment, and the findings have been quite similar.
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Conclusions
In this paper, I have offered the admittedly provocative thesis that spirituality may be a resource for hope and healing of not only clients but providers as well. In support of this point, I have suggested three ways practitioners might access spiritual resources to facilitate hope in their work: (l) by illuminating the sacred character of mental health work; (2) by attending to the sacred dimension of clients’ lives; and (3) by attending to the experience of sacred moments in the healing relationship. It is important to stress that none of these examples necessarily involves a fundamental shift in the practitioners’ own personal spiritual or religious orientation. Rather each involves a potential shift in the way mental health providers see clients, work, and healing relationships. And this shift toward a deeper way of seeing is open and available to nontheists and theists alike. Post (2013) illustrates this transformation of vision in the moving conclusion to his paper on caring for the deeply forgetful. He suggests, “Maybe that deeply forgetful person very near the end has already hopped on that last train for glory, but it just hasn’t quite left the station yet” (p. 24). This is a powerful form of spiritual visioning of the patient that may help sustain the patient, the family of the patient, and the provider. Of course, providers might also gain by accessing spiritual resources more fully in their own personal lives. A few studies have shown that providers benefit from spiritual practices. For example, Oman, Hedberg, and Thoresen (2006) conducted a randomized, clinical evaluation of an 8-week training program for health care providers who were taught to make use of nonsectarian, spiritual self-management tools, such as passage meditation, inspirational reading, and mantram meditation. The program produced significant reductions in levels of stress and improvements in levels of mental health, and these effects persisted 19 weeks after treatment. Similarly, Wasner, Longaker, Fegg, Johannes, and Gian (2005) offered a stress management class to palliative care nurses that included spiritual practices, such as controlled breathing, meditation, and journaling. The nurses reported significant
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increases in job satisfaction and reductions in work-related stress over the course of the program. As interesting as these findings are, questions remain whether they would apply to a wide range of providers, including those who may find personal spiritual practices objectionable. Spiritual beliefs and practices are more than tools that can be applied effectively in purely utilitarian fashion; they are sacred, tied to a deeper philosophy of life that must be ego-syntonic with the world view of providers. Thus, I am not recommending that we train all providers to become more personally religious or spiritual or that we use spirituality as a criterion for admissions to graduate school. I would suggest though that regardless of the providers’ own personal spiritual and religious orientation, greater sensitivity to the spiritual dimension of clients, therapists, and relationships may offer a critical source of hope and healing for both therapists and clients. Movement toward this kind of sensitivity may be challenging; we are after all a pretty secular bunch for the most part, and as Jon Allen (2013b) has noted, we may need crowbars to pry and keep our minds open enough to explore the spiritual domain. But if a crowbar is what we need, so be it, for the capacity to see and connect to people in this deep fashion may very well be a core competency for effective mental health care and a key to a satisfying long-term career in the field (Vieten et al., 2013). In our work, we can often detect the voice of Eeyore—the voice of gloom, defeatism, despair, and hopelessness. The voice of Eeyore can be heard not only from our clients but also from within ourselves, call it our inner Eeyore. We need to be attuned to that voice wherever it comes from. As we engage in our healing conversations with Eeyore, spirituality offers a potentially crucial resource to us, an anchor that can keep our own feet rooted on solid hopeful ground. Our conversations with Eeyore can be terribly trying and depleting, but we have to persist for there is one thing we can never allow. We can never let Eeyore have the last word.
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References Allen, J. G. (2013a). Hope in human attachment and spiritual connection. Bulletin of the Menninger Clinic, 77, 302–331. Allen, J. G. (2013b). Restoring mentalizing in attachment relationships: Treating trauma with plain old therapy. Arlington, VA: American Psychiatric Publishing. Allport, G. W. (1937). The functional autonomy of motives. American Journal of Psychology, 50, 141–156. Barrett, J., & Zahl, B. P. (2013). Cognition, evolution, and religion. In K. I. Pargament (Ed.-in-Chief), J. J. Exline & J. Jones (Assoc. Eds.), APA handbook of psychology, religion, and spirituality: Vol 1. Context, theory, and research (pp. 221–237). Washington, DC: American Psychological Association. Bruce, N. G., Manber, R., Shapiro, S. L., & Constantino, M. J. (2010). Psychotherapist mindfulness and the psychotherapy process. Psychotherapy Research: Theory, Research, Practice, Training, 47, 83–97. Buber, M. (1970). I and Thou. New York: Charles Scribner’s Sons. Carroll, S. T. (2008). The role of the sanctification of work, religion, and spirituality as predictors of work-related outcomes for individuals working at religiously affiliated institutions. Dissertation Abstract International: Section B. Sciences and Engineering, 69, 3887. Carroll, S. T. (2013). Addressing religion and spirituality in the workplace. In K. I. Pargament (Ed.-in-Chief), A. Mahoney, & E. Shafranske (Assoc. Eds.), APA handbook of psychology, religion, and spirituality: Vol. 2. An applied psychology of religion and spirituality (pp. 595–612). Washington, DC: American Psychological Association. Duffy, R. D., Dik, B. J., & Steger, M. F. (2011). Calling and work-related outcomes: Career commitment as a mediator. Journal of Vocational Behavior, 78, 210–218. Gabbard, G. O. (1994). Psychotherapists who transgress sexual boundaries with patients. Bulletin of the Menninger Clinic, 58, 124–135. Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16. Johnson, P. E. (1959). Psychology of religion. Nashville, TN: Abingdon Press. Karff, S. E. (2012). Spirituality and religion in health care: A rabbi’s personal journal. CCAR Journal: The Reform Jewish Quarterly, Summer, 8–24. Koenig, H. G., King, D., & Carson, V. B. (2012). Handbook of religion and health (2nd ed.). New York: Oxford Press. Kottler, J. A. (2012). The therapist’s workbook: Self-assessment, self-care, and self-improvement exercises for mental health professionals. Hoboken, NJ: John Wiley. Loewald, H. (1978). Psychoanalysis and the history of the individual. New Haven, CT: Yale University Press.
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Conversations with Eeyore Lomax, J. W., Kripal, J. J., & Pargament, K. I. (2011). Perspectives on “sacred moments” in psychotherapy. American Journal of Psychiatry, 168, 1–8. Lomax, J. W., & Pargament, K. I. (2011). Seeking ‘sacred moments’ in psychotherapy and in life. Psyche & Geloof, 11, 79–90. Miller, M. N., & McGowan, K. R. (2000). The painful truth: Physicians are not invincible. Southern Medical Journal, 93, 966–973. Newberg, A., & Waldman, M. R. (2006). Born to believe: God, science, and the origin of ordinary and extraordinary beliefs. New York: Free Press. Norcross, J. (2000). Psychotherapist self-care: Practitioner-tested, researchinformed strategies. Professional Psychology: Research and Practice, 31, 710–713. Oates, K. (2008). Calling and conflict: A quantitative study of interrole conflict and the sanctification of work and mothering. Dissertation Abstracts International: Section B. Sciences and Engineering, 68, 6326. O’Grady, K. A., & Richards, P. S. (2010). The role of inspiration in the helping professionals. Psychology of Religion and Spirituality, 2, 57–66. Oman, D., Hedberg, J., & Thoresen, C. E. (2006). Passage meditation reduces perceived stress in health professionals: A randomized, clinical trial. Journal of Consulting and Clinical Psychology, 74, 714–719. Panksepp, J. (1998). Affective science: The foundations of human and animal emotions. Oxford: Oxford University Press. Pargament, K. I. (2013). Searching for the sacred: Toward a non-reductionistic theory of spirituality. In K. I. Pargament (Ed.-in-Chief), J. J. Exline & J. Jones (Assoc. Eds.), APA handbook of psychology, religion, and spirituality: Vol 1. Context, theory, and research (pp. 257–274). Washington, DC: American Psychological Association. Pargament, K. I. (Editor-in-Chief), Exline, J. J., Jones, J., Mahoney, A., & Shafranske, E. (Assoc. Eds.). (2013). APA handbook of psychology, religion, and spirituality (Volumes 1 and 2). Washington DC: American Psychiatric Association Press. Pargament, K. I., & Mahoney, A. (2005). Sacred matters: Sanctification as a vital topic for the psychology of religion. International Journal for the Psychology of Religion, 15, 179–198. Post, S. G. (2007, Ed.). Altruism and health: Perspectives from empirical research. Oxford: Oxford University Press. Post, S. G. (2013). Hope in caring for the deeply forgetful: Enduring selfhood and being open to surprises. Bulletin of the Menninger Clinic, 77, 349–368. Reissman, F. (1965). The helper therapy principle. Social Work, 10, 27–32. Roberts, L., Salem, D., Rappaport, J., Toro, P. A., Luke, D. A., & Seidman, E. (1999). Giving and receiving help: Interpersonal transactions in mutual-help meetings and psychosocial adjustment of members. American Journal of Community Psychology, 27, 841–868. Scott, J. G., Scott, R. G., Miller, W. I., Stange, K. C., & Crabtree, B. F. (2009). Healing relationships and the existential philosophy of Martin Buber. Philosophy, Ethics, and Humanities in Medicine, 4, 1–9.
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Pargament Shafranske, E. S., & Cummings, J. P. (2013). Religious and spiritual beliefs, affiliations, and practices of psychologists. In K. I. Pargament (Ed.-inChief), A. Mahoney, & E. P. Shafranske (Assoc. Eds.), APA handbook of psychology, religion, and spirituality: Vol 2. An applied psychology of religion and spirituality (pp. 23–42). Washington, DC: American Psychological Association. Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., et al. (2012). Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population. Archives of Internal Medicine, 172, 1377–1385. Stern, D. N. (2004). The present moment in psychotherapy and everyday life. New York: W. W. Norton. Vieten, C., Scammell, S., Pilato, R., Ammondson, I., Pargament, K. I., & Lukoff, D. (2013). Spiritual and religious competencies for psychologists. Psychology of Religion and Spirituality, 5, 129–144. Walker, A., Jones, M., Wuensch, K., Shahnaz, A., & Cope, J. (2008). Sanctifying work: Effects on satisfaction, commitment, and intent to leave. International Journal for the Psychology of Religion, 18, 132–145. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahway, NJ: Erlbaum. Wasner, M., Longaker, C., Fegg, M., Johannes, B., & Gian, D. (2005). Effects of spiritual care training for palliative care professionals. Palliative Medicine, 19, 99–104. White, R. B. (1963). Ego and reality in psychoanalytic theory. Psychological Issues, 3, 1–120. Wrzesniewski, A., McCauley, C. R., Rozi, P., & Schwartz, B. (1997). Jobs, careers, and callings: People’s relations to their work. Journal of Research in Personality, 31, 21–33.
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