I have been practicing psychodynamic psychotherapy for more than 30 years. During this time, there has been an accepted taboo against coupling psychotherapy with spirituality—despite a number of articles that have been written on this subject.1-5
As the years passed, I realized that maintaining this separation was a mistake. I concluded that by failing to discuss these interrelated issues, I was missing much of what my patients were thinking and feeling—but seldom discussing. To remedy this “disconnect,” I studied the concept of spirituality, aware that I would encounter patients who were and who were not religious. After exploring different disciplines, I learned that “spirituality” did not automatically equate with being religious. I concluded that spiritual people are those who exercise their innate ability to experience “awe” and “wonder.”
In my view, the ability to experience awe and wonder is universal. Certainly, many feel people feel these emotions through a connection to their religion. Others experience these same emotions when they see, for example, a spectacular sunset or a rainbow, or walk through a redwood forest, or experience the birth of their child.
Yet not everyone is aware of, or interested in, pursuing or discussing such “spiritual” moments. Because of this potential “blind spot,” I strongly advocate taking a “spiritual history” from all psychotherapy patients.
Taking a spiritual history is very simple. It begins with a single question: “Have you ever felt awe and wonder?”
If the answer is “yes,” then exploration into the cause of these feelings is warranted. If the answer is “no,” then I recommend posing the question again in a different way later in the interview. Ask, for example, “Have you ever been deeply moved in the presence of some natural occurrence or personal experience, such as a sunset or the birth of a child?” If the patient’s answer is still a strong “no,” then the issue should be dropped, but the therapist should file away the information for future discussions. I suggest this because I have encountered patients who are actually very spiritual but who initially have little or no conscious awareness of this side of their personality. And yet, as therapy continues, their awareness changes.
To illustrate these ideas, I will present 2 brief clinical examples.
Mr A is a middle-aged Christian minister who found himself in serious trouble after admitting that he had had a sexual relationship with an adult congregant. Before seeing me, he had been in psychotherapy for 17 years. During that long period, not one of Mr A’s therapists had dealt with his spirituality. Mr A’s spiritual nature was totally ignored because his therapists were either unfamiliar and/or uncomfortable with religious issues. In my view, this lapse contributed to his worsening psychiatric illness.
When our work started, Mr A was plagued by a sense of guilt, sinfulness, and remorse. His church had branded him as an incorrigible sex offender with a personality disorder—neither of which was true.
When he was growing up, Mr A experienced sexual, physical, and verbal abuse. Like most abused people, he did not interpret his past as being abusive; instead he believed that he deserved all that he had received. By approaching this view through the exploration of his spirituality, it did not take long to see that his real diagnoses were major depression and a generalized anxiety disorder.
When I asked him about the roots of his spirituality, he reported that his feelings of awe and wonder started at age 13. He attributed these feelings to being called to serve God. With further spiritual exploration, he came to understand his abusive past in a way that was not previously apparent to him.
By coming to terms with the abuse and its psychological consequences (depression and anxiety), Mr A began to see that the Church was wrong in its “diagnosis” of him. His distress about his relationship with God subsequently diminished. He still understood that during his sexual relationship with a congregant, he had deliberately and willfully violated both the religious principles of his church as well as his own moral principles. But instead of seeing his behavior as a sign of an immoral nature, he began to better understand it in the context of both his experience of severe abuse and as his response to this abuse.
I prescribed a regimen of antidepressants, anti-anxiety agents, and fairly intensive psychodynamic therapy. As the treatment progressed, Mr A’s self-esteem improved greatly and his guilt subsided considerably. He began to understand how the abuse he was subjected to as a child had played a significant role in his inappropriate religious and sexual behavior.
Certainly, the psychotropic medications helped him feel better. In my opinion, however, Mr A would never have attained full benefit had I not been willing and able to explore with him his religious and spiritual nature.
Mr B is a late-middle-aged professional who had attended a Christian school, but who never really believed what he had been taught about religion. He married at a young age and had 3 children. After each of his children was born, he slowly sank deeper into alcohol addiction. By the time I saw him, he was an alcoholic and was deeply involved in other undesirable behaviors, including pornography addiction and severe social isolation. His marriage suffered greatly.
After several years of therapy, one of Mr B’s children suddenly died . He became increasingly depressed and his addictions worsened.
Our treatment focused first on dealing with his addiction, which he successfully overcame. As we continued therapy, I asked Mr B if he had ever experienced “a sense of awe and wonder.” He indicated that he had never considered this question before, but as he thought about it, he told me that he liked to visit the ocean because it was only there that he felt a sense of inner peace. As our therapy progressed, he realized that he craved this sense of peace but did not know how to find and maintain it. When I asked whether religion might help him find peace, he strongly rejected this notion. He responded that although God may have created the world, He had nothing to do with determining the way it was running. Only proximity to the ocean helped soothe Mr B. But because he did not live near an ocean, his longings could only be satisfied temporarily.
Mr B is still in psychodynamic therapy, and he is still taking psychotropic drugs. His depression has diminished to a great extent, his marriage has improved significantly, and it has been years since he was chemically dependent. Nevertheless, he still has not been able to find what he desperately seeks—a sense of calmness that is present only when he visits the ocean.
It became evident during our years of therapy that Mr B is a very spiritual man and that he easily feels a sense of awe and wonder. However, he has not yet been able to find a path to satisfy his longings; our therapy is now focused on achieving this goal.
Had I not asked Mr B about his spirituality, he never would have brought it up. In my view, our therapy would never have been successful because Mr B would have been left feeling persistently sad and unfulfilled.
I have presented the cases of 2 of my patients—one religious and one not. Neither would have attained emotional health had we not explored their spiritual worlds. Such exploration begins in the history phase of treatment by simply asking the patient if he or she has ever experienced feelings of awe and wonder—a question that I believe should be a mandatory part of every mental status examination.
1. Einstein A. Response to atheist, Alfred Kerr (1927). Cited by Kessler HG. Tagebücher 1918-1937. Frankfurt, Germany: Insel Verlag; 1961; The Diary of a Cosmopolitan. London: Weidenfeld and Nicolson; 1971.
2. Rao MS. Spirituality in psychiatry? http://psychiatrymmc.com/displayArticle.cfm?articleID=article44. Accessed May 4, 2009.
3. Galanter M. The concept of spirituality in relation to addiction recovery and general psychiatry. Recent Dev Alcohol. 2008;18:125-140.
4. Lawrence RM, Head J, Christodoulou G, et al. Clinicians’ attitudes to spirituality in old age psychiatry. Int Psychogeriatr. 2007;19:962-973.
5. Pies R. The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective. Philos Ethics Humanit Med. 2008;3:17. http://www.peh-med.com/content/3/1/17. Accessed May 6, 2009.