Unit 2 FD

McGoldrick, M., Preto, N. A. G., & Carter, B. A. (2015). The expanding family life cycle: Individual, family, and social perspectives (5th ed.). Pearson. https://bookshelf.vitalsource.com/books/9780134001180 Chapter 8 Spirituality and the Family Life Cycle Sueli Petry Learning Objectives Describe ways that spirituality may be used in therapy as a resource throughout the family life cycle.

 Examine spirituality’s significance when facing times of stress.

 Discuss the implications of using spirituality for treatment.

 List and describe tools clinicians can use to track the ways in which spiritual beliefs may change over time and as families encounter different experiences.

 Explain how to do a systemic assessment that takes into account spiritual resources and

family strengths across the life cycle.

 Discuss the benefits and challenges of spirituality for children.

 Explain the role spirituality can play in identity development during adolescence.

 Describe the impact of spirituality on the lives of young adults.

 Express the importance of spirituality during midlife.

 Discuss the relationship between spirituality and the developmental tasks of late life.

Introduction Our spirituality as human beings is a fundamental resource throughout the life cycle. Spirituality has been a healing force through countless generations, embedded in culture and religious traditions. Spiritual beliefs can be a powerful resource for people who have lost their way, are feeling despair, or are suffering from oppression, racism, poverty, and trauma (Aponte, 1994, 2009; Barrett, 2009; Boyd-Franklin, 2003a; Cruz, 2013; Hines, 2008; Kamya, 2005, 2009; Walsh, 2008, 2009). It can be a resource in all phases of the life cycle and may become even more important in later age as a means of reviewing one’s accomplishments, life’s meaning, and coming to terms with the end of life. Yet, very few mental health professionals explore spirituality as a source of strength, although there have been attempts to remedy this situation. The Joint Commission on the Accreditation of Healthcare Organizations requires that a spiritual assessment be conducted with mental health

and substance abuse patients (JCAHO, 2008), and the Professional Codes of Ethics for social workers and psychologists direct professionals to respect religious diversity (NASW, 2008; APA, 2010). Fortunately, psychiatry expanded the category of “religious or spiritual problem” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2013) informed by research on the spiritual and religious aspects of the major diagnostic categories (Peteet, Lu, & Narrow, 2011), and recommends that religion and spirituality be considered as a matter of course within a cultural formulation. In this chapter, we address spirituality in clinical work, within the religious diversity present in the United States, exploring the ways spirituality may be used in therapy as a resource throughout the family life cycle. We offer guidelines for including spirituality in any clinical assessment and discuss implications for treatment. Various models have been proposed for assessing spirituality (Birkenmaier, Behrman, & Berg-Weger, 2005; Hodge, 2004; McGoldrick, Gerson, & Petry, 2008), exploring spirituality over the life cycle (Kelcourse, 2004), and exploring the influence of cultural experiences on spirituality using a genogram or ecomap (Hodge, 2004). Here, we provide a framework for a systemic assessment, which places the presenting problem in the context of spiritual development, culture, and life cycle stage, using genograms and family chronologies. Understanding context provides alternative views of why a problem exists and helps clinicians and clients see opportunities for new ways of being and relating. Genograms help the clinician and the client to consider family members’ spiritual beliefs, how the family has survived and dealt with problems in the past, and to identify people in the family network who might be available as resources for spiritual and emotional support. Family chronologies used in conjunction with genograms facilitate tracking family patterns through time and space (McGoldrick, Gerson, & Petry, 2008). Together, these tools help clinicians track the ways in which spiritual beliefs may change over time and as families encounter different experiences. The emphasis on fluidity and change over time and space creates a sense of hope and helps people to see the various ways their families have transformed suffering and adapted to difficult circumstances, through understanding, forgiveness, and growth. Spirituality and Religion in America Although accurate statistics on spiritual and religious practices are difficult to confirm, recent polls suggest that 60 percent of Americans describe themselves as “very” or “moderately” religious, while only 16 percent endorse “no religious preference” (Gallup, 2012). In recent years, the Internet has created opportunities for “virtual faith communities,” where people may communicate with each other and find inspiration. A Google© search of the word “spirituality” resulted in dozens of spiritual Web sites, one of the largest, “Beliefnet” (www .beliefnet.org), offers a variety of spiritual resources including message boards and prayer circles for multiple faiths. The religions represented in the United States have changed significantly in the last three decades. Although Christianity has remained dominant, the non-Christian population has been increasing steadily. Islamic centers or mosques, and Hindu and Buddhist centers, can be found in nearly every major city in the United States. Americans identify as Jewish, Muslim, Hindu, Buddhist, Baha’i, Jain, Pagan, Zoroastrianist, and more (Pew Forum on Religion and Public Life, 2008). This suggests that therapist and client may have differing views or experiences regarding spirituality, which can affect the way they relate to each other. Understanding how to proceed with a spiritual assessment and how to integrate it into treatment will help therapists raise the topic confidently.

The Family Life Cycle and Spirituality Children and spirituality In the first stages of life, until adolescence (infancy, early childhood, middle childhood, and pubescence), children are dependent on their parents and are the beneficiaries of their parents’ spiritual beliefs. They learn values and social behavior and conform to expectations guided by the family’s spiritual or religious practices. Often, they derive comfort from religious rituals and beliefs. For instance, a prayer before bedtime can allay a child’s anxiety about the darkness or sleeping alone and can help the child feel safe when he or she believes that God, Spirit, or some higher power loves and cares for him or her. Moreover, children develop and grow spiritually just as they do physically and emotionally (Roehlkepartain, King, Wagener, & Benson, 2006). They develop increasing spiritual capacities and experiences as they mature, and their innate sense of wonder leads to exploration and speculation about spirituality (Hart, 2006). When working with traumatized children of varying cultures and religions, asking about spiritual beliefs will likely open up avenues to help them to transform pain and to heal (Kamya, 2009). For those who have lost a parent or sibling, spiritual beliefs can help them to grieve, as all religions have rituals or beliefs for dealing with death and bereavement. Spirituality can be a tremendous resource in working with children, just as it is in later stages of the life cycle. Yet, spiritual beliefs may cause children discomfort when they believe they have not lived up to what is expected of them. Parents may not be aware that their children are agonizing over some small infraction that is inflated in their minds. Children may worry about what will happen to a family member, friend, or others who do not conform to the spiritual practices they have been taught or who do not follow a prescribed code of behavior. In clinical work with children, assessing a child’s spiritual beliefs in the context of their family’s beliefs may uncover areas of concern for the child. Exploring children’s spiritual beliefs is relevant also in working with children in foster care, families struggling with substance abuse, children who have been sexually abused, and even children with less severe problems such as impulsivity and behavioral difficulties. Some children believe God is watching them and will punish them for their bad behavior. Understanding the child’s beliefs, as well as the family and cultural beliefs, will allow the clinician to address areas of concern for the child and parent and will provide a means to draw on those beliefs to foster healing. Case Illustration Anthony and Angelina—Children’s Spiritual Beliefs May Comfort or Cause Anxiety This case illustrates how a spiritual assessment helped the parents in this Brazilian American evangelical family to comfort and support their children, and fostered the family’s healing. At this stage of families with young children, Anthony (10 years old) and Angelina (8 years old) were the recipients of their parents’ beliefs. The children feared that God would punish their mother when she relapsed in substance abuse, but with clinical intervention the parents had the power to allay the children’s fears. Anthony and Angelina were living with their father (Hugo) after their parents separated and at the time of separation, their mother (Mariza) was abusing drugs. When they started therapy, Mariza was in treatment for substance abuse and had weekly supervised visits with the children. To assess this family, it was important to meet each parent separately and the children alone to allow everyone to speak frankly, and to limit the children’s exposure to any of the parents’

negative reports about the other. Although children are often exposed to parents’ arguments at home, it is best to protect children from such scenes in the therapeutic setting. In the parent sessions, both Hugo and Mariza said they had drifted away from their religious beliefs and experimented with drugs before getting married. Later they stopped using drugs and returned to their religious practice in the evangelical Church. The couple remained active in the Church until their separation; Hugo and the children continued their religious practices, but Mariza stopped attending services. The reason for the parents’ separation seemed to be related to Mariza’s substance abuse, but would need further exploration. When I met Anthony, alone, I asked him about his spiritual beliefs, and he hesitantly said that using drugs was a sin and he worried that God would punish his mother because she had used drugs. His loyalty to his mother prevented him from discussing this with his father or anyone else. In a later session with both children, I asked if they had any fears about God and learned they were afraid that God would punish them because they were sometimes angry with their mother. The children’s spiritual beliefs caused them feelings of anxiety and guilt. However, as I continued with the spiritual assessment, I discovered that their spirituality gave this family something to believe in that was larger than themselves, a belief that could be drawn on to comfort the children and help them to heal. In separate sessions with each parent, Hugo said he believed in the guidelines of his religion, but having lived through many experiences including abusing drugs himself, he concluded that God was forgiving and provided guidance rather than punishment. Mariza was ambivalent about her beliefs. She believed God would help her find the strength to overcome her addiction and be reunited with her children, but she was struggling with feelings of anxiety and guilt over her behavior, and anger because she felt judged by some members of her congregation. It was clear that Mariza could not be helpful in allaying the children’s fears until she resolved her own mixed emotions. Hugo, on the other hand, was in a better position to do so. After coaching him on how to encourage his children to share their feelings and fears, he comforted them and told them that God loved them and their mother. He told his children that God would look after their family and would help them to get through their troubles. Hugo’s spiritual belief gave the children hope. If he had taken a different position, it would have been harder for the children to reconcile their feelings of anxiety. Anthony, because he was older, would be more likely to begin to question his parents’ beliefs at this age and to start to form his own views in order to reconcile his religious beliefs with his love for his mother. However, at this stage of the life cycle, both children would have been vulnerable to increasing feelings of anxiety, had it not been for their father’s reassurance. If Hugo had not been able to reassure his children, I may have sought help from his pastor. When parents have stricter religious views, it may be more difficult for children to reconcile religious beliefs when they or their loved ones do not live up to prescribed codes of behavior or when they encounter people with different beliefs. In that scenario, spirituality and religion can become a source of struggle, rather than strength. At such times, the clinician will need to accept the parents’ beliefs and look to other avenues for intervention.

Often children feel guilty when they misbehave. Once they are aware of the problem, parents can usually figure out a way to help their children reconcile their spiritual beliefs with the realities of the world. Parents want their children to feel safe and loved. We as clinicians can help by respecting the parents’ beliefs and coaching them to talk to their children in a way that invites children to ask questions, rather than to suffer silently. Children in families who practice a religion that is marginalized in our society are vulnerable to teasing and prejudice from other children or even adults. Clinicians can intervene by inquiring about experiences of prejudice and coaching parents so that they can in turn raise the issue with their children. Children feel protected and buffered from the cruelty of the outside world when families provide such a safe haven. When treating children whose parents have left, died, or are otherwise not available, asking about children’s beliefs and enlarging the genogram to include beliefs of family, friends, relatives, teachers, and mentors will help children to draw on spiritual strengths. We should not overlook this resource just because a client is young. Children of all ages have the capacity for spiritual thoughts and beliefs, and very often their spirituality can help them to heal. Adolescence: Identity Development and Spirituality As children enter adolescence, they can be more autonomous, seek out experiences on their own, and challenge the system as they search for meaning and form their own opinions about their family’s spiritual beliefs. This is the stage when young people are searching for an identity and voicing authentic opinions and feelings in the context of societal, parental, and peer pressure to conform to age, gender, and racial stereotypes. Some adolescents will question their families’ spiritual beliefs as they try to develop an independent sense of identity. While others, particularly those in marginalized groups, may embrace their families’ beliefs as they try to affirm their sense of identity within a dominant culture that marginalizes them, such as Muslim teens growing up in a predominantly Christian community (Chaudhury & Miller, 2008). African American adolescents tend to draw on spiritual strengths to foster a positive racial identity and to overcome the insults of living in a racist society (Moore-Thomas & Day-Vines, 2008), and are often better adjusted in communities where spirituality is emphasized because it increases their sense of belonging, pride, and self-worth (Aponte, 1994; Boyd-Franklin, 2003a; Marsiglia, Parsai, Kulis, & Nieri, 2005; Roehlkepartain, King, Wagener, & Benson, 2006). Still some adolescents in nondominant religious groups may rebel against their family’s traditions in order to “fit” with the dominant group. Given all that we know about spirituality as a resource for helping adolescents in therapy, clinicians need to ask questions about adolescents’ beliefs. However, adolescents with a religious affiliation different from the clinician’s, or no religion, may be uncomfortable with this topic. First acknowledging that you have different religious beliefs and then asking an open-ended question such as “Will you tell me about your belief?” is one way to communicate that you are comfortable with your differences and that you honor the adolescents’ beliefs. Case Illustration Joshua—Adolescents Challenge Family Beliefs

The following case illustrates how an adolescent may shake up the family system and challenge adult beliefs, leading adults to reconsider their own views on religion and spirituality. The case evolved over many months and the treatment is reported here in four phases. Joshua (18) and his parents Michael (56) and Marcy (53) sought family therapy when Joshua stopped attending high school in his senior year. The crisis occurred when Joshua told his parents he was gay. Joshua felt accepted in his circle of friends, and he wanted the same acceptance from his family. Michael and Marcy were anguished by their son’s coming out and their religious belief that homosexuality was a sin, as it is considered in nearly all organized religions due to the rigid constructs of sexuality created by patriarchy. Phase 1: The genogram (see Genogram 8.1) set the context for examining the challenges to spiritual beliefs

Genogram 8.1 Joshua’s Genogram In the initial stage of treatment, we explored what Joshua’s coming out meant for the family. I asked the parents to meet alone first to allow them to speak freely without hurting their son. I met Joshua alone once, and later we moved to sessions including all of them, with short meetings with each of them to check on how they were feeling. As shown on the genogram, both Michael

and Marcy came from religious families where homosexuality was not accepted, and both had suffered family losses related to religious beliefs. Phase 2: The chronology (see Figure 8.1) highlighted how earlier generations either turned away from religion or turned toward religion in response to loss, and ultimately transformed the pain of loss and found ways to remain connected through their beliefs I asked about the family’s history of religious beliefs and practices and wrote down the dates of various events they reported. Michael’s uncle Joseph was cut off from his family in 1940 when he married a Christian woman; this was a difficult loss for Michael’s father, David, who had been very close to Joseph. Figure 8.1

The brothers remained connected through corres-pondence. The cutoff lasted 20 years and was repaired when David’s son, Jared, returned to the Jewish religion in his adolescence. As we tracked these dates related to the challenges to the family’s religious beliefs and created a chronology of the family history, a pattern of loss of family, loss of faith, and return to faith emerged. Michael saw that his family had survived challenges of faith and family cutoffs in the past. The family became hopeful that they would survive this new challenge. Marcy’s paternal grandparents, uncles, and aunt were all killed in the Holocaust in 1944, a tragic loss for her father, Irving, who was the sole survivor. In 1945, Irving moved to New York, found a Jewish community where he felt welcomed, and began to heal from the loss of his family. From 1992 through 1999, Marcy’s sister Lauren suffered several miscarriages and was very distraught. Her faith carried her through those difficult years, and when she celebrated the birth of her son, in 1999, the religious ceremony was especially meaningful for the family. Tracking these events and writing them down on the chronology reinforced for Marcy that her family had

already suffered too many losses, and that being Jewish was very important for her. She could neither lose her son nor her religion. Phase 3: Therapy enlarged the context to explore religious beliefs about homosexuality within the societal constructs of patriarchy and oppression We discussed the implications of Joshua’s coming out in light of patriarchy, homophobia, and society’s constructs about love and marriage. Enlarging the context brought to light how rigid constructs of sexuality were created by patriarchy and oppression so that nearly all of the world’s major religions and governments colluded in dictating sexual behavior and marginalizing homosexuality. These conversations helped to alleviate feelings of shame and opened up multiple possibilities for spirituality, religion, and sexuality. As a result, the family moved to a more liberal congregation that allowed gay and lesbian rabbis. Joshua had challenged his parents’ beliefs. Their determination to remain connected to their son made them reconsider their own views on religion and find an alternative they could live with. Phase 4: The genogram identified family members who would be good sources of support for the family in coming out to their extended family and friends Using the genogram, we identified Marcy’s sister and her husband, Lauren and Alan, as “good resources” who would be supportive. They chose to tell them first and then to gradually tell the others. The systemic spiritual assessment enlarged the context and created a space where Joshua felt like a fully accepted member of his nuclear family, which they then extended to their relatives and larger community. This treatment evolved over many months and many families do not have such a successful outcome. However, this family was very committed to each other, as they realized all the more through the exploration of their struggles with religion and spirituality over several generations. Early Adulthood: Time to Explore and Make Choices About Spiritual Beliefs As young adults differentiate from their families of origin, they may move away from their religion, especially as they come in contact with a wider social network in our diverse society and go to college or enter the workforce. They may become less involved in their family’s religious practices and many explore other spiritual paths. Some may wish to distance from practices they felt were oppressive; however, more often this is simply a result of exposure to others’ beliefs intersecting with the developmental task of differentiation. Young adults who grew up with no religion may become more religious or may engage in “shopping” for religion or searching for a community. Young people are more likely to engage in varying religious practices and alternative spiritual beliefs (Pew Forum on Religion and Public Life, 2009). Others may need to let go of religion, and say they do not believe, in order to feel freer. At some point, individuals have to make a choice about where they stand in relation to their family’s beliefs. Often this happens when they move away from home or when they engage in intimate relationships. For many, a crucial time when they need to take a position about their beliefs occurs as they form relationships and make decisions about marriage ceremonies.

Approximately one fourth of American adults who are married or living with a partner are in religiously mixed relationships, and the number would be much higher if families with different Protestant denominations were included (Pew Forum on Religion and Public Life, 2008). Jewish communities in particular are concerned about the high rate of intermarriage, and Jewish families may react with disappointment or disapproval (Walsh, 2009). Historically, many religions prohibited interfaith marriages, but as society has become more open, interfaith marriages have become more prevalent. This is a relevant issue in marriage and family therapy. Spouses with similar beliefs and religious practices report greater personal well-being, more relationship satisfaction, and lower likelihood of divorce (Myers, 2006). Some questions that are helpful in gathering data for the spiritual genogram when working with couples are as follows: What are their spiritual beliefs? What is the history of their family’s religious beliefs and practices, including changes in belief? What has been the impact of intra-family religious differences or those between the family and the surrounding community? Have any family members changed religion? How did other family members react to this change? (McGoldrick et al., 2008). These questions will help the clinician immediately assess the complexities of the spiritual resources available to the couple. Case Illustration Lorraine and Richard—Interfaith Couple’s Counseling Lorraine sought couple’s counseling before marriage. One major point of contention was that Richard had not told his family that they did not want a religious wedding ceremony. Lorraine felt that Richard

was behaving in a cowardly manner. She wondered whether this was going to be a pattern in their relationship and wanted to address it before they married.

Getting the family and spiritual history for the genogram helped me to learn that Lorraine was an atheist, she was the eldest of three girls, and her ethnicity was Norwegian (see Genogram 8.2). Her grandparents were Protestant but not very religious and her parents were atheists. Richard was Catholic but had not attended services since he moved away from home in his first year of college. He was the only son of an Irish-Catholic father and Italian-Catholic mother. When he was 10 years old, his mother died in a car accident. The father was driving and afterwards went into a depression and never remarried. All four grandparents helped raise Richard after his mother died. I asked the couple to tell me more about their spiritual beliefs. Lorraine said she believed in science, nature, and charity and she had high moral values. She felt that Richard should be proud of her. Instead he was behaving as if he were ashamed of her and afraid of his family. Richard said he was not religious but he was not sure what he believed. I wondered if his indecision was related to loss and asked Richard how his family had grieved the death of his mother. Richard said that he and his grandmother lit a candle in church every day for his mother for many years. He said that thinking about it now, he still envisioned his mother in Heaven. Encouraging the couple to talk about their spiritual beliefs in the context of their family history through the use of the genogram helped Richard realize that he was more religious than he thought. In future sessions, I encouraged Lorraine and Richard to consider how they would raise their children, celebrate holidays, and commemorate other occasions in the future. They were thoughtful young people who loved and respected each other. They had a lot to talk about, now that Richard was finally talking. Even when couples of different faiths have made the adjustments with their families and each other, spiritual and religious beliefs may become a source of conflict as they decide how they wish to raise their children. Often couples who viewed religion as unimportant find that the birth of a child changes their perspective and they feel strongly in providing religious instruction for their children (Walsh, 2009). As young adults move from coupling to starting a family, they consider what they want their children to learn and believe about religion and spirituality. This may become a source of conflict, as couples try to decide how they wish to raise their children, as illustrated in the case of Ana and Luis. In this case, questions about their spiritual beliefs, in conjunction with the genogram, quickly identified complex issues related to spirituality, class, gender, and oppression. Case Illustration Ana and Luis—Spirituality Overcomes Oppression Ana called for an appointment for marriage counseling—she said she was feeling sad and lonely because Luis spent many hours out of the home working and studying while she stayed home with young children. She felt they had been growing apart lately. The initial genogram questions revealed that Ana and Luis were married in 2004, they immigrated from Peru 3 years later and they had two children, Miguel (age 5) and Anita (age 2) (see Genogram 8.3). In response to questions about their spiritual beliefs, Ana and Luis said their family was Catholic. This was a vague answer and it gave me a hint that there might be a problem in this area. I asked, “Your family is

Genogram 8.3 Ana and Luis’ Genogram Catholic, but what is your belief?” Luis said he was agnostic and uncertain about religion. He disagreed with many of the conservative tenets of Catholicism and he did not want to teach his children such conservative beliefs. Ana said she believed in God, and before the birth of their children she had not given much thought to religion, but now felt strongly that she wanted her children to be baptized. She said that since she and her husband disagreed, they had put off making a decision about baptizing their children rather than arguing about it. My hypothesis that they had a problem regarding spiritual beliefs was confirmed. Clinicians may feel uncomfortable pushing for an answer in this area, but probing gently often reveals important clinical information. I suspected that Ana was feeling lonely because in their effort to avoid conflict, she and Luis did not talk to each other about their differences of opinion. I wondered whether gender role expectations made it difficult for her to be assertive with Luis regarding her religious beliefs, and I asked her to tell me about her feelings about baptizing her children. She said she was embarrassed to say that she worried that the children might suffer harm if they were not baptized. She said she knew that she was just being superstitious, but at times she thought that her children would be vulnerable to an “evil eye,” or kept out of Heaven if they died without the sacrament of Baptism. This generated further hypotheses that their differences in spiritual beliefs were related to social class status. Luis’s upper-middle-class family was likely less tolerant of indigenous beliefs deemed to be superstitious than Ana’s family who had risen from poor to middle class and had indigenous ancestry. Also, Ana’s description of her beliefs as “superstitious” marginalized them, and I speculated that her embarrassment was a result of internalized oppression.

We tracked family history and religious beliefs, and related them to social class, power, and oppression. Luis’ family immigrated to Peru in the 1930s from Italy where Catholicism had a 2000-year history, and the family continued to practice Catholicism in much the same way they had in Italy. Ana’s family had been in Peru for a long time; she did not know when her Spanish ancestors first arrived. Their spiritual beliefs were a mixture of Roman Catholic and indigenous beliefs. I asked about the timing and changes in spiritual practices and tracked them on the chronology (see Figure 8.2). Figure 8.2 Chronology for the case of Ana and Luis. Relevant historical context relating to spiritual beliefs: Religion in Peru was influenced by the Spanish conquest in the sixteenth century and currently more than 75 percent of the population is Catholic. Historically, Catholicism was mixed with expressions of the indigenous and African religions.

I also recorded the context of class, race, culture, and spiritual beliefs on the genogram, which I showed to the couple. It helped Luis and Ana to see the influence of class and colonization on their beliefs. The upper social classes in Peru were less likely to include indigenous people, and indigenous beliefs were devalued as a consequence of the oppression of colonization. Ana’s family moved in socioeconomic status from poor to middle class through her father’s education and employment, and they had combined Catholic and Incan rituals for many years. But her parents abandoned those rituals when they moved from their village to the capital city of Lima. I talked about the concept of internalized oppression and asked Ana whether she believed it had influenced her parents’ decision to abandon the indigenous rituals in order to be accepted among their new cosmopolitan friends in the corporate world of Lima. The question enlarged the context for Ana and Luis. Ana thought her family felt slightly ashamed of their indigenous ways. She wondered whether her mother had felt as lonely after they moved to Lima as she herself was feeling now. Luis began to consider whether his disillusionment with Catholicism was in response to subtle but similar societal pressures he might be feeling to fit into the scientific community, as a medical student in the United States. The changes in spiritual beliefs over time were tracked through the chronology, and genogram questions facilitated discussions of the contexts of ethnicity, social class, gender role expectations, power, and oppression. Ana and Luis saw their marital problems in a larger context. They knew that spiritual beliefs had sustained their ancestors. They began to see the loss of spiritual beliefs in their family as a result of internalized oppression and disconnection from their community. They recognized the benefits of spiritual beliefs and community as protective factors and wanted them for their children and themselves. They made plans to join a church and to visit Peru more often. Spirituality can be a source of strength as well as difficulty for couples. Luis and Ana were alone and far from their home and family. As young adults who were busy working and establishing a career and family in a new country, they had not been overly concerned about spiritual matters. The birth of their children brought spirituality to the forefront, and it became a source of conflict. Ana avoided the conflict and became sad and lonely as a result. Talking about the historical, political, and familial context of their spiritual beliefs helped the couple draw on their spiritual resources and the strength of their community to reconnect with each other. Middle Age: Beliefs Reaffirmed As in any stage of the life cycle, under particularly difficult circumstances, middle-aged people will draw on their spiritual beliefs to sustain them. However, for most, middle age is not a time of deep spiritual change because generally people have already made decisions about their spiritual beliefs earlier in life, usually in early adulthood. Midlife is roughly between ages 45 and 65—the age of launching children and/or caring for elderly parents or aging relatives, in some cultures more than others. By this age, most people have had a number of losses and other negative experiences. Some people may turn deeper into spirituality or renew their faith in their religion to make meaning of their losses and disappointments (Wink & Dillon, 2002), or as they deal with other challenging issues. For example, adult children caring for their aging parents with chronic illness may experience a deeper intimacy and spiritual bond with them (Walsh, 2009), and they may find that spiritual resources are especially important at this time (Smith &

Harkness, 2002). The importance of spirituality may increase as middle-age adults become older, or have health problems, and face their own mortality. People who had put aside spiritual beliefs may find a need to reconsider their beliefs especially as they try to make sense of loss, trauma, disillusionment, and lost dreams. Case Illustration Lucy—Spirituality, Spirits, and Resiliency in the face of Untimely Loss This case illustrates the need for clinicians to be open to multiple possibilities regarding spiritual beliefs. It is not enough to be sensitive to other beliefs. We must be ready to embrace spiritual and cultural resources we may not understand and that may make us uncomfortable, in order to provide good clinical care. Lucy, a 53-year-old Cuban American woman, who had been diagnosed with chronic major depressive disorder with psychotic features, was grieving the recent death of her 33-year-old daughter from brain cancer (see Genogram 8.4). After her daughter died, Lucy became withdrawn, tearful, restless, and unable to sleep. Although spirituality can be a resource in many circumstances, it is particularly appropriate for bereavement issues because all religions have rituals or beliefs for dealing with death, and this comforts many people. When asked about her spiritual belief, Lucy said she converted to Catholicism when she married into a very religious Catholic family. I asked about her spiritual belief before marriage, and she hesitantly told me that her own family of origin had practiced espiritismo (the belief in spirits), not unusual in Cuba and other Latino cultures (Petry, 2004; Korin & Petry, 2005). She seemed conflicted about her belief in spirits and needed encouragement. I acknowledged that I was aware of the practice of espiritismo and said I would like to know more about her belief. Still hesitant, Lucy told me that she saw her daughter’s spirit. I suspected Lucy was having a psychotic hallucination and asked about conversations she may have had with her daughter to assess for psychosis and suicidal ideation. Other than telling me she saw her daughter’s spirit, all of Lucy’s answers, as well as her mood and affect, were appropriate. She denied suicidal ideation. She was tearful but said she felt comforted by her daughter’s presence and that she needed to be well to help raise her grandchildren. Although my hypothesis needed more testing, I felt reasonably sure that she was safe at this point, and Lucy seemed to be more at ease. I felt I had established rapport with her. At the end of our first session, Lucy asked me if she might take the risk of telling me something. I nodded and said, “Yes, certainly.” She told me the spirit of a man named Francisco was standing near and guarding me. She caught me off-guard and I was visibly surprised. Lucy said, “I know you recognize his name by the look on your face,” and she described his

Genogram 8.4 Lucy’s Genogram appearance, a White man with gray hair and a receding hairline descending in a V-shaped point known as a widow’s peak. She was describing my grandfather, Francisco Separovich, who died in 1973. This was the first time I met Lucy; she could not have known about my grandfather. Lucy had the ability to see the dead. She saw my grandfather. Now I had to reconsider my hypothesis. Was Lucy clairvoyant? Was her long-term depression caused by a lifetime of being misunderstood? I had joined with Lucy and encouraged her to talk to me about her belief by telling her I knew of espiritismo. Yet, I had not expected this. I had tried to be sensitive to Lucy’s beliefs, but I had not believed in her. Now I had to accept that Lucy had abilities I did not understand! And I had to be comfortable with not understanding in order to do a better assessment. In subsequent sessions, we worked on her genogram and discussed her family’s spiritual beliefs. Lucy spoke about a family myth that her Aunt Adriana was clairvoyant and that she had inherited her aunt’s abilities. As a child, Lucy had been close to this aunt, but as a young adult she distanced from her family and from her belief in espiritismo when she met her husband. Even though many people in Cuba believed in espiritismo, it was nonetheless an unconventional belief. Lucy described a typical progression of spiritual development over the life cycle: she questioned her spiritual beliefs as a young adult and then abandoned her old beliefs and adopted Catholicism, which she thought was a more acceptable religion. Having struggled with her beliefs in young adulthood and having made her choice, Lucy probably would not have given too much thought to her spiritual beliefs in middle age. However, the loss of her daughter compelled her to reconsider her decision. She derived little comfort from her adopted religion, and perhaps her chronic depression was caused, at least in part, by the denial of her earlier beliefs and her abilities.

Using the genogram to explore spiritual, cultural, and family themes helped Lucy to reconnect with her family’s history and beliefs. She began to feel better as she acknowledged that she had felt lost when she denied her belief to practice a more conventional religion. She decided that she could indeed hold both beliefs. She could be Catholic and also believe in spirits. Eventually, she told me that her daughter’s spirit had gone on its journey, which she understood to mean that her daughter was at peace. From a clinical perspective, I understood this as progress in the process of grief, and believed that Lucy was feeling stronger and therefore could let her daughter go. My systemic assessment brought out Lucy’s strengths, derived from her spirituality and culture. Spiritual beliefs that had been denied because they were unconventional were revived, and they transformed pain and suffering for Lucy. She was still reluctant to talk about her belief in spirits outside of our therapy sessions, but remembering her Aunt Adriana and talking about her spiritual beliefs and childhood experiences in Cuba helped Lucy to find a more inclusive spirituality. Feeling that her spiritual beliefs were validated helped Lucy begin to heal. No doubt, I was more comfortable than others may have been with Lucy’s story because we have similar cultural backgrounds, and her beliefs were familiar to me. However, clinicians can be prepared to hear about uncommon spiritual beliefs by doing the work of self-exploration, which leaves one centered and better able to listen. Sometimes, we do not need to understand or share the belief. Simply listening, with an open heart, can be validating and empowering for the client. Older Adults: Aging and Facing Mortality The developmental task at this stage of the life cycle, reviewing a lifetime’s relationships and accomplishments and coming to terms with aging and mortality, is spiritual. People who are lucky enough to reach old age in relatively good health and have the time and energy to contemplate death usually want to prepare to dispense of worldly goods, repair relationships, and review their life’s work. People do not necessarily become more religious or spiritual as they age, but the process of making sense of life is spiritual. Those who are religious may turn toward the rituals and community of their religious practice to accomplish this task. Those who are not particularly religious or spiritual nonetheless often engage in this spiritual process as they approach the end of life. We all want to believe that our life has meaning and love. This is the essence of spirituality. Spirituality can be a powerful resource especially for the elderly who are poor, disadvantaged, and disempowered. Poverty and oppression leave people with diminished power over their destiny. It contributes to the loss of a sense of identity and self-worth, making the task of reviewing one’s life particularly painful. Spirituality can give meaning to people’s struggles and help them transcend the deprivation of poverty and oppression (Aponte, 2009; Boyd-Franklin & Lockwood, 2009). It can be the light that gives purpose and value to life. Case Illustration Pearl—Spirituality Promotes Dignity in the Face of Poverty and Oppression Pearl was a 76-year-old African American great-grandmother raising her 15-year-old great- grandson, Jerome. Pearl was diagnosed with terminal cancer and was referred by her primary care physician for therapy. I began with the family history using the genogram and asked Pearl about her spiritual belief. Pearl told me that her faith in God and her church community had always pulled her through. She said she had struggled all her life, but she was a survivor. She had

raised three children and helped to raise nine grandchildren. She had no fear of dying as she was at peace with God, but she wanted to work on a plan for someone to care for Jerome after she died. Pearl had had more than her share of troubles. She had endured the stresses of poverty and discrimination, but she did not feel defeated. She drew strength from her faith. She was facing a terminal illness and nearing the end of her life, but her spiritual beliefs gave her strength to carry on with dignity and grace. Unfortunately, medical advances and our Western beliefs have made acceptance of death more difficult with the emphasis on mastery over destiny. Some older adults believe that good health and the belief that one is in control of one’s life is more important than spirituality (Lewis et al., 2009), but as physical health declines, a focus on psychological and spiritual well-being will help older adults deal with losses related to health issues, diminishing physical stamina and productivity, deaths of loved ones, and their own mortality. Therapists can encourage the elderly to share their life story and assess for spiritual resources to help them avoid depression, disillusionment, or fear of illness and death. At the same time, while spirituality can be a significant source of strength, unresolved spiritual struggles, such as conflicts over religious beliefs, can cause difficulties leading to declines in health, stress, anxiety, depression, and even death (Ano & Vasconcelles, 2005; McConnell, Pargament, Ellison, & Flanell, 2006). A systemic assessment will help clinicians probe beyond the surface and evaluate for spiritual resources as well as areas for concern. Good questions that can be asked at this stage of the life cycle are as follows: Have your beliefs changed over the years? Do your beliefs bring you comfort? Do you consider spirituality to be a source of strength? Whether the answer is “yes” or “no,” follow up each question by asking, How? and Why? or Why not? and Are you at peace? Case Illustration Eleanor—Unresolved Spiritual Issues and Depression This case illustrates how unresolved struggles with religious beliefs made it difficult for Eleanor to find peace. In order for her to move forward, the therapy had to address her spiritual conflict. Eleanor, an 86-year-old widow of Polish descent, was referred for treatment of depression. She had completed treatment for colon cancer, which was in remission, yet she was sad, withdrawn, and isolated. Before this illness, Eleanor had been perky and energetic. After retiring from her position as a secretary in a manufacturing company, she had remained active for many years. Until recently she had volunteered at a hospital, taken classes at the local community college, and taken care of herself and her apartment. Now she had to force herself to get out of bed before noon; she had lost interest in everything, and she was afraid to leave home. In exploring her history, Eleanor told me she was Polish Catholic, the eldest of four children, but had not attended church for many years. I asked if her beliefs had changed over the years, and she told me that she did believe in God but was disillusioned with the Catholic Church a few years ago when she learned that a priest had sexually abused her brothers when they were boys.

Eleanor had been married to Joe, who was also Polish Catholic, and they had raised their children in the Catholic religion. She said that she was afraid to die. She enjo-yed good relationships with family members, and was especially close to her sister, but she could not talk to them about her fear of dying. As Eleanor spoke about her family history, I wondered whether her unresolved issues with the Catholic Church were exacerbating her stress, anxiety, and depression. At this stage in the life cycle, Eleanor’s develop-- mental tasks included dealing with chronic illness and making meaning of her life. My hypothesis was that she needed to resolve her conflicts with the Catholic religion in order to manage those tasks and be at peace. I encouraged her to bring her sister, Caroline, to therapy because they were close. I asked about their belief in God and afterlife. Eleanor’s conversations with Caroline helped her realize that she could believe in God and pray at home. She concluded that her decision not to attend church was the right one for her, but she could still honor her spiritual and religious beliefs in her own way. The systemic assessment including questions about spirituality helped Eleanor to see her problem in the context of her family’s history with the Catholic religion. She found spiritual peace by speaking directly to God and sharing her thoughts with her family. Finding peace allowed her to work on her life cycle tasks of dealing with chronic illness and facing death. Conclusion Throughout history and across cultures, people around the world have relied on religion and spirituality to promote emotional well-being during times of celebration and times of loss or trauma. Our positive emotions made us spiritual (Vaillant, 2008). Spiritual awareness and growth are possible throughout all life cycle stages, and spirituality becomes especially significant when facing times of stress. The case illustrations presented highlight how to do a systemic assessment that takes into account spiritual resources and family strengths across the life cycle, tracking changes over time and looking for opportunities to enlarge the context in order to transform pain into healing.