What Can and Cannot be Said (Discourses of Spirituality and Religion in Clinical Psychology)

What Can and Cannot be Said: Discourses of Spirituality and Religion in

Clinical Psychology

Introduction

The United Kingdom (UK) is a nation of increasing religious diversity.

Minority religions are steadily growing, particularly Islam, while a significant but

declining percentage of individuals identify as Christian (Office for National

Statistics, 2012). Whilst the census may over-represent religious affiliation

(Zurlo & Johnson, 2016; YouGov, 2014), many people endorse some

nontheistic spiritual beliefs (Ipsos MORI, 2007). Spirituality and religion are

personally meaningful for many individuals with mental health difficulties (Hefti,

2011), including depression (Fitchett, Burton, & Sivan, 1997; Bosworth, Park,

McQuoid, Hays, & Steffens, 2003), schizophrenia (Mohr, Brandt, Borras,

Gilliéron, & Huguelet, 2006), substance misuse (Flynn, Joe, Broome, Simpson,

& Brown, 2003) and physical comorbidities (Hebert, Zdaniuk, Schulz, & Scheier,

2009).

National documents recommend attending to the religious and spiritual

preferences and needs of service users across a range of settings where

clinical psychologists (CPs) work (Commission for Healthcare Audit and

Inspection, 2007; Department of Health, 2009; Mental Health Foundation, 2006;

Royal College of Psychiatrists, 2013). However, there is no guidance specific to

SPIRITUALITY IN CLINICAL PSYCHOLOGY 2

UK psychology, other than that it should be addressed as an area of diversity

(British Psychological Society [BPS], 2009; Health Professions Council, 2008)

and considered in a culturally sensitive formulation (BPS, 2011).

Practitioners can be hesitant to bring up spirituality if not first introduced by

the client (Lee & Baumann, 2013), but many clients who value religion do not

raise it with their clinicians (Huguelet, Mohr, Borras, Gillieron, & Brandt, 2006).

Individuals in the UK who hold spiritual beliefs report using them to cope with

psychological problems (Mayers, Leavey, Vallianatou, & Barker, 2007), and

voice concerns that secular-based help may be insensitive to their beliefs, or

weaken their faith (Mayers et al., 2007; Mitchell & Baker, 2000). Clinicians are

often unaware that clients experience conflict between their spiritual beliefs and

treatment (Huguelet et al., 2006).

Spirituality may be an unfamiliar concept for many CPs. Research in the

United States of America (US) has found that psychologists report lower levels

of religious affiliation and spirituality than the general population, or other mental

health professions (Bergin & Jensen, 1990; Bilgrave & Deluty, 1998).

Worryingly, a mismatch between clinician and client ideology has been linked to

reduced therapist empathy, and assessments of clients as less mature and less

open to therapy (Gartner, Harmatz, Hohmann, Larson, & Gartner, 1990).

Research suggests that many professionals pathologise religious beliefs and

practices (McClure & Livingston, 2000), whilst even those who view spirituality

as important rarely discuss it (Ellis, Vinson, & Ewigman, 1999).

If spirituality is of high importance to clients, but not addressed in

therapeutic work individuals may drop out of therapy, potentially influencing both

current and future treatment outcomes. The attitudes of CPs to spirituality may

SPIRITUALITY IN CLINICAL PSYCHOLOGY 3

further impact treatment efficacy via the therapeutic alliance, which may be

more difficult to establish if CPs take a negative view of those with religious

beliefs (Gartner et al, 1990 and McClure & Livingston, 2000) or clients percieve

beliefs which are important to them as being overlooked. Without an

understanding of CP attitudes to spirituality and religion in the UK this cannot be

assessed or addressed.

There is evidence that spiritual beliefs and/or practices benefit physical

and emotional wellbeing for some individuals (Larson & Larson, 2003), including

those with mental health diagnoses (Mohr et al., 2006). However, religion has

been used to legitimise both physical and emotional abuse (Capps, 1992), and

religious distress can exacerbate negative emotional states (Exline, Yali, &

Lobel, 1999). Negative experiences with spirituality or religion can have a

detrimental impact on mental health, increasing a person’s sense of alienation,

depression and hopelessness (Bussema & Bussema, 2000; Exline, 2002;

Exline, Yali, & Sanderson, 2000).

Whether the impact is positive or negative, an individual’s spiritual history,

practice and beliefs, should be assessed if the most comprehensive support

and accurate formulation is to be developed (Hathaway, Scott, & Garver, 2004).

Spiritual beliefs and practices can influence individuals’ worldviews, social

functioning and expressions of distress (Mitchell & Baker, 2000; Richards &

Bergin, 1997).

Defining Religion and Spirituality

The terms spirituality and religion are difficult to separate and some have

recommended that they remain undifferentiated in research (Oman, 2013;

SPIRITUALITY IN CLINICAL PSYCHOLOGY 4

Masters, 2010). However, they are distinct constructs (Saucier & Skrzypińska,

2006), with some groups being more likely to describe themselves as spiritual

than religious (Phillips, 2010). Spirituality is considered an umbrella term

concerned with individual experiences and personal meaning (Zinnbauer &

Pargament, 2005), with religion forming a subset of spirituality as expressed in

behaviour and rituals (Huguelet & Koenig, 2009). The term spirituality is used

here to encompass both broader spirituality and religion.

Systematic Review Rationale

Despite increasing interest in spirituality within UK clinical psychology,

there have been no systematic reviews of the literature to determine how CPs in

the UK address this area. Much of the literature on spirituality in clinical

psychology practice originates in the US. There are significant cultural and

demographic differences between the UK and the US, with religion forming a

larger part of mainstream culture in America. Only 15% of the US population

report having no religious affiliation (United States Census Bureau, 2010),

compared to 25% in England and Wales (Office for National Statistics, 2011).

Unlike the UK, some accredited training courses in the US are run by explicitly

religious institutions (Campbell, 2011). The substantial variations in healthcare

delivery between the two countries also mean that evidence from America must

be treated with caution when extrapolating to the UK.

Clinicians’ attitudes towards spiritual issues appear to influence whether

service users raise them in appointments (Koenig, Bearon, & Dayringer, 1989).

Personal attitudes have also been found to influence therapeutic practice more

than clinical training (Shafranske & Malony, 1990). It is therefore important to

SPIRITUALITY IN CLINICAL PSYCHOLOGY 5

review the current literature to gain an understanding of UK CPs’ attitudes

towards spirituality in their professional practice.

Aim of the Review

This systematic review aimed answer the question: What are the attitudes,

beliefs and practices of CPs in the UK regarding raising, considering or

discussing spiritual issues in any part of their practice? Critically evaluating and

compiling these findings was considered helpful as research in this area

remains sparse, with the majority carried out in the US.

Methods

This systematic review was conducted using an adapted version of the

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

(PRISMA) reporting protocol (Moher, Liberati, Tetzlaff, & Altman, 2009). It is

important to follow clear guidelines to ensure that a review is systematic,

unbiased and repeatable. The PRISMA guidelines were developed with a focus

on randomised trials, and are particularly designed for evaluations of

interventions (PRISMA Homepage, 2015). Adaptation was therefore necessary,

as some aspects were less relevant for qualitative, non-interventive studies. For

example, the focus on PICOS (participants, interventions, comparators,

outcomes, study design) required alteration, with participants’ occupation and

location, and the concepts studied, instead forming the inclusion and exclusion

criteria.

As there has not been extensive research into this area in the UK, the

search terms were kept broad to ensure all relevant papers would be captured.

The searches comprised the following terms:

SPIRITUALITY IN CLINICAL PSYCHOLOGY 6

1 spiritual*

2 religio*

3 faith

4 sacred

5 clinical psycholog*

6 1 OR 2 OR 3 OR 4

7 6 AND 5

The search terms were applied to the PubMed, PsychInfo and Web of

Knowledge databases in line with their respective search grammars and

structures (Appendix A).

Screening Procedure

Inclusion/Exclusion Criteria. Inclusion criteria were studies where the

participants were CPs working and/or training in the UK. Studies which

examined more than one profession were included if clinical psychology results

were reported separately, or formed the majority (>50%) of the sample with

other professions being closely allied to clinical psychology (i.e., counselling

psychologists, psychological therapists, counsellors, psychoanalysts). Both

quantitative and qualitative papers were included if they constituted research

into the beliefs, attitudes, or practices of clinical psychology as related to

spirituality. This included surveys of professional practice, questionnaire

assessment of beliefs or practice which specifically ask about spiritual or

religious matters, and qualitative research addressing spirituality and/or religion.

Initial screening of titles and abstracts was carried out to identify

potentially relevant papers. Research papers where the participants were not

CPs, for example those looking at nursing attitudes or service user experience,

SPIRITUALITY IN CLINICAL PSYCHOLOGY 7

were excluded. Where participants were clearly identified as practising outside

the UK papers were also excluded at this stage.

The remaining papers were accessed in full where possible and screened

to check that they were original research, carried out with CPs from the UK, and

addressing spirituality in relation to clinical practice (including training).

Duplicate results or papers based on duplicate data were excluded at this

stage. The grey literature was searched via GoogleScholar and the British

Library’s electronic record of UK doctoral theses (EThOS), using the terms

above. A manual search of the references of identified papers was also carried

out. Finally, the resulting cohort of studies was quality assessed, using the

critical appraisal skills programme (CASP) qualitative checklist (CASP, 2013) to

evaluate qualitative studies in the sample. One point was awarded for each

criterion fully met (Appendix B).

Results

The initial searches of the PubMed, PsychInfo and Web of Knowledge

databases returned 2,804, 3,728 and 94 results respectively, totalling 6,626

records (including duplications). After applying inclusion and exclusion criteria to

titles and abstracts, 28 articles remained. Most papers were excluded from titles

only, as they focussed on non-psychology professionals, client outcomes or

client population characteristics. After reviewing abstracts, papers which

included CPs but were carried out outside the UK (mainly in the US), or did not

report original research, were excluded.

Of the 28 papers reviewed in full, 25 were excluded due to not meeting

inclusion criteria. Fifteen studies were conducted exclusively outside the UK,

with a further three not including UK psychologists in their sample. Three

SPIRITUALITY IN CLINICAL PSYCHOLOGY 8

papers did not state where participants lived and worked. However, as all

authors worked at US institutions or the articles were published in US state

journals, they were excluded. Two papers did not report original research and

two were based on duplicated data. Three papers remained for inclusion in the

qualitative synthesis.

A search of the grey literature (GoogleScholar and EThOS) was

undertaken using the search terms above. Six additional results meeting

inclusion criteria were identified from these sources. Finally, a manual search of

the references of identified papers returned a further four studies that met

inclusion criteria, giving a total of thirteen papers for review.

Figure 1. Flow diagram showing the number of records identified and excluded

through the different phases of the review.

PubMed

2804

results

returned

PsychInfo

results

3728

returned

Web of

Knowledge

results

returned

Titles and abstracts screened for inclusion and exclusion criteria

papers

remaining for

scree

ning of full

text

papers excluded

non

UK sample

not research

not clinical

psychology

duplications

Search of grey

literature (Google

Scholar & EthOS)

results meeting

inclusion criteria

Searching papers

referenced by

nclu

ded results

results

meeting

inclusion criteria

papers

included in

qualitative

synthesis

papers eligible

for inclusion

Running head: SPIRITUALITY IN CLINICAL PSYCHOLOGY

Table 1

Summary of main findings from the systematic review

Reference

CASP

Score

Aim

Design and

Analysis

Data

Risk of bias/

Limitations

Findings and Clinical Relevance

Arshad, R. (2007).

How do clinical

psychologists work

with religious themes

in psychosis?

(Doctoral dissertation).

Retrieved from British

Library e-thesis online

service

(uk.bl.ethos.697398)

7/8

How do clinical

psychologists

address religious

themes in work

with individuals

with psychosis.

Including how

their values may

impact their

practice in this

area.

Qualitative

study.

Grounded

Theory

analysis of

interview

transcripts.

Semi

structured

interviews

with 10

qualified

clinical

psychologists

working with

psychosis for

over a year.

Volunteers likely

to have a

particular

interest in this

area.

Response rate

is not clear.

Notes that the

identity of the

researcher as a

British Muslim

would influence

both the

interviews and

analysis.

Core category ‘unravelling’ and three

main categories; defining roles,

unpicking cases and interacting with

religious themes.

Highlighted limited guidance, lack of

reflection and the defined boundaries

of the clinical psychologist role (we

don’t impose our beliefs and work to

reduce distress).

Challenging; drawing out discrepancies

between the individual’s beliefs and a

religious source to which the client

attributes authority and meaning. The

area is seen as “hard work” in part due

to the “impermeability of a higher

power” to challenge.

SPIRITUALITY IN CLINICAL PSYCHOLOGY 10

Baker, M. & Wang, M.

(2004). Examining

connections between

values and practice in

religiously committed

U.K. clinical

psychologists. Journal

of Psychology and

Theology, 32(2),

126136.

6/8

To investigate the

interaction of

personal

Christian values,

and clinical

psychological

practice.

Qualitative

study.

Grounded

theory

analysis of

semistructured

phone

interview

transcripts,

based on

repertory grid

responses.

Telephone

interviews

with 14

qualified

clinical

psychologists

who were

working in the

NHS and

members of

“network of

Christians in

psychology”.

Lack of

consideration

of the influence

of the

researcher on

the interviews

and analysis.

Acknowledges

that the

sample is likely

to hold extreme

rather than

representative

views.

Added value: enhanced performance

and spiritual support.

Speaking Out: religious disclosure to

colleagues, and to clients. This was an

area of tension, as training advocated

non-disclosure. Hostility and disrespect

were expected from colleagues.

Challenge: value clash between beliefs

and wider society or psychology.

Harmony: value congruence with

nonjudgement and respect.

The Big Picture: the sense of broader

involvement in kingdom of God and as

psychologists who were also members

of the Christian community.

SPIRITUALITY IN CLINICAL PSYCHOLOGY 11

Begum, N. (2012).

Trainee clinical

psychologists talking

about religion and

spirituality in their work

(Doctoral dissertation).

Retrieved from British

Library e-thesis online

service (uk.bl.ethos.

575830)

6/8

To explore

trainee clinical

psychologists’

experiences of

religion and

spirituality, and

how this relates

to and impacts

upon their

professional

training.

Including how

trainee clinical

psychologists

define and

understand their

own values with

regards to

religion and

spirituality.

Qualitative

study.

Interpretive

phenomenolo

gical analysis

(IPA) on

transcripts of

semistructured

interviews.

Eight

interviews

with 2nd and

3rd year

clinical

psychology

trainees.

Opportunistic

sampling via

word of mouth.

The sample

were all white

female trainees.

Use of IPA at

odds with the

fact that

individuals

talked

academically

rather than

about their

experience.

Conceptualising religion and

spirituality: spirituality as free-flowing,

yet ‘containing’ religion which is rigid. A

preference for spirituality was stated,

but the majority of discussion covered

religion, which seemed easier to

consider.

Self within a religious/ spiritual context:

Influences (e.g. family and school) and

identity (e.g. spiritual but not religious

or Jewish but not believing in God)

Experiences of religion and spirituality

as a trainee clinical psychologist:

shared framework with clients (or lack

of). Belief is not actively explored.

Topics are hard to bring to supervision

if not shared with supervisor or client.

Culture and stereotypes, assuming

more relevance for ethnic minorities.

‘There’s no space for religion’;

attributing blame. Clinical psychology

as tending not to address religion and

spirituality although it could. The

profession as mirroring secular society

and scientist-practitioner model being

inconsistent with religion or spirituality.

Facilitating religion and spirituality –

finding less stigmatising words to use

(e.g. faith, strengths or values rather

than spirituality/religion) and struggling

to articulate themselves, as these

topics are difficult to think and talk

about.

SPIRITUALITY IN CLINICAL PSYCHOLOGY 12

SPIRITUALITY IN CLINICAL PSYCHOLOGY 13

Betteridge, S. (2012).

Exploring the clinical

experiences of Muslim

psychologists in the

UK when working with

religion in therapy

(Doctoral dissertation).

Retrieved from British

Library e-thesis online

service

(uk.bl.ethos.637577)

6/8

How do Muslim

psychologists

trained in the UK

experience

religion in a

therapeutic

setting and

what does it

mean to them?

How do the

religious beliefs

of Muslim

psychologists in

the UK impact

upon their

therapeutic

approach with

religious clients?

Qualitative

study.

Grounded

theory

analysis of

semistructured

interview

transcripts.

Interviews

with six

qualified

psychologists

who identified

as Muslim.

Four clinical

psychologists,

two

counselling

psychologists.

Sampling bias

due to

emailing

people whose

names

appeared to be

Muslim. Lack

of clarity in

write up

between

cultural and

religious

Muslim

identities of

participants.

Religious journeys in therapy:

Important to listen, give permission to

discuss religion, respect potential

importance and be at ease with

religious language.

Therapeutic approaches: Adapt

models to fit with the client and their

religious beliefs; use explicitly religious

strategies; identify and encourage

religious strategies used previously.

Therapeutic relationship: Matching

religion may not be beneficial.

Therapists enjoy work with shared

beliefs more. When relevant, difference

should be proactively addressed.

Therapist’ identity: Personal beliefs

impact management of religion in

therapy. Disclosure was seen as

complicated by religious dress and

most helpful to other Muslims. Context

of therapy: NHS limits time, modality,

and discussion of religion.

Cultural context of ‘islamophobia’.

SPIRITUALITY IN CLINICAL PSYCHOLOGY 14

Crossley, J. P. & Salter,

D. P. (2005). A question

of finding harmony: A

grounded

theory study of clinical

psychologists’

experience of

addressing spiritual

beliefs in therapy.

Psychology and

Psychotherapy:

Theory, Research and

Practice, 78, 295–313.

5/8

To develop an

account of the

way in which

clinical

psychologists

understand and

address

spirituality within

therapy.

Qualitative

study.

Grounded

theory

analysis of

semistructured

interview

transcripts.

Interview

transcripts

with eight

qualified

clinical

psychologists

Relationship

between

researcher and

participants not

adequately

considered.

Potential

sampling bias,

individuals

volunteered,

response rate

not clear.

Spirituality as an elusive concept,

avoided in clinical psychology due to

cultural unease, personal irrelevance

and lack of familiarity with appropriate

language.

Participants aimed to understand and

respect client beliefs and to suspend

judgment. This became difficult when

beliefs were contributing to distress.

They would then disengage from the

beliefs, seek understanding that

reduces distress but fits with beliefs, or

refer on to a religious leader.

Harbidge, P. R. (2015).

An exploration of how

clinical psychologists

make sense of the

roles of religion and

spirituality in their

clinical work with

adults who have

experienced trauma

(Doctoral dissertation).

Retrieved from British

Library e-thesis online

service

(uk.bl.ethos.667987).

7/8

To explore: How

clinical

psychologists

define and

understand their

own values with

regard to

religion and

spirituality. The

role of religion

and spirituality

within clinical

psychologists’

therapeutic

work with adults

who

have

experienced

trauma.

Qualitative

study.

Thematic

analysis of

transcripts of

semistructured

interviews.

Interview

transcripts

with eight

qualified

clinical

psychologists

with

experience of

working with

trauma.

Recruitment

methods are not

clearly stated.

Researcher

acknowledges

that her identity

as a Christian

may impact the

interviews and

analysis. All

female sample.

Participants felt more connected with

spirituality than religion. They found

these topics difficult to discuss and

their talk contained contradictions. The

influence of personal experiences and

psychological theory was noted.

Participants felt there was a lack of

psychological theory beyond religion

as symbolic or a psychological

defence. Wider contexts: NHS time

constraints, the medical model,

radicalisation and terrorism all

influence practice. Trauma: Theoretical

definition versus subjective

experience. Religion as an anchor in

extreme distress and central to

meaning making, which can be helpful

or can increase distress.

Aim to be curious, to value client’s

beliefs, and to notice difference.

SPIRITUALITY IN CLINICAL PSYCHOLOGY 15

However, participants could give few

examples of working with these topics.

Malins, S. (2011).

Clinical psychologists'

experiences of

addressing spiritual

issues in supervision:

An interpretative

phenomenological

analysis (Doctoral

dissertation).

Retrieved from British

Library e-thesis online

service

(uk.bl.ethos.580379)

6/8

To explore how

clinical

psychologists

address spiritual

issues in

supervision.

Qualitative

study.

Interpretive

phenomenolo

gical analysis

on transcripts

semistructured

interviews.

Interview

transcripts

with seven

qualified

clinical

psychologists.

Recruitment

biased to those

who had

successfully

raised the topic

in supervision.

Impact of the

religious beliefs

of researcher

not considered.

The Ineffable Nature of Spirituality:

Spirituality as difficult to put into words

and hard to challenge.

Struggles with Spirituality: Tension

between exploring clients’ experiences

and psychological theory. Caution

about revealing personal views due to

potential judgment from colleagues.

Negotiating Struggles: Recognising

what they do get from supervision and

that risk has to be a priority.

Substituting acceptable terms such as

existential questions or death anxiety

for spiritual or religious terms.

SPIRITUALITY IN CLINICAL PSYCHOLOGY 16

Mills, J. (2010). An

exploration of trainee

clinical psychologists'

experiences of

engaging with psycho

spiritual issues in

clinical practice

(Doctoral dissertation).

Retrieved from British

Library e-thesis online

service

(uk.bl.ethos.522435)

6/8

To explore trainee

psychologist’s

experience of

engaging with

psycho spiritual

constructs in

clinical practice.

Questionnair

es sent to

clinical

psychology

course staff,

asking about

provision of

training on

spirituality.

Interviews

with third

year trainees.

12 courses

responded to

questionnaire

asking about

training

provision

Eight

individual

interviews

asking about

experiences.

Sample bias.

75% described

themselves as

religious. Lack

consideration

of the impact

of researcher’s

own faith on

interviews or

analysis. All

female sample.

Range of teaching reported: 0-2.5 days

(25% = 0).

Provision of training on religion and

spirituality was seen as inadequate.

Scientist practitioner model viewed as

reducing openness to spiritual ideas.

Personal history and training were

recognised as impacting practice.

Existential issues: dilemmas arose

around life and death issues, which

participants felt unprepared to discuss.

Locus of control: Internal barriers: fear

of compromising the therapeutic

relationship through bias, ignorance,

invested interest & personal disclosure.

External barriers: NHS philosophies;

socio-political views; lack of training or

professional guidelines, psychology’s

lack of clarity on including religion and

spirituality into clinical practice.

Personal beliefs as causing tension

around disclosure, confidentiality, bias,

assumptions and causing offence.

SPIRITUALITY IN CLINICAL PSYCHOLOGY 17

Mulla, A. (2012). How

British NHS Clinical

Psychologists talk

about their experiences

of considering

spirituality in

therapeutic sessions

(Doctoral dissertation).

Retrieved from British

Library e-thesis online

service

(uk.bl.ethos.542399 )

5/8

How do clinical

psychologists talk

about their

experiences of

dealing with

spirituality in

therapeutic

sessions, the

clinical skills

required and how

these skills

develop?

Qualitative

study.

Grounded

theory

analysis of

interview

transcripts.

Interviews

with 12

qualified

clinical

psychologists

working in the

NHS.

Lack of clarity

about how the

final

participants

were recruited.

Researcher

acknowledges

the impact of

her Muslim faith

and dress on

the interviews

and analysis.

Including people's spiritual beliefs was

seen to improve engagement and

outcome. Tolerance, open discussion

and better training were desired.

Competence as based on experience,

knowledge, confidence and training.

Negative staff reactions to discussing

spirituality were reported, resulting in

avoidance in discussions or training.

Religion as a ‘luxury topic’ and not a

priority, particularly in supervision.

Spirituality located in the otherness of

patients, including race.

Myers, J. & Baker, M.

(1998). Religiously

committed clinical

psychologists, talking.

Clinical Psychology

Forum, 117, 30-32.

4/8

Not clearly stated.

Qualitative

study.

Grounded

theory

analysis of

interview

transcripts.

Interviews

with 5

religiously

committed

NHS clinical

psychologists.

Recruitment

methods not

clear. All

female

sample.

Lack of clarity

in aims of the

research. No

consideration

of the impact of

the researcher

on the

research.

Capabilities of religious psychologists:

Attunement to client (religious) issues.

Religious understanding could inform

assessment and intervention.

Professional self-care: linking with the

infinite and energising work.

Serious inattention paid to the religious

dimension: Neglect of client’s religious

concerns by secular colleagues,

negative talk towards religion in the

workplace. Concerns not shared as

expected them to be dismissed.

Psychological theory and training were

seen to overlook religion, perpetuating

neglect.

SPIRITUALITY IN CLINICAL PSYCHOLOGY 18

Read, R., Moberly, N.

J., Salter, D., &

Broome, M. R. (2016).

Concepts of mental

disorders in trainee

clinical psychologists.

Clinical Psychology

and Psychotherapy.

DOI:

10.1002/cpp.2013

N/A

To explore the

attitudes of

trainee clinical

psychologists

towards mental

disorders.

Online

questionnaire.

Quantitative

analysis.

Maudsley

Attitude

Questionnair

e. (MAQ)

Responses

on a Likert

scale. 289

respondents.

Not clear what

proportion of

those invited to

take part

responded to

the

questionnaire.

Acknowledges

that the MAQ

has not been

validated with a

clinical

psychology

sample.

The hierarchy of model endorsement

(from most to least) was: social realist,

social constructionist, cognitive,

psychodynamic, behavioural,

biological, nihilist and spiritual [with the

mean score for spiritual falling between

disagree and strongly disagree across

all four components for all four

diagnoses].

Psychologists endorsed the spiritual

model more strongly than psychiatrists

for schizophrenia but not for the other

diagnostic categories.

A significant association between

religion and a “psychodynamic–

spiritual” dimension was found. The

atheist group had a significantly lower

average score on the

psychodynamicspiritual dimension than

the Christian, agnostic and no religion

groups.

SPIRITUALITY IN CLINICAL PSYCHOLOGY 19

Smiley, T. (2001a).

Non-religious

psychologists talking:

What happens when a

psychologist who is not

committed to any

religion encounters

religious beliefs from

clients? (Unpublished

qualitative research

project). Retrieved

from British Library

ethesis online service

(uk.bl.ethos.699806)

5/8

To explore what

happens when a

psychologist who

is not committed

to a particular

religion

encounters

religious beliefs

from clients.

Qualitative

study.

Interpretive

phenomenolo

gical analysis

on interview

transcripts.

Interviews

with six

psychologists

(five clinical,

one

counselling)

without

religious

affiliation or

belief.

Impact of the

researcher on

the process of

research is not

considered.

Recruitment

process and

sample

population not

clear.

Dominant theme was the difference

between therapist and client beliefs,

particularly ignorance about client

beliefs, which was seen as potentially

positive or negative, and disagreement

with client beliefs, which was primarily

seen as harmful to engagement.

Including religion in clinical work was

rare. When raised most said it might be

in the formulation but less agreement

on inclusion in intervention planning. All

discussed potential negative impacts of

religion, five of six discussed potential

positive impacts.

Smiley, T. (2001b).

Clinical psychology

and religion: A survey

of the attitudes and

practices of clinical

psychologists in South

East England

(Doctoral dissertation).

Retrieved from British

Library e-thesis online

service

(uk.bl.ethos.699806)

N/A

Survey the

religious

orientations and

attitudes of a

population of

clinical

psychologists and

their experience

of, and approach

to, religion in the

clinical setting.

Descriptive

statistics.

Comparisons

between

different

groups and

with research

carried out in

the USA.

Developed a

survey based

on past

research.

Sent by post

to clinical

psychologists

working in the

South

Thames

Region. 246

responses.

Likely bias in

those taking

the time to

respond. Use

of a scale

developed for

the research

rather than

validated or

previously used

tools.

62% of respondents did not identify

with a religion. 52% reported

nontraditional forms of spirituality

(NTS) as important in their lives. 68%

indicated religious affiliation or value of

NTS. 56% say therapy can be

conducted independent of

metaphysical beliefs. 73% disagreed

that therapy is more helpful when

beliefs are shared. 76% of

respondents felt it was often or always

appropriate to consider client religious

values, but only 36% felt it was

appropriate to often or always ask

about them at assessment.

The most frequently reported religious

issues were existential (19%).

Religious psychologists were more

likely to report that their orientation

influences and enhances clinical work.

Running head: SPIRITUALITY IN CLINICAL PSYCHOLOGY

Findings

A summary of the 13 studies included for review is presented in

Table 1. The majority of the research utilized qualitative methods, with

only two papers following a quantitative design. Eleven studies

conducted interviews with CPs, analysed using: grounded theory (six

papers), IPA (four papers) or thematic analysis (one paper). Nine

studies were conducted with qualified psychologists, two with trainees.

Two focused on particular areas of work, trauma (Harbidge, 2015), and

psychosis (Arshad, 2007). Four identified participants based on their

beliefs: no religion (Smiley, 2001a), Muslim (Betteridge, 2012) or

Christian (Baker & Wang, 2004; Myers & Baker, 1998). One paper

selected participants who had raised spirituality in supervision (Malins,

2011).

The quantitative studies administered questionnaires to CPs. One

was developed specifically for the study in question based on prior

research (Smiley, 2001b) and administered by post to CPs working in

South East England. The other delivered the Maudsley Attitude

Questionnaire (MAQ) to clinical psychology trainees online. Smiley

(2001b) found that although the majority (62%) of respondents did not

identify with a religion, a minority could be considered “strongly

religious” (18%), and 52% valued non-traditional forms of spirituality.

Although roughly similar proportions of religious and non-religious

psychologists believed that therapy can be offered without the influence

of one’s metaphysical beliefs (an average of 56%), more religious

psychologists reported that their beliefs impact on, and enhance, their

practice. A strong majority (76%) felt it was appropriate to consider client

religious values, but only 36% felt it was appropriate to routinely ask

about them at assessment. When asked to provide examples of the

sorts of religious issues clients bring to therapy, the most common

category was existential issues (19% of responses), although there was

variation depending on specialism.

The MAQ was developed to assess trainee psychiatrists’ concepts

of mental illness (Harland et al., 2009). It examines eight conceptual

models (biological, cognitive, behavioural, psychodynamic, social realist,

social constructionist, nihilist, spiritual) across the domains of aetiology,

classification, research and treatment, for four diagnoses. Read et al.

(2016) found that trainee psychologists endorse the spiritual model for

schizophrenia more than trainee psychiatrists, although the spiritual

model was the least endorsed overall. Three components were

identified which accounted for 57.54% of the variance of the aggregated

attitude scores, loading psychodynamic and spiritual understandings

onto one dimension. Individuals identifying as atheists were less likely

than their peers to endorse this understanding of mental health

diagnoses.

The aims of the studies were all exploratory, looking to investigate

how religious or spiritual topics are conceptualized, addressed in clinical

practice, and/or raised in supervision. The impact of personal beliefs on

this process was included for seven studies (Arshad, 2007; Baker &

Wang, 2004; Begum, 2012; Betteridge, 2012; Harbidge, 2015; Read et

al., 2016; Smiley, 2001b).

There were several themes which occurred consistently across

most qualitative studies. These included participants reporting

insufficient training, theory and/or guidance on addressing spiritual

issues in clinical practice

(Arshad, 2007; Baker & Wang, 2004; Harbidge, 2015; Malins, 2011;

Mills, 2010; Mulla, 2012; Myers & Baker, 1998). Spirituality was

described as hard to discuss and to put into language (Begum, 2012;

Crossley & Salter, 2005; Harbidge, 2015; Malins, 2011) and in line with

the BPS code of ethics and conduct (BPS, 2009) the importance of

maintaining a curious, open therapeutic stance which respects and

addresses differences in beliefs was emphasized (Arshad, 2007;

Betteridge, 2012; Crossley & Salter, 2005; Harbidge, 2015; Malins,

2011). However, in Harbidge (2015) it was noted that although these

therapeutic aims were widely endorsed, when requested, few examples

of engaging with spirituality in practice were forthcoming.

The impact of wider context was also noted across several studies.

NHS culture and time constraints of public sector work were seen as

limiting what can be discussed, and spirituality was reported to be a

secondary, ‘luxury’ topic (Betteridge, 2012; Harbidge, 2015; Malins,

2011; Mills, 2010; Mulla, 2012). The scientist-practitioner model

espoused by clinical psychology was considered to be at odds with

openness to spiritual ideas in two studies (Begum, 2012; Mills, 2010).

A reluctance to disclose one’s own position to colleagues or clients

was also reported in several studies (Baker & Wang, 2004; Betteridge,

2012; Malins, 2011; Mills, 2010). This may link to the wider social

discomfort around these topics which was identified (Betteridge, 2012;

Crossley & Salter, 2005; Harbidge, 2015), and to individuals’

expectation of negative reactions from colleagues (Baker & Wang,

2004; Betteridge, 2012; Malins, 2011; Mulla, 2012; Myers & Baker,

1998). Three of the five studies where negative colleague reactions

were reported or anticipated were those which specifically interviewed

religious CPs. It may be that the experience of being a religious

psychologist working in the NHS increases the expectation of a hostile

response. As Malins

(2011) and Mulla (2012) did not report the levels of religiosity in their samples,

it is not possible to examine its impact. The sense of risk in discussing these

topics in a work setting contrasts with Harbidge’s (2015) report that participants

talked about these topics lightly. This difference may partially be due to the

majority of Harbidge’s sample having no religious affiliation.

Participants in qualitative studies that specifically recruited

religious individuals viewed their religiosity as enhancing their ability to

engage with spirituality, and bolstering personal resilience at work

(Baker & Wang, 2004; Betteridge, 2012; Myers & Baker, 1998). This is

consistent with Smiley’s (2001b) finding that a greater proportion of

religious individuals than nonreligious individuals, reported that their

beliefs enhanced clinical practice.

Beyond these core themes, disparate findings were reported

across the studies, in part reflecting variations in the research questions

investigated and methods of analysis. The influence of past experiences

on current practice was recognised (Begum, 2012; Harbidge, 2015;

Mills, 2010), and participants described feeling more comfortable with

spirituality than religion (Begum, 2012; Harbidge, 2015). An increased

sense of difficulty was reported when aspects of clients’ beliefs were

disagreed with (Smiley, 2001a) or appeared to contribute to client

distress (Crossley & Salter, 2005). Some studies reported an

acknowledgement that religion can be either helpful or detrimental

depending on the meanings made and how religious beliefs relate to

negative experiences (Crossley & Salter, 2005; Harbidge, 2015; Smiley,

2001a).

One study reported that participants aimed to challenge unhelpful

religious beliefs, but saw this area as ‘hard work’ (Arshad, 2007).

Trainees in Mill’s (2010) study reported fearing being seen as biased or

ignorant, and that their lack of expertise may damage the therapeutic

relationship. Similarly, Smiley’s (2001a) non-religious psychologists

spoke of their ignorance regarding religious issues. Two studies

reported that these topics may be rephrased in order to be acceptable in

clinical settings, such as referring to ‘existential issues’ or ‘values’

(Begum, 2012; Malins, 2011). Mulla (2012) noted that her participants

distanced themselves from religion, viewing it as ‘other’.

Discussion

This review covered thirteen papers, eleven qualitative interview

studies and two quantitative questionnaire studies. Psychologists taking

part in the research tended to report a lack of training and guidance in

this area, and discomfort with the topic. Overall, religiously committed

individuals are more likely to view their beliefs as positively influencing

their practice, and report reluctance to disclose these beliefs at work.

Trainee psychologists do not endorse a spiritual understanding of

mental illness, but are less opposed to this than psychiatry trainees.

NHS culture, societal attitudes and the scientistpractitioner model were

all reported as constraining the profession’s engagement with these

topics. The importance of maintaining a curious and open stance which

respects clients’ beliefs and addresses difference in therapy was also

highlighted.

A notable limitation of this review is the high proportion of

unpublished doctoral theses included. Whilst including unpublished

studies in a systematic review when eligible and appropriate can help to

minimise publication bias (Higgins & Green, 2011), it can introduce other

biases. For example, researchers may be more reluctant to share

unpublished studies with no significant results, and unpublished studies

may be poorer quality than published studies (Egger, Jüni, Bartlett,

Holenstein, & Sterne, 2003), although this has been disputed (Hopewell,

2004). The absence of peer review which can call unpublished studies

into question (Higgins & Green, 2011), is less relevant for the studies

included here, as they have been examined at doctoral level. Whilst

most of the unpublished studies scored reasonably on the CASP, scores

on rating scales are themselves prone to bias (Petticrew & Roberts,

2006).

A further limitation of this review is the lack of availability of a

second researcher to assess the eligibility of a portion of search results

for inclusion. Similarly due to a lack of resources, inherent in

undertaking a review as part of a doctoral research project, it was not

possible to include a second rater to check the assessment of study

quality.

The lack of publication may indicate that this area is not a priority

for clinical psychology, or may be an artefact of the context in which the

research was generated, as many doctoral theses are not submitted for

publication. The research reviewed spans two decades; this has

increased over the last five years, with almost half the studies being

carried out in that time. This suggests interest in these areas is

increasing. A lack of training and guidance was raised in even the most

recent qualitative research (Harbidge, 2015), indicating that the lack of

publication has resulted in poor dissemination of the results and minimal

impact on training.

All of the studies were undertaken as part of doctoral training. This

may have made themes related to training quality particularly salient.

Similarly, of the twelve authors, nine have their own religious faith (six

Christians and three

Muslims), and two reported religious heritage but current non-practice

(one

Jewish, one Muslim). Only for one study was the spiritual background of

the researcher not discernable. The religious beliefs of the researchers

may introduce bias at various stages. It may affect the choice of

research question or methodology. For qualitative research, it may

influence the interview schedule, as well as impacting on analysis and

the salience of different themes. In some studies the potential influence

of the researcher on the interviews or on the development of themes

during analysis was acknowledged. Attempts to address this were made

in some studies, for example, by making possible concerns explicit in

the interview, or asking supervisors and non-religious peers to check

qualitative analysis.

As all of the studies relied on individuals volunteering to take part,

the participants were more likely to be interested in, or have strong

views about, spirituality. This is the case for all except Read et al.

(2016), which did not focus solely on spirituality. The extent of this bias

could not be fully assessed across all studies as several did not report

the proportion of the total population that took part.

One author acknowledged that, because the topic was

uncomfortable, people talked generally rather than about their personal

experiences, making IPA less appropriate as a method of analysis. This

discomfort may have introduced a bias across the qualitative papers,

with participants potentially speaking in abstract and politically correct

ways.

The literature reviewed above has all been based on either

questionnaire or individual interview data. It could be argued that

research has failed to attend to the social aspect of decision making and

influence of professional training, culture, and colleagues on values and

practice (Goffman, 1986). Future research should examine the impact of

professional discourses and group dynamics on how these topics may,

or may not, be addressed in training cohorts and staff teams. As it is

designed and delivered, the impact of training on staff and clients should

be studied, with training modified and reassessed on the basis of the

findings.

Questionnaire research has looked at attitudes in the South East

of England. It would be helpful for this to be repeated in other areas of

the UK to see whether responses differ. Building on the consistent

report of a lack of training in this area, future research could examine

the effectiveness and acceptability of proposed training methods or

models across trainee or qualified psychologists.

Conclusion

A relatively small number of studies have been conducted in the

UK exploring the attitudes, beliefs and practices of CPs in relation to

spirituality. Some CPs are religiously committed and view their faith as

enhancing their clinical practice. However, population studies suggest

that the majority are not religiously affiliated and believe their practice to

be value free. Most studies find that psychologists describe these topics

as difficult and report insufficient

training and guidance.

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Appendix A

Search Terms and Results

03/11/16 – Searched PubMed 2,804 Results

((Spiritual*[Title/Abstract] OR religio*[Title/Abstract] OR

faith[Title/Abstract] OR sacred[Title/Abstract]) OR

(Spiritual*[Supplementary Concept] OR religio*[Supplementary Concept]

OR faith[Supplementary Concept] OR sacred[Supplementary Concept])

OR (Spiritual* OR religio* OR faith OR sacred[MeSH Major Topic])) OR

(Spiritual*[MeSH Subheading] OR religio*[MeSH Subheading] OR

faith[MeSH Subheading] OR sacred[MeSH Subheading])) OR (Spiritual*

OR religio* OR faith OR sacred[MeSH Terms])) AND ((clinical

psycholog*[Title/Abstract]) OR (clinical

psycholog*[Supplementary Concept]) OR (clinical psycholog*[MeSH

Major Topic]) OR (clinical psycholog*[MeSH Subheading]) OR (clinical

psycholog*[MeSH Terms]))

04/11/16 – Searched PsychInfo Via open Athens HDAS 3,728 Results

Document title, abstract, identifier (keyword), Exact major subject

heading, Exact subject heading, subject heading, subject heading all,

word in major subject heading

1 Spiritual*

2 religio*

3 faith

4 sacred

5 clinical psycholog*

6 1 OR 2 OR 3 OR 4

7 6 AND 5

13/12/2016 – Searched Web of knowledge 94 results

TS=((Spiritual* OR religio* OR faith OR sacred) AND “clinical

psycholog*”)

Appendix B CASP Qualitative Research Checklist

(CASP, 2013)

Item

Question

Was the research design appropriate to address the aims of the research?

Was the recruitment strategy appropriate to the aims of the research?

Was the data collected in a way that addressed the research issue?

Has the relationship between researcher and participants been adequately

considered?

Have ethical issues been taken into consideration?

Was the data analysis sufficiently rigorous?

Is there a clear statement of findings?

Is the research valuable?

SCHOOL OF PSYCHOLOGY

DOCTORATE IN CLINICAL PSYCHOLOGY

EMPIRICAL PAPER

What Can and Cannot be Said: Discourses of Spirituality and Religion

Clinical Psychology

Trainee Name: Elizabeth Challis

Primary Research Supervisor: Dr Janet Smithson

Senior Lecturer, University of Exeter

Secondary Research Supervisor: Professor Ed Watkins

Professor of Experimental and

Applied

Clinical Psychology/Director of

Research for

Professional Doctorates

Target Journal: Qualitative Health Research

Word Count: 7,995 words (excluding abstract, table of

contents, list of figures, references,

footnotes, appendices)

Submitted in partial fulfilment of requirements for the Doctorate Degree

in Clinical Psychology, University of Exeter

Abstract

Objective: To examine the discourses used by trainee and qualified

clinical psychologists from the South West of England to manage

discussions of spirituality and religion as they relate to clinical practice.

Methods: Four focus groups were carried out with a total of 25 qualified

and trainee clinical psychologists.Transcripts were analysed using

discourse analysis.

Results: Three key discourses were identified, giving insight into how

cohorts of qualified and trainee clinical psychologists manage

discussions of these difficult topics. These were: balancing medical and

therapeutic discourses, particularly when discussing psychosis and

religious or spiritual beliefs; positioning and the Other, including religion

and spirituality as a proxy for talking about race; and negotiating what

can or cannot be said, principally when sharing personal views.

Conclusion: Ensuring that clinical psychologists have an awareness of

the different discourses in use within the profession and how these may

impact practice is important. Explicit discussion of the medical and

therapeutic discourses likely to arise across different settings should be

encouraged, including how these can constrain discussions around

difficult topics such as spirituality and religion, race, and sexuality.

Training should equip psychologists to have an awareness of othering,

particularly in relation to religion or spirituality and race, and the

potential effects this could have on power and engagement in therapy

and broader work.

Keywords: Discourse Analysis, Spirituality, Religion, Culturally Sensitive

Practice, Clinical Psychology

Introduction

Spirituality and Clinical Psychology

Over a decade ago the Mental Health Foundation (MHF, 2006)

reviewed the literature examining the impact of spirituality on mental

health, and recommended that spiritual and religious needs routinely be

discussed with service users in mental health settings. However,

qualified clinical psychologists (CPs), and trainees (TCPs) report a lack

of training and guidance on addressing spiritual and/or religious material

in clinical practice (Arshad, 2007; Baker &

Wang, 2004; Harbidge, 2015; Malins, 2011; Mills, 2010; Mulla, 2012;

Myers & Baker, 1998). While national guidelines for including spirituality

and religion into healthcare are available (Commission for Healthcare

Audit and Inspection, 2007; Department of Health [DoH], 2009), their

primary focus is physical health services. The British Psychological

Society (BPS) only broadly acknowledges that religious diversity should

be recognised and respected in ethical conduct and psychological

formulations (BPS, 2009; 2011).

An apparent ‘discomfort’ between UK clinical psychology and

religion has been noted (Peden, 2012), supported by research in which

CPs and TCPs report difficulty discussing spirituality and religion

(Begum, 2012; Crossley & Salter, 2005; Harbidge, 2015; Malins, 2011).

This difficulty likely impacts training provision, guideline development

and reflection by individuals and teams. Given national documents

promoting discussion of spirituality and religion in mental health

services, the perceived lack of training and guidance, and that clinician

attitudes impact clinical decision making (Gartner, Harmatz, Hohmann,

Larson, & Gartner, 1990), clinical psychology as a profession needs to

better engage with these topics. This is key as they may influence

engagement, from both clinician and client, which in turn has been

shown to impact therapeutic outcomes (Horvath, 2001).

The current literature on clinical psychology, spirituality and religion

is based almost exclusively on interview data (e.g., Harbidge, 2015;

Malins, 2011; Mills, 2010;Mulla, 2012). However, practice is constrained

and shaped by professional roles, training, and the expectations of

colleagues (Goffman, 1986). Individuals’ responses vary depending on

context, who is addressed and how one is positioned in relation to them

(Billig, 1988; Willig, 2000). What individuals say during interviews with

researchers who are investigating this area, may therefore differ from

the normative professional discourses that exist in wider professional

training and work contexts.

This study builds on previous research on the attitudes of

individual psychologists by conducting focus groups with professional

colleagues to see how they negotiate these controversial topics.

Although not a natural setting, focus groups can provide access to a

population within its social context (Hoppe, Wells, Wilsdon, Gilmore, &

Morrison, 1994; Kitzinger, 1994). Analysis looking at what strategies and

discourses are used in discussing spirituality and religion can inform the

design and delivery of future training. As prior research has particularly

identified a reluctance to disclose one’s own beliefs to colleagues

(Baker & Wang, 2004; Betteridge, 2012; Malins, 2011; Mills, 2010)

attending to examples of where and how this reluctance is overcome (if

at all) may be particularly useful.

Focus Groups and Discourse Analysis

Focus groups produce interactive data which allow for the

negotiation and construction of meaning to be studied (Wilkinson, 1998)

and public discourses examined (Smithson, 2000). Focus groups can

be particularly useful for identifying obstacles preventing adherence to

guidance, or limiting behaviour modification (Wilkinson, 1998). This is

relevant to the discussion of spirituality and religion, which is

recommended (DoH, 2009; MHF, 2006) but uncomfortable for CPs

(Peden, 2012).

Discourse analysis (DA) views language as performing social

actions like persuasion, entertainment, blame or justification, rather than

expressing stable internal states such as attitudes or opinions (Potter &

Wiggins, 2007). It is more than a method of analysis, encapsulating a

social constructionist or critical realist epistemology (Billig, 1997), and

recognising the role discursive practices play in constructing, rather than

simply describing, reality. It is supported by research demonstrating that

people express different views in different settings (Billig, 1988), and

that power and position are (re)negotiated and maintained using

discursive practices (van Dijk, 1993). A glossary of key DA terms used in

this study is provided in Appendix A.

When studying individuals within professional and institutional

settings discourse is a key domain for research (Edwards & Potter,

2001). Positioning theory (Davies & Harré, 1990) is one aspect of DA

which examines what an individual may or may not do or say within a

professional context; how their positions and subsequent actions are

constrained (Harré, Moghaddam, Cairnie,

Rothbart, & Sabat, 2009). It asks: “Who speaks? In whose name do

they speak? Who do they address? Who do they speak for?” (Georgaca

& Avdi, 2011, p. 155). The ways individuals and groups position

themselves, each other, and the clients they serve will define how CPs

practice.

Attending to the detail of focus group talk, participants’ rhetorical

strategies and discursive agendas, is key when the topic is sensitive or

potentially inflammatory, and individuals risk accusations of prejudice,

bias or unprofessionalism (Potter & Wetherell, 1988). Individuals may

speak to forestall argument or portray an utterance as objective, rather

than opinion or evaluation (Jørgensen & Phillips, 2002).

This study expands the existing literature by examining the

discursive strategies which may impact the construction of professional

discourses in this area. Where past research has looked only at

interview or survey data, and has not considered discursive influences,

the use of DA and focus groups in this study allows for the interactions

between CPs and TCPs to be explored.

This study aims to answer the following research question: What

discourses do TCPs and CPs from South West England use to manage

discussions of spirituality and religion as they relate to clinical practice?

Method

Participants

Trainee and qualified psychologists from Exeter University and

Somerset Partnership NHS Foundation Trust were approached to

participate in focus groups between October 2016 and January 2017.

First year trainees were excluded as at this time they had minimal

clinical experience on training. All second and third year trainees were

approached to participate. To facilitate open discussion the focus groups

were carried out as professional cohorts. Trainees were not in focus

groups with qualified psychologists; second and third year trainees were

in separate groups. Qualified groups were planned within specialisms.

Potential participants were contacted by email with a brief

description of the study and participant information sheet (Appendix B).

They were invited to ask questions and express interest via email.

Trainee psychologists were also approached as a cohort to request

participation, particularly of those with little interest in religious or

spiritual matters.

Participants were not asked explicitly about demographic

categories such as ethnicity, gender or religious affiliation. DA

acknowledges that the context of how, where and by whom people are

addressed will influence how they respond or the positions they take up.

Asking for demographic information via a questionnaire or at the start of

the focus groups would set a particular context, and may have

constrained the positions which individuals felt were available to them in

subsequent discussions. Not asking participants to choose a particular

‘category’ for their religious or spiritual views also aimed to avoid unduly

influencing how I interacted with them and their discourses during

facilitation, transcription or analysis, based on how they had identified.

Four focus groups were carried out, three with trainees and one

with qualified psychologists. Of the 14 individuals in the second year of

training at Exeter, nine (64%) participated. Of the 13 trainees in year

three, 12 (92%) took part across two groups. The qualified focus group

included all four psychologists present at the bimonthly specialism

meeting. Overall 81% of those contacted agreed to participate.

Design

The study used a qualitative focus group design. DA methodology

was used to examine how professional cohorts discussed the inclusion

of spirituality and religion in clinical work.

Procedure

Ethical Approval. The study was approved by the University of Exeter

School of Psychology Ethics Committee and the Health Research

Authority (Appendix C). At the start of the focus group individuals were

asked to read the participant information (Appendix B) and opportunity

was given to ask questions. The voluntary nature of the research and

right to withdraw were emphasised. Participants were asked to respect

the confidentiality of other group members and the limits of

confidentiality for research carried out in a group setting were

highlighted. If happy to participate individuals then signed a consent

form (Appendix D). A debrief sheet (Appendix E) was provided after the

group.

Focus Group Schedule. A focus group schedule was developed

based on the existing literature, covering participants’ views on and

experience of talking about spiritual and religious matters with clients,

supervisors, and in training. A pilot interview was conducted with a Band

7 clinician from specialist psychological services. This identified possible

prompts, checked intelligibility and ensured flow of topics. It also served

as an opportunity for me to prepare for the role as researcher and group

facilitator. The resulting schedule (Appendix F) was applied flexibly to

maintain the flow of discussion as far as possible. Slight changes were

made to adapt the schedule for use with qualified staff (e.g. asking

about current practice as supervisors rather than future expectations).

The groups lasted between 45 and 70 minutes and were audiorecorded.

I transcribed each focus group within a week of completion using

Jefferson notation (Jefferson, 2004; see Appendix G). Completing

transcription prior to

the subsequent group aimed to increase recall of non-verbal

communication and aid with sections of poor sound quality.

Method of Analysis

The analysis was based on a discursive psychology approach, a

form of DA concerned with how psychological business is conducted in

talk. In particular, I focussed on how people attend to identities, attitudes

and cognitions (Potter & Wiggins, 2007). I also focussed on positioning

theory

(Davies & Harré, 1990), looking at how individuals’ discourses were

used to position themselves and others to construct relevant identities,

and participants’ discursive agendas (Georgaca & Avdi, 2011), the

rhetorical strategies individuals employed to manage and influence the

interaction. Although discourse analysts typically emphasise the

importance of the overall approach rather than specific rules, seven

steps to good practice in discursive research have been put forward by

Potter and Wiggins (2007) and were used to guide this research

(Appendix H).

The transcripts were initially coded in NVivo, identifying discourses

which emerged from the transcripts when focusing on positioning,

discursive agendas, and the influence of power and context on the

discussion. Key discourses were chosen for in-depth analysis based on

emergence across all four focus groups with reasonable coverage

(summary table in Appendix I). Discourses which occurred across all

groups were chosen to minimise bias. Representative extracts were

selected illustrating the discourses and discursive practices in use

(Jørgensen & Phillips, 2002), ensuring consistency with the analysis of

the transcripts as a whole (Potter & Wetherell, 1987). Extended extracts

are included to allow the reader to judge the coherence and plausibility

of the analysis. Coherence and plausibility form the basis of validity in

DA, alongside grounding analysis in previous research (Wetherell,

2001).

Quality Checks

DA acknowledges that research is itself a discursive activity and

the context of the research and the researcher cannot be partialled out

from the analysis (Jørgensen & Phillips, 2002). Coherence and

plausibility form the basis of validity in DA, alongside grounding analysis

in previous research (Wetherell, 2001). Coherence requires that analytic

claims form a coherent discourse, with all aspects of the analysis being

consistent with the analytic account. Plausibility is in part achieved by

situating the research within existing knowledge, and requires that the

account appears plausible and persuasive (Wood & Kroger, 2000).

Extended extracts have been presented in this write up to allow the

reader to assess both coherence and plausibility in the analysis (Madill,

Jordan, & Shirley, 2000).

Fidelity to DA methodology was ensured by presenting extracts

from the data at a DA researchers’ group and discussing the analysis

and findings with clinical psychology qualitative students. Further the

analysis and findings were reviewed by both my primary supervisor, a

discourse analysist, and secondary supervisor, a clinical psychologist.

Results

Analysis

The key discourses selected for analysis were: balancing medical

and therapeutic discourses, particularly when discussing psychosis and

religious or spiritual beliefs; positioning and the Other, including religion

and spirituality as a proxy for talking about race; and negotiating what

can or cannot be said, principally when sharing personal practice.

Definitions of othering, and medical and therapeutic discourses are

provided in Appendix A.

Balancing medical and therapeutic discourses. The medical

discourse attributes individuals’ religious or spiritual experiences to a

diagnosis of psychosis (Georgaca, 2004). It views symptoms as

indicative of a diagnosable disorder, usually of organic aetiology, and

positions individuals as “ill”. This discourse was present in all groups,

alongside, and in contrast to, a therapeutic discourse, in which religious

or spiritual experiences were viewed as either helpful or unhelpful

(Georgaca & Avdi, 2011). Couching discussions of spirituality or religion

within the medical discourse strongly positions clients as pathological

(Georgaca, 2004).

Extract one. This extract comes from group three, which had eight

members, all third year trainees. It was coded primarily under balancing

medical and therapeutic discourses, but includes disclosure of personal

spiritual beliefs (lines 14-16). The extract is split into two parts for ease

of reading.

Extract 1a

8 C5: mine was with a adult, because she had a psychotic

↑episode and 9 it was all around her, it was all around like

religious ideas and stuff so

10 she’d had experience of kind of erm, something kind of coming

into her

11 and she, something she described as God, and she talked a lot

about

12 like her religious beliefs and this idea that she was like innately

bad

13 and it was like God punishing her in some way, so that was

quite

14 interesting. And quite hard for me, because I don’t believe in

God, 15 (slight laugh) so, I was, I was trying to manage that in

terms of my own 16 (slight laugh) what do I believe about this

kind of thing.

Medical, religious and therapeutic understandings of patient

experience are illustrated in this extract. It forms the response given to

my initial question about people’s experience of discussing religion or

spirituality in clinical work, and focusses on religious, rather than

spiritual beliefs. In starting the discussion, the speaker is responding to

the demands of the focus group setting and my question (Myers, 2007).

She establishes the case as relevant by specifying that the client

attributed the experience to God, which also serves to distance her from

that interpretation (line 11). With this vignette she orients the group to

religion within a medical discourse, with religious experiences attributed

to psychosis (Goffman, 1986; Georgaca, 2004). However, the rising

tone she uses when introducing the term “psychotic episode” (line 8)

and her repeated use of the discourse markers “kind of”, “like”, and “and

stuff”, signal to the group that

she is not overly invested in that description were they to disagree

(Billig, 1988).

The ways in which spiritual experiences are unhelpful to the client

(lines

12-13) are prefixed with “like” and followed with the comment that this is

“quite interesting” (lines 13-14). In describing these things non-factually

(“like”), and as the view of the client, she has taken up a particular

stance (DuBois, 2007), and protected her own position as a non-

judgmental, scientist practitioner (Myers,

2010). The speaker reports discomfort in addressing this topic in

therapy (lines 14-16), and displays unease around disclosing and

questioning her beliefs, which she dispels by laughing (Jefferson, 1984).

Extract 1b

17 R: And how was that

18 C5: Erm… yeah it was ok (2 secs) erm, but I, maybe it was

easier

19 because she was kind of very much, although she was

religious she

20 was very much putting like that experience down to her

psychosis and,

21 and experience of psychotic episode, as opposed to (1.5

secs) actually

22 kind of saying I do actually think kind of God entered me

and all of this

23 stuff. So I suppose I was, it was easier for me to manage it

because I

24 could put it down to a mental health ↑thing as well, because

that’s how

25 she was interpreting it. (1.5 sec) but I don’t know, I can’t

imagine how

26 difficult it would be if you’re saying but I genuinely believed

God, in

27 God, and I believe that God touched me in some way and

other people

28 are just saying “yeah but that’s just your psychosis”, and

like (1.5 secs) 29 I don’t know how that would have played out if

people were doing that 30 differently.

In the second half of the extract, the speaker differentiates the

client’s religiosity from her beliefs with religious content which are

labelled as psychosis. She pauses in line 21, appearing to avoid

contrasting the attribution of experience to psychosis with ‘really

believing it’. The use of the phrases “actually”, “kind of”, and “and all of

this stuff” (lines 21-22) reduce the impact of what is being said. The

client is described as using the medical discourse to make sense of her

experiences (lines 20-21), which the speaker found “easier” to manage

within a mental health setting (Coyle, 2008).

The speaker positions herself alongside the hypothetical ‘believer’

whose

‘genuine’ beliefs are being dismissed as “just psychosis” (lines 25-28),

distancing herself from those making that judgment. This shift from the

medical discourse, which positions the client as psychotic (lines 8-13),

to the therapeutic discourse where one is positioned as alongside the

client, accepting their interpretation of experiences (lines 24-25), meets

the requirement for CPs to respect diverse beliefs (BPS, 2009)

Extract two. The second example of balancing medical and

therapeutic discourses is also drawn from focus group three. The extract

has been split.

Extract 2a

46 C7: yeah, that’s really interesting ‘cause I’ve had similar

experiences 47 about people having protective, erm, things around

errr, their religion.

48 So, erm, when I was working on the inpatient ward actually

49 interestingly it came up more than anywhere else since I’ve

been

50 working. And we had a lady who was very psychotic, and she

had

51 some negative, erm, voices, and she had some positive

voices. The

52 negative voices went away with medication, but the positive

voices

53 didn’t. The positive voice was God telling her she was ok. She

was a

54 nice person, that er, she was valuable and she should be here.

Erm (.)

55 and, interestingly, had a quite interesting conversation with the

56 psychiatrist about why, that meant that then she ↑couldn’t go

home

57 because she still had, these voices. I said those are protective

for her,

58 they (.) they help her function. They are really (.) helping her

still get on

59 with her life. Erm (.) and he was, yeah, he was very [no she

has voices]

60 C1: [s-,s-,s-, so] because it didn’t

61 coincide with his view of reality, that was, erm, blocking her

from 62 returning °back to the community°.

As she introduces this service user the speaker emphasises her

psychosis, stating that she was “very psychotic” (line 50). It seems

important to establish her as a legitimate or even archetypal ‘psychotic

patient’, reinforced by the “negative voices” having resolved with

medication (line 52), aligning with the medical discourse. The distinction

between someone who is very psychotic and someone whose beliefs

are helpful is emphasised. From that point the medical discourse is

attributed to the psychiatrist and religious discourse to the client. The

speaker positions herself outside the medical discourse, arguing against

the psychiatrist, drawing on a therapeutic discourse (Georgaca & Avdi,

2011), emphasising the helpfulness or unhelpfulness of the voices (lines

57-59).

C1’s interjection amplifies the argument against the position

attributed to the psychiatrist (lines 60-62). Her phrasing suggests that

the psychiatrist’s view of reality is no more valid than the client’s,

unusual given the power differential between physician and patient

(Pilnick & Dingwall, 2011). This permits the possibility of alternative

truths, again aligning with the therapeutic discourse rather than the

medical. However, the drop in volume of her voice as she finished

speaking may be a recognition of psychiatry’s continuing power within

mental health services (Georgaca, 2004).

Extract 2b

63 C7: yeh (.) And then, an-, and so that kind of started off a

conversation 64 (1.5 secs) erm, between me and some of the

other patients as well

65 about, religion and religion in terms of erm, mental health, and

just that

66 kind of thing of (.) erm (.) I don’t know people might disagree

with me,

67 but if people say “I am the son of god” or “I am”, erm, you know

“god

68 speaks through me” or whatever (.) instantly in our line of work,

they’re

69 psychotic, there’s something really wrong with them, they’re

grandiose,

70 they’re psychotic. (2 secs) but actually I wonder whether,

sometimes,

71 you know, if it were, if it was a different circumstance and it

was a

72 religious group where people were ↑°speaking in tongues or

73 ↑whatever° [(2 secs), quiet mm’s of agreement] would you see

it as

74 ↑psychotic °experience, I don’t know°. It’s just interesting in

how it can 75 be protective in some (.) situations and not

protective in others.

C7 qualifies the strength of her statement about the assumptions

made in mental health settings (line 66), perhaps pre-empting

disagreement and signalling she does not have an axe to grind

(Edwards, 2003). Most members of the focus group are working in

mental health, and an outright challenge of the medical discourse

dominant in this setting (Bassett & Baker, 2015) may result in counter-

argument. However, despite this qualification, she identifies with clinical

psychology (“in our line of work”, line 68) to support her claim that

individuals reporting religious experiences are positioned as

“grandiose”, ill and “psychotic” (lines 69-70). Her discussion of religious

settings (lines 72-75) is more hesitant, with rising intonation and softly

spoken phrases. It seems that C7 is less confident to speak to these

settings, possibly as some group members are religiously committed.

In this extract and in other groups the term ‘protective’ (Rutter,

1985) was used of religious beliefs as part of the therapeutic discourse

(lines 47,57,75).

This allowed the impact of the belief on individuals’ mental wellbeing to

be assessed, without the need to address their truth or whether TCPs

agree. This is one way that CPs have engaged with spirituality in clinical

settings (Arshad, 2007; Crossley & Salter, 2005).

Positioning and the Other. Although race was not directly asked

about, in all groups it was suggested that discussing spirituality is rare

because of ethnic homogeneity in the South West. Mulla (2012)

highlighted that CPs in her study located spirituality in the otherness of

patients. Othering has been defined as “a process (...) through which

identities are set up in an unequal relationship”

(Crang, 1998, p.61). Constructing the other is a discursive means to

constructing the self and maintaining position and power (Lin & Kubota,

2011; Johnson et al., 2004; Kitzinger & Wilkinson, 1996). By defining the

Other as

“them”, different from ourselves, a self-identity can be established for

“us” which positions us favourably. Othering often occurs on the basis of

race or culture (Johnson et al., 2004; Lin & Kubota, 2011). There are

examples of othering in extracts one and two, as speakers distance

themselves from the client’s position (extract one line 11; extract two

lines 47-50). Within psychology othering of clients, particularly those

with psychosis, can be achieved by positioning them as ill or irrational

(Boyle, 1996).

Extract three. This extract comes from group two, which had four

members, all third year trainees. It follows a question from me about

training, and a joke from B4.

464 B2: It wou-, I, I personally would have found it really helpful to

know

465 more about religion and spirituality because, I, I’m gonna say I

am very

466 ignorant, erm, ok our demographics down here don’t have

huge variety

467 of religions, but elsewhere in the country we would encounter a

lot

468 more [difference] so it would be really interesting to have a bit

of 469 teaching around that to know, you know.

470 B4:[exactly]

471 B2: Some very basics of what you can and cannot say in

certain

472 situations. I dunno, I [think it would’ve been really helpful]

473 B4: [I wonder if part of it] is a sort of south west trap maybe,

that the

474 course has fallen into that trap a little bit it’s just th-, that the

475 demographic’s taken as yeah, white (.) and rural

B2 describes herself as “very ignorant” of spiritual and religious

topics (lines 464-465), and emphases a desire for more teaching in this

area, which would be really helpful (line 464) and really interesting (line

468). Despite initially referencing both spirituality and religion, in line

with previous research (Begum, 2012) she goes on to talk only about

religion, apparently meaning religions beside indigenous Christianity

(lines 466-469). Perhaps to forestall argument, she prefixes her

statement with the disclaimer “personally” (line 464), acknowledging that

the desire for more training may not be shared. Her suggestion that it

would be good to cover “the very basics” (line 471) positions

her as an interested student whose needs have not been met.

The purpose of further training is to know “what you can and

cannot say” (line 471), apparently linked to a wish not to offend people

of diverse ethnicities or religious beliefs. B4 agrees, suggesting that the

course has made assumptions that the local area is “white and rural”

(line 475), implying that spirituality and religion are not relevant, or at

least not problematic, in white, rural areas.

The location of spirituality and religion within the Other has been

noted in previous research (Mulla, 2012). All focus group members were

white. By constructing a discourse of these topics as relevant elsewhere

in the country (lines 466-468), rather than the white South West (line

475), the speakers distance themselves from spirituality or religion as

personally relevant. This may avoid the uncomfortable thoughts about

personal beliefs reported in extract one, and establish individuals as

speaking from a more objective, external position. In focus group one an

individual highlighted the othering process she felt was occurring in the

group.

136 A6: I think in my experience it’s been almost a bit othering, I

think if it

137 was sort of a predominant sort of Christian religion it won’t

necessarily

138 be attended to, but I think if there’s someone from a different

ethnic

139 background or something that some people start thinking about

religion

…

156 A6: I, it, it’s felt to me sometimes like services, when they’re

looking at

157 people, perhaps from a different ethnic background or

something it’s

158 like, it, they’re somehow different therefore be different,

therefore in 159 that sort of respect rather than the kind of

religion being central to their 160 presentation or their

difficulties.

This extract reinforces that religion is only considered relevant

when nonindigenous, other and unknown. This is linked by A6 to

ethnicity (lines 138,157), and therefore race (van Dijk, 1996), being

restated with the qualification that it was how things had felt to her (line

156), dispelling argument. Othering often occurs on the basis of race

(Johnson et al., 2004), preserving the status quo and silencing the

Other (Kitzinger & Wilkinson, 1996). As noted in previous research

(Arshad, 2007; Mulla, 2012), religion appears to be aligned with race,

sometimes under the broader heading of culture.

Extract four. The following extract is from group four, which

had four qualified CP members. It follows me asking about

spirituality and religion in training.

495 D3: And I mean I remember pre-training I worked up in the

West

496 Midlands and it was rea-, obviously very multi-cultural. And we

had, we 497 had training on, on all the different religions and

spirituality etc. 498 Because of the, um, the great possibility of

putting our, a big foot in 499 (laughing) putting our foot in it.

500 Mmm

501 D3: um, and that, but that was very useful but, down in

Somerset it,

502 (laughing) I haven’t had much use for a lot of that. Um (.)

503 D4: it’s changing a little bit [(.) occasionally, I had] a, a very

spiritual… 504 Burmese, lovely lady, who used to=

505 D3: [a little, you see a little]

506 D4: =Salom’ed me when she came in. She was, you just have

507 take it in your stride. [mm] and get her up off the floor and sit

her in a 508 chair (.) And she was absolutely charming

This extract is an example of race and spirituality being combined

under the heading “culture”. The more culturally diverse West Midlands

is assumed to be somewhere that ideas of spirituality and religion are

more relevant. Having positioned herself as someone who knows about

diversity of spiritual and religious beliefs because of previous work (lines

495-497), D3 paints Somerset as somewhere that her existing religious

and racial knowledge and sensitivity is not required (lines 501-502). She

laughs when discussing the possibility of

‘putting one’s foot in it’ when working with individuals from another race

or religion (lines 498-499), apparently expressing discomfort at the

thought (Jefferson, 1984). This may be due to how negative it is to be

seen as prejudiced or racist, particularly at work (Potter & Wetherell,

1988).

As race is a taboo topic (Augoustinos & Every, 2007), the link

made between religion, spirituality and race may make these topics

even more difficult to discuss. By situating spiritual concerns as things

that happen “elsewhere” in the country, in the Other of a different ethnic

group, it perhaps becomes easier for group members to discuss them,

as they position themselves as external and objective. The overall

message from D3 in this extract appears to be that although it may be

regrettable that these topics are not discussed, it is a product of

geography and demographics, rather than clinician choice (lines 501-

502).

The lack of spiritual or religious material in Somerset is challenged

by D4

(line 503), and D3 acquiesces, acknowledging that there is ‘a little’ (line

505). D4 then talks about a past client, presenting her nationality and

spirituality together, furthering the alliance of spirituality and religion with

ethnicity (lines

503-504). She speaks highly positively of the “lovely” lady, who was

“absolutely charming” (lines 504,508), but discusses her spiritual

behaviour as an idiosyncrasy to be “taken in your stride” (line 507). The

matter appears not to be taken seriously, as you need to “get her up off

the floor and sit her in a chair” (lines 507-508), implying that then the

real work can continue.

Extract five. The next, brief, extract comes from focus group

three, comprised of eight third year trainees. The group had been asked

which patient groups they would be more or less likely to discuss

spirituality or religion with. They suggested that spirituality and religion

were less relevant in CAMHS, as young people are “less religiously

orientated”. The below exchange followed.

563 C1: what about young people that are being radicalised?

564 (4 secs)

565 C2: not in North Devon

566 Group: (laughter/giggles)

567 C3: only with this surfing cult.

568 Group: (deeper laughter)

C1 challenges the discourse that was in place in the

discussion, namely that these topics were not relevant for CAMHS

settings. Although explicit mention is not made of race, the

introduction of the racially loaded term “radicalisation” produces a

long pause (line 564), before its relevance is denied and discomfort

diffused by laughter (lines 565-568).

Radicalisation is an increasingly common phrase, including within

the NHS (e.g. prevent training; NHS England, n.d., para. 4), and is,

like terrorism (Jenkins, 1980), a power-loaded term. While

radicalisation is not defined in terms of religion or race, Muslim

individuals form the majority of referrals to the UK’s Channel

programme, which aims to support and divert those at risk of

radicalisation (National Police Chief’s Council, n.d., para.1).

The discomfort both of the challenge and the introduction of a

political and racial term is managed in this extract by denial and

humour (Jefferson, 1984). Jokes are made and the laughter of the

group intensifies, in line with how race is often managed in popular

culture (Howells, 2006). I reoriented the group to think about why

spirituality and religion did not feel appropriate to discuss in

CAMHS, but the idea of radicalisation was not returned to, possibly

as that discourse had been effectively avoided within this

exchange.

Negotiating What Can Be Said. Across the groups some

participants shared their personal religious or spiritual views and

practices. As prior research has reported CPs’ and TCPs’ reluctance to

disclose their position to colleagues or to clients (Baker & Wang, 2004;

Betteridge, 2012; Malins, 2011; Mills, 2010), how this topic is negotiated

within professional groups is key for facilitating meaningful discussion.

Extract six. This extract is from focus group one, carried out with

nine second year trainees, with whom I had minimal previous contact.

This extract occurred close to the end of the hour long group. The

extract is split into two parts.

Extract 6a

722 A4: I wonder if people are less willing to invest time into it because it’s

not 723 spoken about that much in this day and age and thinking about

extremist

724 views like Richard Dawkins that religion’s going to die out, it

won’t exist one

725 day so is that just us like (inaudible) it as well

726 R: he goes further than that, he says it’s um, damaging doesn’t

he= 727 A4: =yeah, he does yeah.

728 A1: But then if you flip it round you’re like is science not just another

form of 729 religion that people have blind faith that you can find the truth.

730 (inaudible) (Group laughter)

731 A2: it’s really interesting having this conversation actually in a

clinical

732 setting compared to when I was working in research where I

was pretty

733 much the only person who practiced a religious (.) faith. And

that was

734 seen as like this major, flaw (laughs) [in my ability to think

clearly or

735 something] ((blushed))

736 (Group laughter)

A4 has previously disclosed his position as an atheist within the

focus group, which received no comment. Here he begins to expand on

that position with reference to a prominent atheistic scientist. While

drawing on his theories, A6 distances himself from Dawkins’ views,

calling him ‘extremist’ (line 723).

When I introduce the more controversial of Dawkins’ arguments, that religion is

harmful (line 726), this discourse is rejected by the group, with a hitherto

unmentioned discourse of science as a version of religion presented (lines

728729). The group laughs, signalling their solidarity and togetherness

(Adelswärd, 1989). A1 equates scientific and religious views of reality (lines

728-729), permitting alternative truths as part of the therapeutic discourse (as

in extract one). A2 then discloses her own religious faith (line 733). She appears

embarrassed (blushing, line 735) and laughs, in contrast to stating that previous

colleagues viewed her as flawed and irrational (line 734). The group join with

her laughter, perhaps working to mitigate her embarrassment (Adelswärd,

1989). A2 had not directly addressed her beliefs previously in the group; her

cohort might have known of her beliefs, but I did not.

A2’s statement that past colleagues considered her thinking to be

compromised because of her religion, and dismissal of this view with the

phrase

“or something” (line 735), may have functioned to forestall similar

argument from the group (Billig, 1988). This discourse of religious belief

as indicating irrationality is similar to the medical discourse of psychosis

mentioned above (Boyle, 1996). The distinction she draws between her

previous academic setting and the current clinical context (lines 731-

732) highlights that different discourses may be at work, and makes

positioning her as irrational less accessible from the current clinical

frame. There is similarity between the academic and medical discourses

on the one hand, and clinical, therapeutic discourses on the other.

Extract 6b

737 A6: That’s crazy

738 A2: tha-that’s the science that informs our practice of course

739 A6: Yeah (.) yeah that’s true, it’s interesting to think actually. I

think we

740 can quite often overlook it as a resource as well because

there’s so

741 much there with the religious communities that’s really positive

and you

742 know we go to the third sector organisations like charities and

you

743 know all sorts of things but I think we’re I dunno maybe I’m

over

744 generalising but we’re maybe more reluctant to kind of get

involved,

745 you know if someone does hold a religion, then getting

involved with

746 their network [their] religious network, whatever that might be=

747 A1: [yeah] =And absolutely

actually

748 because my cousin, um struggles with um bipolar and her like

749 cousin and family are all, um Mormon, and actually the support

they

750 received from the community is massive, erm, like not even j-,

751 financially as well because if you think about a lot of churches

people

752 pay in money to support the community and stuff and like

financial

753 when she couldn’t work, she’d been admitted and all that stuff

like, it-I,

754 you are right actually, there’s a lot of stuff we could tap into

there=

755 A6: =The really like practical aspects of religion

Following A2’s disclosure A6’s response is supportive, calling the

attitudes of past academic colleagues “crazy” (line 737). She appears

keen not to alienate other members of the group, adding “I dunno

maybe I’m over generalising” (lines 743-744) before speaking from a

position within psychology, of a professional reluctance to engage with

religious groups (lines 744-746). She simultaneously distances herself

from religious individuals (lines 745-746), making reference to religious

communities, a phrase which can be shorthand for minority ethnic

groups (Bauman, 1996).

A6 describes religion as a possible resource which psychology

could tap into (line 740-724). A1 agrees with her (line 747) and recounts

personal experience of religion being socially and financially helpful

(lines 748-754). An explicit move is made away from the difficult topics

of personal belief and professional disagreements. A1 differentiates

“just” social or spiritual support from financial support (lines 751-753),

which is furthered by a latched statement from A6 highlighting the

“practical aspects” of religion (line 755). These more concrete and

positive ideas seem easier for the group to discuss than the more

controversial topics of what individuals do or do not believe.

Discussion

This study aimed to explore what discourses TCPs and CPs from

South West England used to manage discussions of spirituality and

religion in clinical practice. The key discourses identified demonstrate

how Othering (Johnson et al., 2004), particularly in terms of race (Lin &

Kubota, 2011), can be used to position spirituality as something distant,

allowing discussions to appear more objective and not relevant to work

in the South West (extract four). The medical discourse of spiritual and

religious experiences as indicative of psychosis (Georgaca, 2004) was

also drawn on. TCPs could thereby partially avoid engaging with their

own beliefs (extract one), but experienced tension with the therapeutic

discourse (extract two). The analysis illustrated how medical and

therapeutic discourses were used in turn to allow TCPs and CPs to

occupy positions both as distant from religious experiences, and yet

distant from the medical discourse which might be seen to pathologise

them.

An apparent distinction exists between acceptable personal beliefs

and what can be expressed in professional settings (extract six). This is

not unique to psychology, with the UK media reporting cases where

personal beliefs and professional practice have been differentiated,

including bakers refusing an order due to religious beliefs (BBC, 2016),

and a potential headscarf ban in some workplaces (BBC, 2017). This

analysis demonstrated how groups of clinical psychologists can reject or

take up different discourses in order to manage the demands of a focus

group (Myers, 2007) whilst also moderating the views expressed or

permitted within the group.

The analysis shows some discursive strategies TCPs and CPs use

when discussing spirituality in focus group settings, which are common

to other taboo topics. These include laughter (Jefferson, 1984), tentative

or personalised speech (Edwards, 2003) and discourse markers such

as “you know” or “like” (Edwards, 2003). Although spirituality and

religion were asked about, most of the talk focused on religion, despite

a preference being stated for “spirituality”. This is similar to past

research (Begum, 2012; Harbidge, 2015), and may be linked to poor

familiarity with appropriate language (Crossley & Salter, 2005) or the

inadequacy of language to capture spiritual ideas (Coyle, 2008).

Analysis of the discourses in use expanded previous findings by

highlighting that not only was religion discussed more frequently than

spirituality, particularly when discussing examples from clinical

experience, it was often, though not exclusively, connected with othering

on the basis of race, culture or ethnicity.

The extracts and analysis provide insights into how spirituality and

religion are discussed and negotiated within groups of TCPs and CPs.

Although limited to a relatively small number of clinicians in South West

England, some possible implications for training and practice can be

cautiously drawn out.

Implications for Clinical Psychology Practice

Psychology’s dual position as an academic discipline and clinical

profession creates tension for TCPs. Spirituality appears to be more

acceptable in clinical or therapeutic contexts than in medical or

academic ones, and TCPs are explicitly positioned between the two.

The medical discourse linking spirituality with psychosis (Georgaca,

2004) must be reconciled with the requirement for culturally sensitive

formulation (BPS, 2014), recognition of vital nonspecific relational

factors such as validation (BPS, 2014), and the ethical value of respect

(BPS, 2009). This tension was highlighted in extracts one and two,

arising across all groups. Making the contrast explicit in training may

allow more dialogue and reflection about how different professional

identities can be accommodated.

Race is a key area of diversity and has been poorly differentiated from

religion by CPs in some past research (Arshad, 2007; Mulla, 2012). In

this study

TCPs and CPs across all groups linked religion and race, and viewed

the South

West’s ethnic homogeneity as explaining the lack of engagement with

spirituality and religion in their practice. Facilitating discussion of

othering in training, for example when discussing social identity theory

(Tajfel, 1981), may be helpful for TCPs, and could highlight the potential

for religion and spirituality to function as shorthand for many kinds of

othering. Clinical vignettes could promote discussion of how religion or

spirituality may present, serving to reduce the stereotype that it occurs

primarily with clients from minority ethnic groups or diagnosed with

psychosis. This may help to counter the position taken up within the

focus groups of participants as interested (extract three) or informed

(extract four) clinicians, who do not discuss spirituality due to its

irrelevance to local populations.

Clinicians may avoid addressing these topics if they view the risk

of offending clients as more damaging than the omission of spirituality.

However, it is possible to equip non-religious professionals to interact

helpfully around religion with individuals for whom it is important (Good,

2010; Worthington &

Sandage, 2001). Facilitating discussion of spirituality during training

may equip TCPs to talk more helpfully and comfortably with clients

when qualified. For example, experience of taking a spiritual history

from patients while training improves clinicians’ view of, and comfort in,

doing so (Gonçalves et al., 2016). If discussing spiritual or religious

matters was included as a competency in training, this may increase

exposure and help to decrease difficulty in these areas.

NHS Education for Scotland (2009) recommends that spiritual

education for health professionals incorporates time to discuss personal

and professional experiences of spirituality. However, psychologists who

value religious beliefs or spiritual experiences may fear being positioned

as irrational (Boyle, 1996) if they share their position. In this study

participants used rhetorical strategies to avoid offending others, and

positioning and stance-taking to preserve their sense of identity whilst

expressing potentially controversial views. The inclusion of facilitated

debates in training which require individuals to adopt a more extreme

stance, could give permission for controversial ideas to be expressed

and considered without threatening trainees’ identity as “good” TCPs.

The idea of religion as a potential protective factor or resource

(extracts two and six) may help scientist-practitioner TCPs and CPs to

engage meaningfully with spirituality (Thayne, 1998). Focussing on the

potential benefits (or risks) of spirituality could make discussion of how

to integrate this into practice more manageable, as the truth of beliefs

and personal positions can be avoided.

Limitations

This study relied on individuals volunteering to participate, which

may have resulted in a bias towards those with strong views about

spiritual and religious topics. Specifically highlighting the value of

hearing from disinterested parties aimed to reduce this, and positively

the majority of potential participants did volunteer.

The study was skewed towards the views of current trainees (three

of four groups). Two qualified groups were planned, but the second was

cancelled by the host Trust due to budget constraints. As the context of

clinical psychology training is one of assessment and performance, with

individuals regularly observed and evaluated, there is a need to be seen

to “get it right” and respond with acceptable clinical psychology

discourses. Although this research aimed to examine the normative

discourses which focus groups generally (re)produce (Smithson, 2000),

this also limits what will have been shared. This is likely to have been

particularly pronounced in trainee groups where participants knew each

other well and professional norms were developing (Leask, Hawe, &

Chapman, 2001). The participants who are part of my training cohort

know that I have personal religious beliefs, and other participants may

have assumed my motivation for this research. This will have influenced

what was said, as individuals maybe tried not to offend, to educate, or

challenged assumed views.

Demographic information, including religious and/or religious

beliefs, was not collected for TCPs and CPs taking part in this research.

Whilst this meant that these labels did not influence my interpretation as

a researcher, it also means that impact of beliefs cannot be

systematically explored, nor individuals self-identified ethnicities

examined.

All participants live and work in South West England. As noted in

the groups, the area is ethnically homogenous, and a lack of exposure

to cultural and religious diversity was reported. It is possible that this

lack of exposure means individuals were less comfortable discussing

these topics, and findings may not be generalizable to clinicians working

elsewhere. Furthermore, that the majority of the participants (both CPs

and TCPs) had an existing relationship with myself will have impacted

how the focus group was facilitated, what participants felt able to share,

and, to an extent, the analysis. There may also have been concerns

from TCPs taking part about the limits of confidentiality for research

being undertaken in the department where they were also training.

Researcher Reflexivity

In qualitative research on spirituality (West, 2009) the relationship

of the researcher to the material needs to be made clear via personal

reflexivity (Madill et al., 2000), which acknowledges how personal

interests and values influence research from initial ideas to outcome

(Banister, Burman, Parker, Taylor, & Tindall, 1994). Functional reflexivity

is key in DA and requires

“continuous, critical examination of the practice/process of research to

reveal its assumptions, values and biases” (Wilkinson, 1988, p.495).

My own position as a committed Christian and TCP influenced my

interest and opinions on spirituality and religion, and the saliency of

discourses during analysis. My clinical experience of individuals of faith

expressing fear of judgment or criticism for their beliefs also influenced

my choices and interpretations. As a member of the clinical psychology

profession, and of the same training cohort as two of the groups, there

may have been aspects of culture or professional discourses which I

overlooked. This was mitigated by receiving feedback from discursive

researchers outside the profession. Such

‘confessions’ do not bracket the influence of these factors (West, 2009),

and should not reduce criticism of observed stake and interest (Potter,

Edwards, & Wetherell, 1993), but hopefully can help readers to critically

assess their impact on this research.

The assumptions of DA about the function and use of language

have been outlined above. My choice to focus on positioning, rhetorical

strategies and identity influenced the discourses identified from the

transcripts. With more time and resources further analysis would be

possible and other discourses could be

identified.

Further research with professional cohorts working in areas which

are more ethnically diverse would help to establish whether positioning

religion as Other occurs generally on the basis of race, or if this is

heightened by a lack of exposure in clinical practice. Similarly, repeating

this research with cohorts which are more ethnically diverse would also

be useful. Conducting DA on course materials which address spirituality

could also help to examine the ways that training may influence and

perpetuate professional discourses in this area.

Conclusion

This study adds to previous research into the professional attitudes

of psychologists to spirituality and religion by examining the normative

discourses that were constructed between professional cohorts during

focus group discussions. Three key discourses were identified, giving

insight into how professional cohorts of TCPs and CPs manage

discussion of these difficult topics. These were: balancing medical and

therapeutic discourses, particularly when discussing psychosis and

religious or spiritual beliefs; positioning and the Other, including religion

and spirituality as a proxy for talking about race; and negotiating what

can or cannot be said, principally when sharing personal practice.

Ensuring that clinical psychologists have an awareness of the

different discourses in use within the profession and how these may

impact clinical practice is important. Explicit discussion of the medical

and therapeutic discourses likely to arise across different settings

should be encouraged, including how these can constrain discussions

around difficult topics. Training should equip psychologists to have an

awareness of othering, particularly in relation to religion or spirituality

and race, and the potential effects this could have on power and

engagement in therapy and broader work. The discursive practices

highlighted here, and implications for training, have relevance not only

to spirituality and religion, but also to other “difficult” topics, including

sexuality,

ethnicity and race.

What Can and Cannot be Said (Discourses of Spirituality and Religion in Clinical Psychology)

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