Creating Sacred Space: Spirituality in the Medical Encounter—Part 2

Creating a Safe Space for Client Spiritual Exploration

Michelle Pearce, PhD

When Allison walked into my office 3 years ago, and sat down and crossed her arms over her chest, I would never have predicted she would have such a significant positive impact on my life and my career. I had been warned by my colleague, who was referring Allison to me, that she was “a very challenging case,” but that we would likely be a good fit. I think my colleague also mumbled an apology under her breath. The very first thing Allison told me after sitting down was that she hated all psychologists and, because I was a psychologist, she already hated me. She had just interviewed with 5 other psychologists and they had, in her opinion, “ruined” her by “forcing” her to remember and discuss her childhood. I was the last provider on her list. The only reason that she was seeing me was because my colleague had suggested she do so. In a very matter-of-fact voice she said: “Either I work with you or I kill myself.” This was all spoken before I had said “hello.”

I took a deep breath, thought about how much pain she must be in, and told her I was glad she was here—and I genuinely was. Maybe the compassion I felt for her had something to do with the prayer I say every morning before starting my clinic—a prayer in which I ask to be a conduit of love and healing. A conduit, because I know what my clients need is so much more than what I personally have to give.

Allison was a 54-year-old woman whose husband had died just 2 years after they had gotten married. She had a 29-year-old daughter who lived in another state. Allison was on medical leave for a work-related injury and had come with a long list of diagnoses: post traumatic stress disorder; major depressive disorder; panic attacks; borderline personality disorder; eating disorder NOS [not otherwise specified]; and chronic pain. My clinical evaluation revealed that each of these diagnoses was warranted. She reported one of the most severe histories of childhood trauma I had encountered to date. It wasn't uncommon for Allison to vacillate among cheerfulness, anxiety, anger, and periods of dissociation in the sessions. It was amazing to me that, until the last few months, she had reported functioning well and that she was not feeling emotionally distressed. She attributed this to her force field, which she used to keep out all negative emotions, and which was no longer working well because of the psychologists' prodding into her childhood.

Allison had been working through The Feeling Good Handbook ¹ by David D. Burns, MD, with my colleague (before she went on maternity leave) and liked the structured, directive, and practical approach of cognitive behavioral therapy (CBT). Allison also liked homework. CBT seemed like a logical place to start, but I knew we would need a team approach to address the depth of trauma, pain, and dysfunction she was experiencing. I made seeing me contingent upon concurrently being in a dialectical behavior therapy group and seeing a psychiatrist for medication. She was terrified of both prospects, but reluctantly agreed. I thought that she agreed because she was desperate and I was the last provider on her list. Allison told me later she agreed because she believed I was different—she noted: “You spent time learning about me.”

As I do in all my evaluations, I inquired if religion or spirituality was important to her. She said “no,” it wasn't and never had been. I moved on. A few sessions later, she mentioned reading my faculty bio and saw that I had researched the relationship between religion and health, and that I helped people deal with existential distress. She asked what religion I followed. I said I was a Christian. Then, to my surprise, she admitted with downcast eyes that she had been a Christian at one point and that it had been very, very important to her. I asked her what changed. She said she wouldn't speak about anything to do with religion until I gave her my definition of Christianity.

I knew, by this time, that Allison worked hard to please people, to fit the mold perfectly of who she thought they wanted her to be. She was a master of the mask, and she had no concept of herself outside of her relationships with other people. I almost never share what I believe in therapy because religiously integrative therapy is about integrating the client's religious beliefs and practices into treatment—not mine. However, I had a sense that being open and honest about some of my main religious beliefs would help create a safe space for her to speak about her own.

It seemed my clinical intuition had been correct because, after I did so, she thanked me and stated that she felt safer. Unbeknownst to me, it was very important for her to find out that I wasn't a “Sunday/holiday type of Christian.” She needed to know I took my faith seriously—because she believed that, if I took my faith seriously, I would take hers seriously, too. She then began to share, over the next few sessions, what she believed about Christianity, which turned out to be similar, though not identical, to what I believe. She told me later that, if I hadn't asked about her religious beliefs in our first session and if I had refused to share some of my beliefs, she was sure she never would have been able to share her own.

After spending several sessions gathering data, I outlined several options available for treatment. I wanted her to feel a sense of control in treatment, because this was so crucial to her feeling safe. I mentioned religiously integrated CBT, as my collegues and I had just developed a Christian manual and workbook ² for this therapy for treating depression among medically ill patients, a therapy we were about to test in a multisite randomized controlled trial. She was intrigued. Later, she told me just how important this treatment option was to her: “Not only did I want to combine Christianity with therapy because I wanted to come back to God, but I also felt it gave me more safety exposing myself to mental health professionals.”

Integrating religion in therapy was a gradual process. I spent a lot of time getting to know Allison—what she believed, what had changed, what she wanted now. She admitted that she believed her back injury was a punishment from God “because I had been in total control of my life and had not looked to God for anything. I controlled everything and made sure it all went according to my plan. This is how I felt safe. After my injury, and no answers for my nerve pain, and being told it was only going to progress, I fell apart. I had nothing to hold onto. I wanted God back in my life, but I didn't feel equipped or worthy to come back on my own.”

I asked her recently what made therapy a safe space to address the sacred, and she said: “I don't know how to answer this question except to say trust, acceptance, and my being able to feel like I could say anything I wanted. That might sound like a funny statement coming from me—since I was pretty outspoken—but when it came to serious things like Christianity, I felt insecure.” I realized again how important it is to provide a nonjudgmental, caring space for people to say whatever it is they need to say, especially those things they believe or have been taught they cannot say. Allison went on to say: “You validated my pain and showed me empathy, but then you always held me accountable for making changes, showing me that I needed to get unstuck. You always gave me love. I was finally brave enough to say I wanted to pursue Christianity again. I had the way down deep belief that Christianity was true, but I didn't trust it. I felt at that time that God was unfair, and that I was a hypocrite for being a Christian and depressed. You made it O.K. to feel that way.”

We began to talk gradually more about her faith and how it related to her pain and depression. She noted that one of the most helpful things we did was explore how pain and depression were real and acceptable in the Bible. She liked knowing that people in the Bible felt depressed and that they had also failed, as well as knowing what these people did about it. She began reading “Word confession cards,” a series of flashcards with verses on them that were meaningful to her. This was the starting point for cognitive restructuring. She had already learned how to identify unhelpful and inaccurate thoughts. Now she was searching through Scripture to find out what God had to say about her beliefs. She called the Bible her “measuring stick.” We spent a lot of time discussing how she could apply to her life the teachings in the verses she found, and how to make them practical and assessable.

After several months of reading the scriptures and using them to challenge her negative thoughts, she reported starting to feel the presence and love of God again in her life. What accompanied this new sense of God's presence was a surprising desire to go back to church and to be around people. This was a desire she found incredibly difficult and very scary, as she only left her house to attend doctor's appointments. She courageously joined a small group, accompanied the first time by her daughter, who drove 3 hours to go to the meeting with her. Slowly, she made a few friends with whom she spent time individually. Then she started sharing, just a little, in the group. When she found she was not mocked and that she actually had something to contribute, she started speaking up more. Then she joined a second small group.

One week she came to her session and said that she had graduated to becoming a member of her church. She began meeting with the pastor when she felt the need. A few months later, she became an usher and greeter. Now, she coordinates volunteer activities at her church. The change in Allison's mood, functioning, sense of self, and spiritual identity over the last 2 years has been profound. “I couldn't have done it if I hadn't finally felt accepted. Someone understood that I was unique and wonderfully made. You did, and you had proof. You showed me that God had a plan for my life. It didn't have to be the same as everyone else's, and I could start trusting myself through prayer and seeking His will.”

When we discussed what she thought about integrating religion into CBT, she said: “It was important to me that I was getting tools to use for my behavior from the psychology world, but also truth that was everlasting and was going to help me grow and develop eternally. I hadn't been able to see, or use, or allow myself to be in the truth before I calmed down psychologically.” The combination of these resources—CBT and her religious beliefs and practices—was a powerful healing force in her life. I enjoyed working with Allison. It was challenging, as I had been warned, but it was also incredibly satisfying to see her begin to change and heal. I had to be careful to stay out of a spiritual director or pastoral role. I continually directed her to her church, pastor, small group, and Christian friends, and always back to the Bible as the source of truth.

When we create sacred space, we create space for a healing presence greater than ourselves to work in a client's life. In my opinion, that healing force is love. Allison found love in her Christian faith, and therapy was the last place she expected to experience this. She went on to explain the significance of having sacred space in therapy to discuss her religious beliefs: “My decision to come back to Christianity made me a real person. It's the best thing that ever happened to me. It gave me strength and it gave me love. I had the knowledge that God was inside me, and He wanted to help me do these hard things.” I remain in awe of the mystery of the sacred and humbled by the healing power of love in Allison's life. It is a privilege to create sacred space for the brave souls who come to our offices searching for help and truth. It is a profound gift to be used as a conduit for love and healing, because living conduits are not just instruments of transformation, they, themselves, are changed by the sacred substance that flows through them.