The Significance of Existential, Religious, and Spiritual Problems in Psychotherapy
August 14th, 2007 |Written by Nancy Poitou, M.A., M.F.T., C.T.S.
There are several reasons why existential, religious and spiritual problems are important in psychotherapy. First it is important that therapists recognize that existential, religious and spiritual beliefs are at the foundation of individual, cultural, and societal frameworks of expression of internal and external experience. Whether the therapist or client recognizes it as an intregal part of life or not, conscious and unconscious beliefs about the nature of human existence and its meaning lie at the core of our relationships, values, ethics, morals, and how we act and interact in public and private life.
William James (1958) said that religion is the, “. . . belief that there is an unseen order and that our supreme good lies in harmoniously adjusting ourselves thereto” (Wm. James, quoted in Hood, Spilka, Hunsberger, and Gorsuch 1996 p. 6). Hood, Spilka, Hunsberger, and Gorsuch (1996) explain its importance, “The great theologians have always contended that no aspect of living, including the most commonplace of activities, can be divorced from a truly religious perspective. ‘The poet Kahlil Gibran said it well when he claimed that “. . . your daily life is your temple and your religion.” Religion thus becomes life as lived in its prosaic, enlightened, and even seamy aspect.” (Gibran as quoted by Hood, Spilka, Hunsberger, and Gorsuch 1996, p. 7). Brown (1988) finds that, “ . . . religious belief, experience and practice can transform reality, at least for some people and for the groups to which they belong” (p. 28). Wulff (1996) writes that, “ . . religion is the response an individual gives to existential questions-that is, questions issuing out of one’s awareness of the vicissitudes of life and death” (in Shafranske 1996 p. 61). Hood, et al (1996) indicate that “Few human concerns are more seriously regarded than religion. People surround themselves with spiritual reference, making it a context in which the sacred is invoked to convey the significance of every major life event” (p. 1).
There is a second problem or question that lies in the wide variation of how theorists and mental health practitioners regard religion and spirituality. At one extreme Freudian psychological theory regards religion as mass delusion and individual neurosis stemming from childlike fear and anxiety. To the opposite extreme transpersonal psychological theory regards religious and spiritual experiences as a possible cure for society’s ills and earth’s survival. Between those two extremes is a position that prefers not to address the issues as presented but to reduce them to biological processes and psychological factors. Some theories reduce their significance to a defense mechanism. For example Hood, Spilka, Hunsberger, and Gorsuch (1996) review theories that see anxiety, guilt, and deprivation as a source of religion, “For many people moral anxiety based on guilt and guilt activates religious concerns” (p. 19). In this way it could help the anxious and deprived feel more peaceful as to whether the universe is a friendly place or not. Some might explain their deprivation as God’s punishment or can justify the deprivation as something God has done to test our faith, or to purify our souls, or that we will be rewarded for suffering in the afterlife.
A third question or problem asks: without any educational requirements or training of mental health professionals what determines how therapists respond to existential, religious and spiritual problems? Do therapists draw from their own experience and their religious or spiritual beliefs or do they limit their responses to the theories they have accepted as their theoretical orientation? If they respond from one of these two positions, how do they respond to existential, religious and spiritual problems that fall outside of their theoretical orientation or their religious or spiritual beliefs? Shafranske and Gorsuch (1984) ask,
To what extent do psychologists recognize, respect, respond to or
influence the spiritual or religious values of their clients? To
what extent does a psychologist’s personal beliefs and personal
history, in respect to religiosity, influence clinical work? To
what extent does a psychologist’s training prepare the
practitioner to be aware of the religious orientations of clients
and spiritual issues within psychotherapy? (p. 232)
Hood, Spilka, Hunsberger, and Gorsuch (1996) warn that, “Humans are valuing beings, and if there is a specific human nature, it may be to act on valuesÑto accept what is liked and reject what is disliked. People’s interests complement their biases and prejudices, and religion is an area that people do not deal with dispassionately” (p. 3). It becomes impossible to separate the therapist from their beliefs, their chosen theoretical orientation and how they respond to existential, religious and spiritual problems that are addressed in the therapeutic encounter. Value-free therapy does not exist because therapists are not free of values and in the controversial area of religion and spirituality it would be difficult to find a therapist without any opinion. Jones (1996) states, “Psychology is, in American society, filling the void created by the waning influence of religion in answering questions of ultimacy and providing moral guidance” (in Shafranske 1996 p. 131).
To begin with there is a growing awareness that clients do bring these issues into therapy and that with the variety of religions and spiritual beliefs and the cultural diversity of our populations, therapists needed a way to name these presenting problems without delegating them to pathological designations. A significant but subtle addition of a newly added “V” code to the DSM IV. “V62.89 Religious or Spiritual Problem,” moves such problems into the domain of the therapist. The DSM IV. states about this “V” code, “This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution” (1994, p. 685). The APA (1994) reconsidered its former stand in light of demands that they become more sensitive to differing world views arising from an increasingly multicultural society.
A clinician who is unfamiliar with the nuances of an individual’s
cultural frame of reference may incorrectly judge as
psychopathology those normal variations in behavior, belief, or
experience that are particular to the individual’s culture. For
example, certain religious practices or beliefs (e.g., hearing or
seeing a deceased relative during bereavement) may be misdiagnosed
as manifestations of a Psychotic Disorder. Applying Personality
Disorder criteria across cultural settings may be especially
difficult because of the wide cultural variation in concepts of
self, styles of communication, and coping mechanisms
(APA p. xxiv).
The new “V” code can refer to any number of, and, wide range of spiritual and religious crises. These include, religious experiences, peak and transpersonal experiences, ecstatic, blissful experiences, conflict between experience and religious doctrine, religious fear, conflict between conscious and/or unconscious beliefs and experience, conversion and cult experiences, confrontations with mortality, existential crisises of meaning and moral conflict, to mention a few. Because of the inclusion of this new “V” code and the problems it encompasses there is a new awareness. Hood, Spilka, Hunsberger, and Gorsuch (1996) state, “As a part of this new awareness, religion and spirituality can be considered psychotherapeutic tools” (p. 407).
Are psychotherapists ready to deal with the spiritual or religious aspect of their clients? Most psychotherapists are trained to diagnose and treat psychopathology, the scientific study of mental diseases and abnormalities. Evaluating the validity of an individual’s beliefs is of utmost importance in assessing the mental health of a client. Targeting dysfunction and maladaptive behaviors, magical thinking and delusions can be
terms used by therapists for a belief that conflicts with the therapist’s definition of normality. Shafranske and Gorsuch (1984) state, “Within the context of psychologists ‘professional and personal perspectives on religion, it is relevant to address the profession’s preparedness to respond to the spiritual dimension which the majority of Americans’ and we might purport the majority of consumers of psychological services ‘attest to experience within their lives” (p. 232). Bergin, Payne, and Richards (1996) write that,
A therapist needs to be open to an assessment of religious and
spiritual needs even though he or she may not initiate such
topics. Avoiding religious issues or routinely redirecting
spiritual concerns in therapy is no more justifiable than refusing
to deal with the death of a family member or fears of social
encounters. Religious and spiritual concerns can be initiated by
the client, but therapists are always in a position to approve or
disapprove, to be open or closed to the concern, or to show
interest or lack of interest in the experiences and perceptions of
the client as they take on spiritual meanings. Can there be a
separation, in practice, between one’s professional and personal
values (Beutler, Machado, Neufeldt, 1994, p. 120)? (in
Shafranske, 1996, p. 313)
Lukoff, Turner and Lu, (1992) state that, “Knowledge of specific features of religious and spiritual belief systems is often essential in clinical decision-making, e.g., to assess assertions such as, ‘God spoke to me.’ This may, but does not necessarily, indicate the presence of a hallucination and/or a delusion . . .” (p. 48). Pathology or human potential, religious behaviors and spiritual experiences whether adaptive, evolutive or detrimental are not easily discriminated by the untrained eye. Whether termed spiritual experience, transpersonal experience, mystical experience, exceptional human experience, peak experience or religious experience, they refer to experiences that are nearly indistinguishable from each other. Some appear to the observer as mental disturbance. Hood, Spilka, Hunsberger, and Gorsuch (1996) state that, “. . . a committee of the Group for the Advancement of Psychiatry indicated that it was unable ‘to make a firm distinction between a mystical state and a psychopathological state’” (p. 410). To further complicate the distinction Grof (1985) states, “. . . a clearly psychotic state can evolve into an experience of mystical revelation. Individuals involved in spiritual search and practices occasionally confront psychotic territories within themselves, while
schizophrenic patients often visit the mystical experiential realms” (p. 309).
In our most revered testing mechanisms, there is a fine line between creativity and psychosis. Creativity researcher Frank Barron (1977) states, “The creative individual not only respects the irrational in himself, but courts the most promising source of novelty in his own thought . . . The creative person is both more primitive and more cultured, more destructive and more constructive, crazier and saner, than the average person” (in Harman; Rheingold, p. 50). Lukoff, Turner and Lu, (1992) conclude that, “. . . studies have found that people reporting mystical experiences scored lower on psychopathology scales and higher on measures of psychological well-being than controls” (in Hood, Spilka, Hunsberger, and Gorsuch 1996 p. 411). Here too we see that fine line between psychosis and genius.
In a study of Religion and Subjective Well-being in Adulthood: A quantitative synthesis by Witter, Stock, Okun & Haring (1985) found, “Results indicate that religion is significantly and positively related to subjective well-being. The authors conclude that ‘religion should not, as has often occurred, be ignored in testing causal models of subjective well-being in adulthood’” (in Turner, Lukoff and Lu, 1992, p. 49). In a
study of divine relations, social relations, and well-being, Pollner (1989) stated that, “In fact, participation in a divine relation was ‘the strongest correlate in three of four measures of well-being, surpassing in strength such usually potent predictors as race, sex, income, age, marital status, and church attendance’” (in Lukoff, et al., 1992, p. 50). With these facts in mind, it seems as though the mental health profession is operating on an
unconscious level in this area. Turner, et. al. (1992) observe that, “Although the role of religion in therapy has been acknowledged since Jung, little is known of the dynamics and effective components involved” (p. 50-51).
Some therapists may hold negative opinions or have unresolved issues with their religious past. M. Scott Peck (1978) states, “. . . there is a tendency for them [therapists] to consider any passionate belief in God to be pathological. Upon occasion this tendency may go over the line into frank bias and prejudice” (p. 224). Without knowing where the therapist stands on religion, will a client feel safe enough to reveal religious or spiritual concerns? Peck tells a story about a college senior who had been in therapy for a year, but was unable to tell his therapist about his desire to join the monastery. Though Peck wanted to encourage him to talk to his therapist about such a serious life change, and to trust the therapist to be objective, he did not. Peck (1978) wrote,
For I was not at all sure that his therapist would be objective,
that he would understand, in the true meaning of the word.
Psychiatrists and psychotherapists who have simplistic attitudes
toward religion are likely to do a disservice to some of their
patients. This will be true if they regard all religion as good or
healthy. It will also be true if they throw out the baby with the
bath water and regard all religion as sickness or the Enemy. And,
finally, it will be true if in the face of the complexity of the
matter they withdraw themselves from dealing at all with the
religious issues of their patients, hiding behind a cloak of such
total objectivity that they do not consider it to be their role to
be, themselves, in any way spiritually or religiously involved.
For their patients often need their involvement. I do not mean to
imply that they should forsake their objectivity, or that
balancing their objectivity with their own spirituality is an easy
matter. It is not. To the contrary, my plea would be that
psychotherapists of all kinds should push themselves to become not
less involved but rather more sophisticated in religious matters
than they frequently are. (p. 224).
We know that the countertransference of the therapist affects therapy. For example, if sex is an uncomfortable subject for the therapist the client will learn the first time the client brings it up in a session.
Feeling the discomfort of the therapist, the client will take a cue that the therapist does not want to hear about it and this important aspect of the client’s life may never be fully addressed. And so it may be with the spiritual life of the client as well. Currently the Board of Behavioral Science requires that MFCC graduate students receive during their education 10 classroom hours on human sexuality; however there are no requirements in the area of religion and spirituality. Lukoff, Turner and Lu, (1992) say of our more educated mental health professionals, “Despite the importance that religion plays in most patients’ lives, neither psychologists nor psychiatrists are given adequate training to prepare them to deal with issues that arise in this realm” (p. 47). Barnhouse (1986) observed,
Thus psychologists and psychiatrists are often operating outside
the boundaries of their professional competence, which raises
ethical and educational concerns. Barnhouse has pointed out that,
‘Sex and religion are, in some form, universal components of human
experience. . . . . Psychiatrists who know very little about
religion would do well to study it’
(p. 103) (in Lukoff, Turner and Lu, 1992, p. 48).
In “Religions, Values and Peak Experiences,” Abraham Maslow (1964) looked at the ability of psychologists to address these issues and found them wanting, perhaps not willing to address them, and unaware of how little they actually know,
. . . this is true of the psychologist whose ratio of knowledge to
mystery must be the smallest of all scientists . . . Perhaps it
is because he is so innocently unaware of his smallness, of the
feebleness of his knowledge, of the smallness of his playpen, or
the smallness of his portion of the cosmos and because he takes
his narrow limits so for granted that he reminds me of the little
boy who was seen standing uncertainly at a street corner with a
bundle under his arm. A concerned bypasser asked him where he was
going and he replied that he was running away from home. Why was
he waiting at the corner? He wasn’t allowed to cross the street!
(p. 46).
Maslow (1964) urges us to consider the human potential, “. . . aid the person to grow to fullest humanness, to the greatest fulfillment and actualization of his highest potentials, to his greatest possible stature. In a word, it should help him to become the best he is capable of becoming, to become actually what he deeply is potentially” (p. 49). Lukoff, Turner and Lu (1992) state, “In summary, available research has established religion’s potential to foster positive mental health. However, its potential for preventing mental illness can only be inferred at this point” (p. 50). Considering the potential for well-being, and as Menninger (in Walsh and Vaughn, 1988, p. 133) wrote, the possibility of going beyond to become “weller than well” is a significant question to ponder. Why is there a prevalence to pathologize or ignore the religious and spiritual life of clients by the mental health profession and mental health educators?
Maslow (1964) urges us to cross the street and look at the existential, religious and spiritual problems, “Education must be seen as at least partially an effort to produce the good human being, to foster the good life and the good society. Renouncing this is like renouncing the reality and desirability of morals and ethics. Furthermore, ÔAn education which leaves untouched the entire region of transcendental thought is an
education which has nothing important to say about the meaning of human life.” (Manas (July 17, 1963)” (p. 58).
When we see clients do we only look for dysfunction? Do we see them in terms of psychopathology to be eliminated, or can we look deeper? We are taught to look for pathology and ask “what function does this serve?” Waldgrave (1989, 1990) asks, “ . . . when therapists use a physical science model to seek the ‘correct diagnosis’ with the ‘right interpretation or explanation’ in order to ‘treat’ the ‘pathology’, they frequently further entrench the problem-centered web of meaning by further defining it. . . . Thus the meaning created in therapy can actually strengthen their problem’s influence over them, offering scientific explanations for its onset and persistent domination” (p. 13). Do we ever ask what does this mean to the client? “. . . it is intended to emphasize that central to practically all therapeutic problems is meaning, whose created pattern determines the manner in which the problem is responded to” (p. 13). Whether the client’s meaning system depends on religion, spiritual beliefs, or a personally defined existential system of meaning, therapists need to be more attentive. To do this we must engage a different mindset, “Instead of addressing a known pathology, therapists engage in conversation, listening respectfully for the articulation of meaning by the person or family. The conversation enables the generation of new meaning by the therapist. The threads that the family have woven into a problem-focussed pattern, are joined by new threads of new colour with different meanings that encourage new possibilities, or ways of resolution and hope” (p. 13).
The reductive approach is no help to clients trying to find answers, LeShan (1990) states,
Whether it is worse for the scientists who study human feelings
and behavior to explain these as a bunch of connected reflex arcs,
or to explain them as artifacts of an advanced computer, or to
explain them as a collection of reaction-formations to
pathological drives ( which of these is worse for the effect it
has on our attitudes toward ourselves and for the future of
humankind ) is a moot point indeed. All these things play a part
in our being, but they no more explain them than the nuts and
bolts that hold an automobile together explain and make up the
automobile. . . . It is largely for this reason ( that the
scientists who should be responsibly working with the spiritual
and aspirational aspects of human beings have rejected this area
as unworthy of them ) that those people who are seeking to
find these parts of themselves go so frequently to the
irresponsible, kooky, and predatory groups that pretend to have
knowledge and working methods to help us grow in these ways. . .
. When psychologists realize that these positive aspects are real
aspects of being human and they are of tremendous importance to
us, then people will not have to seek the solution to their needs
at the hands of second-rate gurus, nuts, and those seeking to make
personal fortunes out of these hopes and aspirations (p.
126-127).
Invalidated, reduced, ignored, demonized or pathologized therapists could overlook the potential in the “peak experience.” Lack of understanding of “spiritual experiences” and issues is a central theme in the book “Spiritual Emergency,” by transpersonal theorists Stanislav and Christina Grof (1989) who write in the introduction, “. . . some of the dramatic experiences and unusual states of mind that traditional psychiatry diagnoses and treats as mental diseases are actually crises of personal transformation or ‘spiritual emergencies’” (p. x). In an interdisciplinary exploration of these “peak” experiences, the authors state that in many cultures, ancient and modern experience profound transformational consequences that our western society has long invalidated. The Grofs (1989) continue,
The concept of spiritual emergency integrates findings from many
disciplines, including clinical and experimental psychiatry,
modern consciousness research, experiential psychotherapies,
anthropological field studies, parapsychology, thanatology,
comparative religion, and mythology. Observation from all these
fields suggest strongly that spiritual emergencies have a positive
potential and should not be confused with diseases that have a
biological cause and necessitate medical treatment. (p. x).
Grof (1989) writes, “We are now realizing to our surprise that, in the process of relegating mystical experiences to pathology, we may have thrown the baby out with the bath water” (p. xii). If clients bring us their experiences and we pathologize or ignore rather than explore them we may lose the most powerful tool for healing, the human psyche.
What meaning do extraordinary experiences hold for our clients? Near-death experiences have become more prevalent due to advances in medical and resuscitation technology. Studied by transpersonal theorists, the near-death experience has great potential for harm if invalidated and labeled as hallucination and great potential for personal transformation and healing if addressed and integrated by the client. Ignored, it is a lost opportunity. Researcher Cherie Sutherland (1992) after contacting over 200 subjects from all over Australia settled on a sample of 50 which included 15 men and 35 women whom she used in her doctoral dissertation research. Since she was focusing on the aftereffects the near-death experiences, the episode had to have been 2 years or more past, reasonable geographical accessibility within the eastern states of Australia and English-speaking. Sutherland states that, “Almost all of them are changed by the experience and through their interactions with others these changes move beyond the personal, beyond the lives of individual experiencers into the social realm, presaging a profound transformation of great benefit to society as a whole” (p. 243). Morse (1994) states that “Research has also shown that paying attention to spiritual issues has an immediate practical effect on human suffering. Paying attention to a patient’s feelings and spiritual beliefs can lead to shorter hospital stays and the use of less pain medication. It has also been documented to reduce costs and unnecessary procedures” (p. 125).
National surveys from 1980 to 1985 indicated that 15% of Americans have been near death, 8% have had a “near-death experience.” This experience puts an immense strain on personal relationships. The person who has had the near-death experience often becomes more optimistic, yet experiences the breakup of primary relationships. This paradoxical result is due to a change in priorities, and values which result in less interest in acquiring material possessions. This study done by Cherie Sutherland Ph.D. (1992), showed that another change in priority was a “. . . widespread desire for knowledge” and a strong desire to help others. Almost three-quarters of those she interviewed made major career changes, many to a work that involved helping others, many expressing an increased interest is social issues. “When death is no longer feared, it is possible, as has been shown by these experiencers, to engage in meaningful relationships with the dying, to abandon immortality projects and to see attachment to immortality vehicles such as money, fame, and heroism as ultimately illusory. Such crucial changes in attitude provide a fundamental challenge to the widely accepted norms of Western society” (p. 242).
Near-death experiences not only heal the individual but in a transpersonal sense ripple out to benefit the whole of society. Can therapists afford to ignore the possibilities inherent in listening to and facilitating the integration of these experiences and their effects on relationships, the family and society? In the work of the therapist the potential of successful resolution and integration of near-death and other peak, spiritual and paranormal experiences is too great to ignore. Our society stands on the precipice of self destruction. Stanislav Grof (1989) suggests, “On the collective scale, the loss of spirituality might be a significant factor in the current dangerous global crisis that threatens the survival of humanity and of all life on the plane” (p .xiii). Considering this potential how can we afford to ignore or minimize this type of experience in the therapeutic setting? To pathologize it would be a crime. The gap between spirituality and psychology can be bridged.
Authors define religious experiences such as “Mystical Experience,” “Glossolalia” or “speaking in tongues,” “Conversion” and “Scrupulosity” (Mora 1969 in Hood, Spilka, Hunsberger and Gorsuch 1996, p. 414) as “. . . the religious manifestation of Obsessive-Compulsive Disorder” (Askin Palutre, White, and Van Ornum 1993 in Hood, et al., 1996, p. 414). Also, they indicate that the “Religion of Mentally Disordered Persons” deals with concepts which are closest to straddling the fine and variable line between pathology and normal cultural and religious behavior, “. . . refers to intense religious experiences and conversion as ‘adaptive regression” that may “help reorganize a weakened ego’” (Hood, et al., 1996, p. 416). The effects of various religion on the individual has yet to be studied.
Argyle (1959) found context and culture can make a great difference in determining the difference between pathology and religious behavior. Religions such as Roman Catholicism, Greek Orthodoxy, and Orthodox Judaism and the countries in which they predominate show the lowest suicide rates, while suicide rates for Protestants are “two to three times higher” (in Hood, Spilka, Hunsberger and Gorsuch, 1996, p. 417). However members of a religion may be less willing to report the death as suicide, except if evidence is undeniable, witnesses reveal it as such or it is publicly known. Gibbs (1966) observed that the Jewish Zealots at Masada in a mass suicide protested their lack of freedom and are remembered as examples of a principle founded on an admired quality of commitment to human dignity. Contrasted with the mass suicide at Jonestown and the People’s Temple there seems to be no research that can be generalized to all religions and all religious people (in Hood, et al., 1996, p. 417).
The significance of existential, religious and spiritual problems lies in three areas. First, therapists need to be aware that beliefs and meaning are central themes inherent in existential, religious and spiritual problems, which are at the foundation of individual, cultural, and societal frameworks of experience and at the core of values, ethics, morals and therefore how people interact in relationships. Second, without any educational requirements, therapists are faced with wide variations of what theorists say about religion and spirituality. Therapists need to be aware of their own beliefs in order to recognize and respect their influence on clients’ existential, religious and spiritual beliefs and need to consider the issue of values in this controversial area. Third, therapists need to address these problems in a well-informed way so not not to miss the dismiss the human potential nor the opportunities inherent in the cultural, clinical and experiential aspects of existential, religious and spiritual problems.
EXISTENTIAL, RELIGIOUS AND SPIRITUAL WHAT DOES IT MEAN ?
In “A Generation of Seekers” a study of the religious and spiritual experience of “Baby Boomers” started in 1988, Wade Clark Roof and his researchers interviewed hundreds of this generation on the phone, and, also, visited churches and synagogues in an effort to understand their search for a spiritual home. These researchers sought to “. . . learn as much as possible about their religious and spiritual biographies, . . .” (p. 2).
Asked by their research subjects “Why are you asking questions about religion and spirituality?” Roof (1993) answers,
Because there is widespread ferment today that reaches deep within
their lives. Members of this generation are asking questions about
the meaning of their lives, about what they want for themselves
and for their children. They are still exploring, as they did in
their years growing up; but now they are exploring in new, and, we
think, more profound ways. Religious and spiritual themes are
surfacing in a rich variety of ways in Eastern religions, in
evangelical and fundamentalist teachings, in mysticism and New Age
movements, in Goddess worship and other ancient religious rituals,
in the mainline churches and synagogues, in Twelve-Step recovery
groups, in concern about the environment, in holistic health, and
in personal and social transformation. Many within this generation
who dropped out of churches and synagogues years ago are now
shopping around for a congregation. They move freely in and out,
across religious boundaries; many combine elements from various
traditions to create their own personal, tailor-made meaning
systems. Choice, so much a part of life for this generation, now
expresses itself in dynamic and fluid religious styles.
Religion and spirituality, of course, are an integral part
of human culture.
©Copyright 1997 Nancy Poitou, M.A., M.F.T., C.T.S. All Rights Reserved. Permission to publish granted to GoodTherapy.org. Questions or concerns about the article can be directed to the author or posted as a comment to this blog entry. The article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org.
